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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Pyloric stenosis is characterized by the narrowing of the pylorus, the opening between the stomach and the small intestine. This narrowing obstructs the passage of food from the stomach to the small intestine, leading to symptoms such as projectile vomiting.
A. Red currant jelly stools are typically associated with intussusception - telescoping of one segment of the intestine into another.
C. Distended neck veins are not typically associated with pyloric stenosis. Distended neck veins may occur in conditions such as heart failure or superior vena cava obstruction.
D. Ridged abdomen: Pyloric stenosis may lead to a palpable olive-shaped mass in the right upper quadrant of the abdomen, but a ridged abdomen is not a typical finding.
Correct Answer is A
Explanation
A. Furrowed brow is a common sign of discomfort or pain in infants. When babies experience pain, they may frown or have a wrinkled forehead.
B. Infants may have wide-open eyes when they are in pain, as a response to the stress of the discomfort.
C. Decreased muscle tone is not be a direct indicator of pain. Sometimes, in response to pain, an infant's body might become limp due to exhaustion or as a protective response.
D. Dry palms and feet are not typically associated with pain. Dryness of the skin in infants can be related to various factors, including environmental conditions and hydration levels. However, it is not a recognized sign of pain.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.