A nurse is caring for a toddler whose parent states while bathing the child she noticed a mass in his abdominal area and that his urine is a pink color. Which of the following actions is the nurse's priority?
Determine if the child is having pain.
Obtain a urine specimen for a urinalysis.
Instruct the parent to avoid pressing on the abdominal area.
Schedule the child for an abdominal ultrasound.
The Correct Answer is C
A. While assessing for pain is important, it is not the priority in this situation. The presence of pink- colored urine and a palpable mass in the abdominal area are more concerning findings that warrant immediate investigation.
B. 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.
C. 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.
D. The decision to schedule additional diagnostic tests, such as an abdominal ultrasound, can be made based on the results of the urinalysis and further clinical assessment.
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Related Questions
Correct Answer is D
Explanation
A. Most schools have policies allowing children to return to school once they have been treated for head lice, even if nits are still present. Complete nit removal can be challenging, and some nits may remain after treatment.
B. Treating all family members is indeed a recommended practice to prevent the spread of head lice within the household. However, this statement alone does not encompass all aspects of managing pediculosis capitis.
C. Throwing out toys that cannot be dry cleaned or washed is unnecessary and wasteful. The focus should be on thoroughly cleaning and treating the affected person's personal items and surroundings.
D. Washing recently used clothing, bedding, and towels in hot water is an important measure to eliminate head lice and their eggs (nits) from the environment. Hot water helps kill lice and their eggs effectively. This action is a crucial part of the treatment and prevention strategy for pediculosis capitis.
Correct Answer is A
Explanation
The practice as it helps prevent the backflow of stomach contents into the esophagus, which is beneficial for infants with gastroesophageal reflux.
B. This statement does not necessarily indicate an understanding of the teaching. Breast milk or formula can be used for infants with reflux; however, some formulas are designed to be easier to digest or less likely to cause reflux.
C. This is not generally recommended for infants with reflux. The safest position for all infants, including those with reflux, is on their back to reduce the risk of sudden infant death syndrome (SIDS).
D. This may be recommended in some cases to help reduce the symptoms of reflux. However, it's important to do this under the guidance of a healthcare provider to ensure it's done safely and appropriately. Thickening formula should be done with caution as it can increase the risk of choking.
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