A 9-month-old infant is inconsolable and repeatedly tugs at the right ear. The infant also cries when lying down. What is the nurse's best action to determine the source of pain?

A. Administering oxygen via a nonrebreather mask is incorrect as the priority action. Although oxygen can improve fetal oxygenation, it does not directly relieve compression of the umbilical cord, which is the immediate, life-threatening issue in a prolapsed cord. Oxygen may be used after cord compression is relieved, but it is not the first intervention.

B. Placing a rolled towel beneath one of the client’s hips is incorrect because this action alone is insufficient to relieve pressure on the umbilical cord. While positioning such as Trendelenburg or knee-chest may help reduce cord compression, the most immediate and effective intervention is manual elevation of the presenting part.

C. Applying internal upward pressure to the presenting part using two gloved fingers is correct because this action immediately relieves pressure on the prolapsed umbilical cord, restoring fetal blood flow and oxygenation. The nurse must maintain this pressure continuously until the patient is taken for emergency delivery, usually by cesarean section. This is the highest priority life-saving intervention.

D. Increasing the IV infusion rate to provide a fluid bolus is incorrect because fluids do not address the mechanical compression of the umbilical cord. Although IV fluids may be part of overall management, they do not correct the acute cause of fetal hypoxia in cord prolapse.

A. No venipuncture or blood pressure in left arm is incorrect because this precaution is typically used for clients with conditions such as mastectomy or lymphedema risk, not for Wilms’ tumor. There is no indication to restrict venipuncture or blood pressure measurements in a specific arm for this diagnosis.

B. Collect all urine is incorrect because, while monitoring urine output is important in children with renal conditions, this is not the priority safety warning for a child with suspected Wilms’ tumor. Collecting urine does not address the immediate risk associated with the tumor.

C. Contact precautions is incorrect because Wilms’ tumor is not an infectious condition. There is no risk of transmission, so isolation precautions are unnecessary.

D. Do not palpate abdomen is correct because Wilms’ tumor is a renal tumor that can rupture if manipulated. Palpating the abdomen can cause tumor rupture, hemorrhage, and dissemination of malignant cells, which worsens prognosis. Therefore, a clear warning sign should be placed to prevent abdominal palpation by staff or visitors.