A nurse is caring for a toddler whose parent states 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.
Obtain a urine specimen for a urinalysis.
Instruct the parent to avoid pressing on the abdominal area.
Schedule the child for an abdominal ultrasound.
The Correct Answer is C
A. While assessing for pain is important, it is not the priority in this situation. The presence of pink- colored urine and a palpable mass in the abdominal area are more concerning findings that warrant immediate investigation.
B. 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.
C. 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.
D. The decision to schedule additional diagnostic tests, such as an abdominal ultrasound, can be made based on the results of the urinalysis and further clinical assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When assesssing the child with suspected or confirmed Wilm's tumor, it is important to avoid palpation of the abdomem. This is because it can lead to dislodging of the tumor cells
Correct Answer is B
Explanation
A. Booster seats are used for older children who have outgrown their forward-facing car seats. A 24- month-old toddler is typically too young and small for a booster seat.
B. Rear-facing car seats provide the best protection for young children, including toddlers, in the event of a crash.
B. The American Academy of Pediatrics (AAP) recommends keeping children in a rear-facing car seat until they reach the maximum height or weight limit. Rear-facing seats distribute crash forces more evenly across the back of the car seat and the child's body, reducing the risk of injury to the head, neck, and spine.
C. Placing a car seat forward-facing in the front passenger side and inactivating the airbag is not recommended for any child under the age of 13 due to the risk of injury from the airbag in the event of a crash.
D. Placing a car seat rear-facing in the front passenger side is not recommended, especially for a toddler.
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