A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature.
Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

The correct answer is Choice A.

Choice A rationale

Testing the urine for ketones is essential for managing type 1 diabetes, especially during illness. Ketones are produced when the body breaks down fat for energy due to insufficient insulin. High levels of ketones can lead to diabetic ketoacidosis, a serious condition that requires immediate medical attention.

Choice B rationale

While notifying the provider if blood glucose levels are over 350 mg/dL is important, it is not the most immediate action required during illness management. High blood glucose levels can indicate poor diabetes control, but ketone testing is more critical during illness to prevent ketoacidosis.

Choice C rationale

Withholding insulin when feeling nauseous is incorrect. Insulin should not be withheld during illness, as blood glucose levels can increase due to stress or infection. Continuing insulin administration is crucial to prevent hyperglycemia and ketoacidosis.

Choice D rationale

Limiting fluid intake during mealtime is not recommended. Proper hydration is essential for overall health and helps manage blood glucose levels. Fluids should be consumed as needed, especially during illness.

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.