The mother of a 4-year-old client tells the pediatric nurse that the child's abdomen seems to be swollen. During further assessment, the mother tells the nurse that their child is eating well and that their activity level is unchanged. The nurse, suspecting the possibility of Wilms tumor, should avoid which action during the physical assessment?
Monitoring the temperature for the presence of fever
Monitoring the blood pressure for the presence of hypertension
Assessing the urine for the presence of hematuria
Palpating the abdomen for a mass
The Correct Answer is D
A. Monitoring the temperature for fever is appropriate as part of a general assessment and could help identify signs of infection.
B. Monitoring blood pressure is important because hypertension can be associated with Wilms tumor.
C. Assessing the urine for hematuria is appropriate, as hematuria can be a symptom of Wilms tumor.
D. Palpating the abdomen is contraindicated in suspected Wilms tumor cases because it could cause the tumor to rupture, potentially spreading cancerous cells. Therefore, palpating the abdomen should be avoided until further diagnostic procedures are performed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A complete blood count is not specifically required before administering the rubella vaccine.
B. Lead screening is not related to rubella vaccination and is not required for this purpose.
C. The rubella vaccine is a live attenuated vaccine, and it is important to ensure that the patient is not pregnant because the vaccine could potentially harm the fetus. Therefore, a pregnancy test is a necessary precaution.
D. Tuberculosis screening is not related to the rubella vaccination and is not required for this purpose.
Correct Answer is D
Explanation
A. Dry mouth is expected postoperatively, especially if the child is not drinking adequate fluids, but it is not a sign of a complication.
B. Mild to moderate pain is expected after a tonsillectomy and should be managed with analgesics.
C. Dried flecks of blood in oral secretions can be normal immediately after surgery, but active bleeding would be concerning.
D. Frequent swallowing is a sign of possible postoperative bleeding, which is a serious complication that requires immediate evaluation and intervention.
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