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A nurse is assessing a client's risk of breast cancer.
Which of the following would not be included in the education about risks?

A.

Client's sister had breast cancer.

B.

History of radiation exposure.

C.

Currently taking oral contraceptives.

D.

Age less than 25 years old.

Answer and Explanation

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 B

Explanation

Choice A rationale

Turning the newborn's head quickly to one side elicits the tonic neck reflex, not the Moro reflex. The tonic neck reflex involves the newborn's arm extending on the side where the

head is turned and the opposite arm bending at the elbow, resembling a fencing position.

Choice B rationale

Performing a sharp hand clap near the infant elicits the Moro (startle) reflex, which is characterized by the infant throwing their arms outward, opening their hands, and then bringing

the arms back in. This is a response to sudden stimuli and is a normal reflex in newborns.

Choice C rationale

Stroking the outer edge of the sole of the foot from near the heel up toward the toes elicits the Babinski reflex, not the Moro reflex. The Babinski reflex is characterized by the big toe

moving upward or toward the top surface of the foot and the other toes fanning out.

Choice D rationale

Placing a finger at the base of the newborn's toes elicits the plantar grasp reflex, not the Moro reflex. The plantar grasp reflex involves the toes curling around the finger or object

placed at the base of the toes. .

Correct Answer is C

Explanation

Choice A rationale

A maternal blood pressure of 128/88 mm Hg is within normal limits for a pregnant woman. Regular monitoring is necessary, but no immediate follow-up is required unless symptoms

of preeclampsia appear.

Choice B rationale

A fetal heart rate baseline of 115 bpm is within the normal range (110-160 bpm). This does not require immediate follow-up and is a reassuring sign of fetal well-being.

Choice C rationale

A maternal heart rate of 128 bpm is elevated (tachycardia) and may indicate distress, infection, dehydration, or other underlying conditions. This requires immediate follow-up to identify and address the cause.

Choice D rationale

A maternal respiratory rate of 18 breaths per minute is within the normal range (12-20 breaths per minute) and does not require immediate follow-up.

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