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A nurse is caring for a toddler whose parent states that the child has a mass in his abdominal area and his urine is a pink color. Which of the following actions is the nurse’s priority?

Schedule the child for an abdominal ultrasound.

Instruct the parent to avoid pressing on the abdominal area.

Determine if the child is having pain.

Obtain a urine specimen for a urinalysis.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: Instruct the parent to avoid pressing on the abdominal area.

Rationale for each choice:

Choice A: Schedule the child for an abdominal ultrasound. While an ultrasound may be necessary for further diagnosis, it is not the immediate priority. The child’s symptoms suggest a possible Wilms’ tumor, a type of kidney cancer that primarily affects children. An ultrasound can help confirm this diagnosis, but it should not be the first action.
Choice B: Instruct the parent to avoid pressing on the abdominal area. This is the correct answer. If the child has a Wilms’ tumor, pressing on the abdominal area could potentially cause the cancer to spread. Therefore, it is crucial to avoid any unnecessary pressure on the abdomen until further medical evaluation can be performed.
Choice C: Determine if the child is having pain. While assessing for pain is an important part of nursing care, it is not the immediate priority in this situation. The child’s symptoms need urgent medical attention, and assessing for pain will not provide the necessary information to guide immediate care.
Choice D: Obtain a urine specimen for a urinalysis. Although a urinalysis can provide valuable information about a patient’s health, it is not the immediate priority in this situation. The child’s symptoms suggest a possible Wilms’ tumor, which requires immediate medical attention. A urinalysis may be part of the diagnostic process, but it should not be the first action taken.

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Correct Answer is A

Explanation

Choice A rationale
The goal of surgery for Hirschsprung disease is to remove the diseased section of the intestine and then pull the healthy portion of this organ down to the anus. This is typically achieved through a type of surgery called a pull-through procedure. In some cases, doctors recommend ostomy surgery of the bowel followed by a pull-through procedure. During ostomy surgery, surgeons create a stoma on a child’s abdomen and connect the stoma to the large or small intestine. After ostomy surgery, waste will leave the child’s body through the stoma. The stoma is usually temporary. In most cases, surgeons can later close the stoma and connect the healthy part of the intestine to the anus. Waste will move through the intestines, and stool will pass through the anus again. Therefore, the statement “I’m glad that the ostomy is only temporary” indicates understanding of the surgery’s goal.
Choice B rationale
The operation for Hirschsprung’s disease does not involve straightening out a kink in the intestine. Instead, it involves removing the part of the large intestine that is missing nerve cells and then connecting the healthy part of the large intestine to the anus.
Choice C rationale
The use of a feeding tube is not typically associated with the initial surgery for Hirschsprung’s disease. The surgery involves removing the diseased section of the intestine and then pulling the healthy portion of this organ down to the anus.
Choice D rationale
While the ultimate goal of the surgery is to enable normal bowel movements, it is important to note that about half of children may have ongoing problems after surgery. These problems may include constipation and, in some cases, other symptoms of intestinal obstruction, such as a swollen abdomen or vomiting.

A. Urine specific gravity 1.034. B. Bounding pulse. C. BP 46/94 mm Hg. D. Distended neck veins.

Correct Answer is A

Explanation

Choice A rationale
A urine specific gravity of 1.034 is higher than the normal range (1.002-1.030), indicating that the urine is more concentrated due to a lack of hydration.
Choice B rationale
A bounding pulse is not typically associated with dehydration. Dehydration more commonly results in a weak, rapid pulse.
Choice C rationale
A blood pressure reading of 46/94 mm Hg is not indicative of dehydration. Dehydration often leads to low blood pressure.
Choice D rationale
Distended neck veins are not a typical sign of dehydration. Dehydration can lead to decreased blood volume, which would not cause distension of the neck veins.

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A nurse is caring for a toddler whose parent states that the child has a mass in his abdominal area and his urine is a pink color. Which of the following actions is the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement from a parent of a 1-month-old infant undergoing initial surgery for Hirschsprung’s disease indicates understanding of the surgery’s goal?

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