A nurse is assessing a client who has preeclampsia with severe features and is receiving intravenous magnesium sulfate. The nurse notes a respiratory rate of 8/min with absent deep tendon reflexes.
Which of the following actions is the nurse's priority?

Choice A rationale

Biopsy of the tumor is the definitive diagnostic procedure for Wilms tumor. This involves the surgical removal of a tissue sample from the suspected mass, which is then examined microscopically by a pathologist. Histopathological analysis confirms the presence of malignant cells characteristic of nephroblastoma, differentiating it from other renal masses and guiding subsequent treatment protocols. Normal renal tissue structure is preserved in healthy kidneys.

Choice B rationale

Bone marrow aspiration is primarily used to diagnose hematological malignancies or assess for metastatic disease in certain cancers. While Wilms tumor can metastasize, particularly to the lungs, bone marrow involvement is uncommon and not the primary diagnostic method for confirming the initial diagnosis of the tumor itself. Normal bone marrow contains hematopoietic stem cells and a balanced cellularity.

Choice C rationale

A CT scan of the abdomen and chest provides detailed anatomical information about the tumor's size, location, and extent of involvement within the kidney and surrounding structures, as well as checking for metastasis to the lungs. While crucial for staging and surgical planning, a CT scan is an imaging modality and does not provide a definitive tissue diagnosis. Normal abdominal organs appear with distinct densities.

Choice D rationale

Abdominal ultrasonography is often the initial imaging modality used to evaluate a suspected abdominal mass in children due to its non-invasive nature and lack of radiation exposure. It can identify the presence of a renal mass and distinguish between solid and cystic lesions, but like CT, it cannot definitively diagnose Wilms tumor without tissue sampling. Normal kidneys appear as solid, homogeneous organs.

Choice A rationale

Applying wrist and leg restraints significantly restricts a client's movement and can exacerbate confusion and agitation, potentially leading to increased injury risk and psychological distress. This intervention can also impair circulation and skin integrity if not meticulously monitored, and should only be used as a last resort when less restrictive measures have failed. Normal physiological response to restraint includes increased anxiety.

Choice B rationale

Administering medication to sedate a client might reduce restlessness temporarily but could also deepen confusion, increase the risk of falls, and mask underlying medical issues causing the change in mental status. Pharmacological interventions should be carefully considered, with the lowest effective dose, and after a thorough assessment of the cause of the altered mental state. Normal sedation levels aim for calm without excessive drowsiness.

Choice C rationale

While involving family can be supportive, expecting them to stay with the client constantly in a hospital setting may not always be feasible or sustainable. Although family presence can provide comfort and reorientation, it does not directly address the immediate environmental safety needs of a confused and restless client in a hospital. Normal family roles are supportive.

Choice D rationale

Moving the client to a room closer to the nurses' station allows for more frequent and direct observation by nursing staff. This increased proximity enables prompt intervention if the client attempts to get out of bed, falls, or exhibits further changes in mental status, enhancing safety without resorting to restrictive measures. Normal nursing practice prioritizes close monitoring for at-risk clients.