A nurse is caring for a toddler whose parent states that while bathing the child, she noticed a mass in his abdominal area and that his urine is a pink color. Which of the following actions is the nurse's priority?

Determine if the child is having pain.

Instruct the parent to avoid pressing on the abdominal area.

Schedule the child for an abdominal ultrasound.

Obtain a urine specimen for analysis.

Answer and Explanation

The Correct Answer is B

The correct answer is: B

Choice A reason: Determining if the child is having pain is important, but it is not the immediate priority. Pain assessment will help in managing the child’s comfort and can provide additional information about the condition. However, in the case of Wilms tumor, which is a common kidney cancer in children, the priority is to prevent any action that could potentially cause tumor spillage or spread.

Choice B reason: Instructing the parent to avoid pressing on the abdominal area is the priority action. Wilms tumor can rupture with pressure, which can lead to the spread of cancer cells. It is crucial to minimize handling of the tumor to prevent tumor spillage into the abdominal cavity.

Choice C reason: Scheduling the child for an abdominal ultrasound is a necessary diagnostic step, but it is not the immediate priority. The ultrasound will help in assessing the size and extent of the tumor, but the first action should be to ensure that the tumor is not disturbed.

Choice D reason: Obtaining a urine specimen for analysis is important for diagnosing the cause of the hematuria (blood in the urine), which is a common symptom of Wilms tumor. However, this is not the immediate priority compared to preventing potential harm to the child by avoiding pressure on the abdominal area.

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Correct Answer is A

Explanation

Choice A reason: A child with Hirschsprung disease may need a feeding tube after the surgery to provide adequate nutrition and hydration while the bowel recovers. The parent should express interest in learning how to use and care for the feeding tube, as this indicates an understanding of the teaching.

Choice B reason: A child with Hirschsprung disease will not need a urinary catheter after the surgery, unless there is a specific indication for it. The parent should not confuse the feeding tube with the urinary catheter, as this indicates a lack of understanding of the teaching.

Choice C reason: A child with Hirschsprung disease will not have normal bowel movements immediately after the surgery, as the bowel needs time to heal and adapt. The parent should be aware of the possible complications and follow-up care that the child will need.

Choice D reason: A child with Hirschsprung disease may require a temporary or permanent ostomy, depending on the extent of the bowel affected. The parent should be prepared for either outcome and not assume that the ostomy is only temporary.

A. 0.5 mL/kg/hr B. 2 mL/kg/hr C. 15 mL/kg/hr D. 75 mL/kg/hr

Correct Answer is B

Explanation

The correct answer is b. 2 mL/kg/hr. This is within the normal range for infants, indicating adequate hydration.

Choice A reason:

0.5 mL/kg/hr: This is below the normal range for infants, indicating possible dehydration3. Normal urinary output for infants is typically 1-2 mL/kg/hr.

Choice B reason:

2 mL/kg/hr: This is within the normal range for infants, indicating that the fluid imbalance has been corrected.

Choice C reason:

15 mL/kg/hr: This is excessively high and could indicate overhydration or other issues1. Such high output is not typical for infants.

Choice D reason:

75 mL/kg/hr: This is extremely high and unrealistic for normal urinary output1. It suggests a measurement error or a severe medical condition.

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A nurse is caring for a toddler whose parent states that while bathing the child, she noticed a mass in his abdominal area and that his urine is a pink color. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a parent of a child who has Hirschsprung disease and is scheduled for initial surgery. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is admitting a 6-month-old infant who has dehydration. Which of the following amounts of urinary output should indicate to the nurse that the treatment has corrected the fluid imbalance?

Correct Answer is B

Explanation

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A nurse is caring for a toddler whose parent states that while bathing the child, she noticed a mass in his abdominal area and that his urine is a pink color. Which of the following actions is the nurse's priority?