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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This test will confirm if your child had a recent streptococcal infection, as it measures the level of antibodies that the body produces against the streptolysin O enzyme, which is produced by some strains of streptococcal bacteria. A high ASO titer indicates a recent or current streptococcal infection, which can trigger rheumatic fever in some children.
Choice B reason: This test will not indicate if your child has rheumatic fever, as it does not measure the inflammation or damage to the heart, joints, or other organs that rheumatic fever can cause. Rheumatic fever is diagnosed based on the presence of two major or one major and two minor criteria, as well as evidence of a preceding streptococcal infection.
Choice C reason: This test will not indicate if your child has a therapeutic blood level of an aminoglycoside, as it does not measure the concentration of this type of antibiotic in the blood. Aminoglycosides are used to treat serious infections caused by gram-negative bacteria, and their blood levels need to be monitored to prevent toxicity and ensure efficacy.
Choice D reason: This test will not confirm if your child has immunity to streptococcal bacteria, as it does not measure the level of protective antibodies that can prevent future infections. ASO antibodies are not protective, but rather indicate a past or present exposure to streptococcal bacteria.
Correct Answer is C
Explanation
Choice A reason: Ridged abdomen is not an expected finding for an infant who has pyloric stenosis, as it indicates abdominal rigidity or guarding, which can be a sign of peritonitis or bowel obstruction. Pyloric stenosis is a narrowing of the pyloric sphincter, which causes gastric outlet obstruction and delayed gastric emptying.
Choice B reason: Red currant jelly stools are not an expected finding for an infant who has pyloric stenosis, as they indicate blood and mucus in the stools, which can be a sign of intussusception or necrotizing enterocolitis. Pyloric stenosis does not affect the lower gastrointestinal tract, and the infant may have constipation or dehydration due to vomiting.
Choice C reason: Projectile vomiting is an expected finding for an infant who has pyloric stenosis, as it occurs after feeding due to the increased pressure in the stomach and the inability to pass food into the duodenum. Projectile vomiting can cause weight loss, dehydration, electrolyte imbalance, and metabolic alkalosis.
Choice D reason: Distended neck veins are not an expected finding for an infant who has pyloric stenosis, as they indicate increased central venous pressure, which can be a sign of heart failure or superior vena cava syndrome. Pyloric stenosis does not affect the cardiovascular system, and the infant may have sunken fontanels or poor skin turgor due to dehydration.
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