The nurse is admitting a child with a Wilms tumor. Which is the initial assessment finding associated with this tumor?- Nurselytic

Question 1 of 5

The nurse is admitting a child with a Wilms tumor. Which is the initial assessment finding associated with this tumor?

A. Abdominal swelling B. Weight gain C. Hypotension D. Increased urinary output

Correct Answer: A

Rationale: Abdominal swelling is frequently the initial assessment finding associated with a Wilms tumor. This swelling is caused by the tumor's mass in the kidney, leading to abdominal distension. Weight gain (Choice B) is less likely as a primary finding, as it may occur later due to tumor growth or fluid retention. Hypotension (Choice C) is not typically associated with Wilms tumor unless severe complications like hemorrhage develop. Increased urinary output (Choice D) is not a common initial finding; instead, hematuria or other urinary changes may be observed later in the disease process.

Question 2 of 5

At 7 AM, a nurse receives the information that an adolescent with diabetes has a 6:30 AM fasting blood glucose level of 180 mg/dL. What is the priority nursing action at this time?

A. Encourage the adolescent to start exercising. B. Ask the adolescent to obtain an immediate glucometer reading. C. Inform the adolescent that a complex carbohydrate such as cheese should be eaten. D. Tell the adolescent that the prescribed dose of rapid acting insulin should be administered.

Correct Answer: D

Rationale: Rapid acting insulin will help lower the elevated blood glucose level quickly.

Question 3 of 5

When evaluating the laboratory report of a 1-year-old infant's hematocrit, a healthcare provider compares it with the expected hematocrit range for this age group. What is the hematocrit of a healthy 12-month-old infant?

A. 19% to 32% B. 29% to 41% C. 37% to 47% D. 42% to 69%

Correct Answer: C

Rationale: The correct hematocrit range for a healthy 12-month-old infant is between 37% to 47%. At this age, this range reflects the normal blood volume and red blood cell (RBC) levels in infants. Choice A (19% to 32%) is too low for a healthy hematocrit level in a 12-month-old. Choice B (29% to 41%) is also below the typical range for a 12-month-old. Choice D (42% to 69%) includes an upper limit that is higher than expected for a healthy infant, making it an incorrect option.

Question 4 of 5

What is a key assessment the nurse should perform for a 5-year-old child diagnosed with acute glomerulonephritis?

A. Monitor blood glucose levels B. Monitor respiratory rate C. Monitor urine output D. Monitor for signs of infection

Correct Answer: C

Rationale: Monitoring urine output is crucial in assessing kidney function in a child with acute glomerulonephritis. In this condition, there is inflammation in the glomeruli of the kidneys, affecting their ability to filter waste and excess fluids from the blood. Monitoring urine output helps evaluate the kidneys' ability to excrete waste and maintain fluid balance. Options A, B, and D are less relevant in the context of acute glomerulonephritis. Monitoring blood glucose levels is more pertinent in conditions like diabetes, monitoring respiratory rate is important for respiratory conditions, and monitoring for signs of infection is crucial in cases of suspected infections but is not the primary assessment focus in acute glomerulonephritis.

Question 5 of 5

At 0345, you receive a call for a woman in labor. Upon arriving at the scene, you are greeted by a very anxious man who tells you that his wife is having her baby 'now.' This man escorts you into the living room where a 25-year-old woman is lying on the couch in obvious pain. After determining that delivery is not imminent, you begin transport. While en route, the mother tells you that she feels the urge to push. You assess her and see the top of the baby's head bulging from the vagina. What is your most appropriate first action?

A. Allow the head to deliver and check for the location of the cord. B. Advise your partner to stop the ambulance and assist with the delivery. C. Tell the mother to take short, quick breaths until you arrive at the hospital. D. Prepare the mother for an emergency delivery and open the obstetrics kit.

Correct Answer: B

Rationale: In this scenario, the most appropriate first action is to advise your partner to stop the ambulance and assist with the delivery. When the baby's head is visible and delivery is imminent, it is crucial to provide immediate assistance to ensure the safety of both the mother and the baby. Allowing the head to deliver and checking for the location of the cord (Choice A) may delay necessary actions during an imminent delivery. Instructing the mother to take short, quick breaths (Choice C) is not suitable as active delivery is already in progress. Preparing the mother for an emergency delivery and opening the obstetrics kit (Choice D) is not the most immediate action needed when the baby's head is already visible and delivery is imminent.

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