When performing a breast examination, the nurse notes the presence of Montgomerys tubercles, soft tissue bilaterally, palpable infraclavicular lymph nodes, and slight tenderness to deep palpation bilaterally. Which of the findings would the nurse consider a deviation from normal?
A. The presence of Montgomery s tubercles B. Soft tissue bilaterally C. Slight tenderness to deep palpation D. Palpable infraclavicular lymph nodes
Normal lymph nodes should be nonpalpable. The presence of Montgomerys tubercles, which are tiny sebaceous glands on the areolae, is normal. The tissue of the breast should be soft. Tenderness to deep palpation is not as concerning as palpable lymph nodes in the breast assessment.
Nursing Process Step: Assessment
Cognitive Level: Application
Client Need: Physiological Integrity