A nurse in a clinic is assessing a 9-month-old infant.
Which of the following findings requires further intervention?

The correct answers are B. Assess the client’s airway patency,

C. Remove objects from the client’s bed, and D. Place the client in a side-lying position.

Choice A rationale

Restraining the client during a seizure is not recommended as it can cause injury. The focus should be on ensuring the client’s safety and preventing harm.

Choice B rationale

Assessing the client’s airway patency is crucial during a seizure to ensure that the client is breathing properly and that the airway is not obstructed.

Choice C rationale

Removing objects from the client’s bed helps prevent injury during a seizure. Objects in the bed can pose a risk of harm if the client hits them during the seizure.

Choice D rationale

Placing the client in a side-lying position helps maintain an open airway and reduces the risk of aspiration. This position allows any secretions to drain out of the mouth, preventing choking.

Choice E rationale

Placing a tongue depressor in the client’s mouth is not recommended and can cause injury. It is a common misconception that this prevents the client from swallowing their tongue, but it can actually cause more harm.

The correct answer is Choice A.

Choice A rationale

Wilms tumor, also known as nephroblastoma, is a type of kidney cancer that primarily affects children. It is crucial not to palpate the abdomen of a child with a suspected Wilms tumor because this can cause the tumor to rupture and spread cancerous cells to other parts of the body.

Choice B rationale

This choice is incorrect because there is no specific restriction on venipuncture or blood pressure measurements in the left arm for children with Wilms tumor. This precaution is typically associated with conditions like lymphedema or after a mastectomy.

Choice C rationale

Collecting all urine is not a specific precaution for Wilms tumor. While monitoring urine output can be important in various conditions, it is not a primary concern for Wilms tumor.

Choice D rationale

Contact precautions are not necessary for Wilms tumor as it is not an infectious disease. Contact precautions are typically used for conditions that are contagious or spread through direct contact.