A 6-week-old infant with poor weight gain is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?
Mark an outline of the "olive-shaped" mass in the right epigastric area.
Maintain a continuous infusion of IV fluids per prescription.
Monitor amount of intake and infant's response to feedings.
Instruct parents regarding care of the incisional area.
The Correct Answer is B
Choice A reason: Marking an outline of the "olive-shaped" mass in the right epigastric area is not a priority nursing action. The mass is caused by hypertrophy of the pyloric sphincter, which obstructs gastric emptying and causes projectile vomiting. The mass may not be palpable in all cases.
Choice C reason: Monitoring amount of intake and infant's response to feedings is important, but not the highest priority. The infant may have difficulty feeding due to nausea, vomiting, and abdominal pain.
Choice D reason: Instructing parents regarding care of the incisional area is a post-operative nursing action, not a pre-operative one. The parents will need to learn how to keep the incision clean and dry, monitor for signs of infection, and administer pain medication as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Creatinine is not a relevant laboratory test for the nurse to monitor, as this reflects renal function and is not affected by naproxen or arthritis. This is a distractor choice.
Choice B: Serum calcium is not a pertinent laboratory test for the nurse to monitor, as this indicates bone metabolism and is not related to naproxen or arthritis. This is another distractor choice.
Choice C: Erythrocyte sedimentation rate is not an important laboratory test for the nurse to monitor, as this measures inflammation and is not influenced by naproxen or stomach pain. This is another distractor choice.
Choice D: Hemoglobin is an essential laboratory test for the nurse to monitor, as this shows blood oxygen-carrying capacity and can be reduced by naproxen-induced gastrointestinal bleeding, which can cause stomach pain, weakness, and fatigue. Therefore, this is the correct choice.
Correct Answer is D
Explanation
Choice A: Mark an outline of the 'olive-shaped' mass in the right epigastric area. This is not a priority action, as it does not address the immediate needs of the infant. The 'olive-shaped' mass is a sign of pyloric stenosis, but it does not affect the infant's hydration or nutrition.
Choice B: Instruct parents regarding care of the incisional area. This is an important action, but not a priority before surgery. The parents need to know how to care for the incisional area after surgery, but this can be done later.
Choice C: Monitor amount of intake and infant's response to feedings. This is a relevant action, but not a priority before surgery. The infant with pyloric stenosis may have vomiting, dehydration, and electrolyte imbalance due to gastric outlet obstruction. Monitoring intake and output can help assess the severity of these problems, but it does not correct them.
Choice D: Initiate a continuous infusion of IV fluids per prescription. This is the priority action before surgery, as it can prevent or treat dehydration and electrolyte imbalance in the infant. IV fluids can also help maintain blood volume and perfusion during surgery.
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