An infant who has a Wilms' tumor is admitted for surgery. Which intervention should the nurse implement during the preoperative period?

Administer pain medication based on the FACES pain scale.

Include the prone position in the every 2 hour turning schedule,

Careful bathing and handling that avoids abdominal manipulation.

Give antiemetic medications to prevent nausea and vomiting.

Answer and Explanation

The Correct Answer is C

A. Administering pain medication based on the FACES pain scale is not the most relevant intervention in the preoperative period for a Wilms' tumor. Pain management may be addressed postoperatively, as needed.

B. Including the prone position in the every 2-hour turning schedule may not be the most appropriate intervention, as it may not be suitable for an infant with a Wilms' tumor, considering the location and potential size of the tumor.

C. Careful bathing and handling that avoids abdominal manipulation.

Wilms' tumor, also known as nephroblastoma, is a pediatric kidney cancer. Prior to surgery, it's crucial to handle the infant with care and avoid any abdominal manipulation to prevent any further complications or disruption to the tumor. This involves gentle handling and avoiding activities that may put pressure on the tumor or cause discomfort to the infant.

D. Giving antiemetic medications to prevent nausea and vomiting is a potential intervention, but it may be more relevant in the postoperative period, and its necessity would depend on the infant's individual condition and the surgical plan.

The priority during the preoperative period for an infant with a Wilms' tumor is to handle the infant carefully and avoid any actions that could exacerbate the condition or cause discomfort. The specific surgical plan and other preoperative preparations would be determined by the healthcare provider.

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Correct Answer is D

Explanation

Correct answer: D

A.This can be a good distraction technique, but it might not directly facilitate the lung sound assessment.

B.This activity might help engage the child but could make it difficult for the nurse to listen to breath sounds accurately.

C.Holding a toy might keep the child occupied but does not directly relate to the assessment process and might not ensure cooperation as effectively as using a stethoscope on a stuffed animal.

D.Allowing the child to use the stethoscope on a stuffed animal can help reduce fear and anxiety by making the procedure more familiar and less intimidating. It engages the child in a playful and interactive manner, helping to build trust and cooperation.

A. Assess for teeth clenching or grinding. B. Inspect the posterior oropharynx. C. Ask the child to speak to evaluate change in voice tone. D. Touch the tonsillar pillars to stimulate the gag reflex.

Correct Answer is B

Explanation

A. Assessing for teeth clenching or grinding is not the most appropriate assessment in this situation. While teeth clenching or grinding may indicate discomfort or anxiety, it may not directly address the specific concern of post-operative bleeding after a tonsillectomy.

B Inspect the posterior oropharynx.

Observing a child who has had a tonsillectomy frequently swallowing may raise concerns about post-operative bleeding. Inspecting the posterior oropharynx is essential to assess for any signs of bleeding, such as fresh blood or bleeding sites.

C. Asking the child to speak to evaluate a change in voice tone is not the primary assessment needed in this scenario. The primary concern is to assess for any signs of bleeding, and this can be done by inspecting the posterior oropharynx.

D. Touching the tonsillar pillars to stimulate the gag reflex is not necessary and may not be well-tolerated by the child who has had a tonsillectomy. It's also not the primary assessment to address the concern of post-operative bleeding.

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An infant who has a Wilms' tumor is admitted for surgery. Which intervention should the nurse implement during the preoperative period?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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