A nurse is assessing a client's risk of breast cancer.
Which of the following would not be included in the education about risks?
Client's sister had breast cancer.
History of radiation exposure.
Currently taking oral contraceptives.
Age less than 25 years old.
The Correct Answer is D
Choice A rationale
A family history of breast cancer, particularly in a close relative like a sister, is a significant risk factor for breast cancer.
Choice B rationale
Exposure to radiation, particularly in the chest area, increases the risk of developing breast cancer.
Choice C rationale
Current use of oral contraceptives can slightly increase the risk of breast cancer, though the risk diminishes after stopping the pills.
Choice D rationale
Age less than 25 years is not a risk factor for breast cancer; risk increases with age.
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Correct Answer is D
Explanation
Choice A rationale
Breast tenderness is considered a presumptive sign of pregnancy, as it can result from hormonal changes, but it is not definitive enough to confirm pregnancy.
Choice B rationale
Fetal heart tones detected by ultrasound are a positive sign of pregnancy. However, it is not a probable sign as it is definitive evidence of an existing pregnancy.
Choice C rationale
Fetal movement, often felt later in pregnancy, is a positive sign. It indicates an existing pregnancy but is not used to initially diagnose pregnancy.
Choice D rationale
A positive urine pregnancy test is a probable sign of pregnancy. It detects the presence of hCG (human chorionic gonadotropin), a hormone produced during pregnancy, and is a widely used indicator of probable pregnancy. .
Correct Answer is D
Explanation
Choice A rationale
Blue coloring of the hands and feet in an 8-hour-old newborn (acrocyanosis) is a common, benign finding as the newborn’s circulatory system adjusts post-birth. It does not require immediate intervention.
Choice B rationale
Small raised pearly spots on the nose (milia) are harmless and common in newborns. They do not necessitate any intervention.
Choice C rationale
An apical heart rate of 140 bpm is within the normal range for newborns and does not require intervention.
Choice D rationale
Nasal flaring and grunting are signs of respiratory distress in a newborn. This condition demands immediate intervention to ensure the newborn’s airway is clear and breathing is adequately supported.