A nurse is caring for a 6-month-old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which of the following fluids should the nurse select for the infant?

The correct answer is: B

Choice A reason: Determining if the child is having pain is important, but it is not the immediate priority. Pain assessment will help in managing the child’s comfort and can provide additional information about the condition. However, in the case of Wilms tumor, which is a common kidney cancer in children, the priority is to prevent any action that could potentially cause tumor spillage or spread.

Choice B reason: 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.

Choice C reason: Scheduling the child for an abdominal ultrasound is a necessary diagnostic step, but it is not the immediate priority. The ultrasound will help in assessing the size and extent of the tumor, but the first action should be to ensure that the tumor is not disturbed.

Choice D reason: 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.

Choice A reason: 60 beats per minute is too low for an infant's apical heart rate. The normal range for a 6-month-old infant is 100 to 160 beats per minute. A low heart rate can indicate digoxin toxicity, which can cause serious complications such as bradycardia, arrhythmias, and cardiac arrest.

Choice B reason: 80 beats per minute is also too low for an infant's apical heart rate. The normal range for a 6-month-old infant is 100 to 160 beats per minute. A low heart rate can indicate digoxin toxicity, which can cause serious complications such as bradycardia, arrhythmias, and cardiac arrest.

Choice C reason: 100 beats per minute is the lower limit of the normal range for a 6-month-old infant's apical heart rate. The nurse should withhold the dose of digoxin if the infant's apical heart rate is less than 100 beats per minute, as this can indicate digoxin toxicity, which can cause serious complications such as bradycardia, arrhythmias, and cardiac arrest.

Choice D reason: 120 beats per minute is within the normal range for a 6-month-old infant's apical heart rate. The nurse does not need to withhold the dose of digoxin if the infant's apical heart rate is 120 beats per minute, as this does not indicate digoxin toxicity. However, the nurse should still monitor the infant's heart rate, blood pressure, and digoxin level closely, as digoxin has a narrow therapeutic window and can cause adverse effects even at therapeutic doses.