A child is admitted with a suspected diagnosis of Wilms tumor.
The nurse should place a sign with which of the following warnings over the child’s bed?

Do not palpate abdomen.

No venipuncture or blood pressure in left arm.

Collect all urine.

Contact precautions.

Answer and Explanation

The Correct Answer is A

The correct answer is Choice A.

Choice A rationale

Wilms tumor, also known as nephroblastoma, is a type of kidney cancer that primarily affects children. It is crucial not to palpate the abdomen of a child with a suspected Wilms tumor because this can cause the tumor to rupture and spread cancerous cells to other parts of the body.

Choice B rationale

This choice is incorrect because there is no specific restriction on venipuncture or blood pressure measurements in the left arm for children with Wilms tumor. This precaution is typically associated with conditions like lymphedema or after a mastectomy.

Choice C rationale

Collecting all urine is not a specific precaution for Wilms tumor. While monitoring urine output can be important in various conditions, it is not a primary concern for Wilms tumor.

Choice D rationale

Contact precautions are not necessary for Wilms tumor as it is not an infectious disease. Contact precautions are typically used for conditions that are contagious or spread through direct contact.

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Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale

Encouraging the parents to rock the infant provides comfort and emotional support, which is crucial for the infant’s recovery. Rocking can also help soothe the infant and promote bonding between the parents and the child.

Choice B rationale

Administering ibuprofen as needed for pain is not recommended for infants under 6 months of age due to the risk of adverse effects such as gastrointestinal bleeding and kidney damage.

Choice C rationale

Positioning the infant on her abdomen is contraindicated after cleft lip repair surgery as it can put pressure on the surgical site, potentially causing damage and increasing the risk of infection.

Choice D rationale

Offering the infant a pacifier is not advisable as sucking can put strain on the surgical site, potentially leading to complications and delaying the healing process.

A. BP 90/40 mm Hg, heart rate 135/min, respirations 32/min, and oral temperature of 38°C (100.4°F). B. BP 88/45 mm Hg, heart rate 113/min, respirations 28/min, and oral temperature 37.6°C (99.7°F). C. BP 85/50 mm Hg, heart rate 95/min, respirations 26/min, and axillary temperature of 36.7°C (98.1°F). D. BP 90/52 mm Hg, heart rate 120/min, respirations 28/min, and axillary temperature of 37.3°C (99.1°F). . .

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale

A blood pressure of 90/40 mm Hg, heart rate of 135/min, respirations of 32/min, and an oral temperature of 38°C (100.4°F) indicate potential signs of sepsis or another serious condition. The elevated heart rate and respiratory rate, along with the fever, suggest an infection that requires immediate medical attention.

Choice B rationale

While the vital signs in this option are slightly elevated, they are not as concerning as those in Choice A. The heart rate and respiratory rate are within acceptable ranges for a 2-year-old, and the temperature is only slightly elevated.

Choice C rationale

The vital signs in this option are within normal ranges for a 2-year-old child. There is no immediate cause for concern based on these vital signs.

Choice D rationale

The vital signs in this option are also within acceptable ranges for a 2-year-old child. While the heart rate is slightly elevated, it is not as concerning as the vital signs in Choice A. .

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A child is admitted with a suspected diagnosis of Wilms tumor.The nurse should place a sign with which of the following warnings over the child’s bed?

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A child is admitted with a suspected diagnosis of Wilms tumor.
The nurse should place a sign with which of the following warnings over the child’s bed?