A nurse is providing care to an infant who has tetralogy of Fallot. The infant's caregiver reports increased irritability and a bluish discoloration of the infant's oral mucous membranes. Which of the following interventions is the nurse's priority?

Rationale:

A. Witness the signature for informed consent for surgery is incorrect because while informed consent is a necessary legal and ethical step before a cesarean section, it does not address the immediate threat to maternal safety. In this case, the client is actively bleeding and showing early signs of hypovolemia (tachycardia and low-normal blood pressure). The priority is to stabilize the client physiologically before procedural steps like signing consent.

B. Initiate IV access is correct because the client is exhibiting signs of hypovolemic compromise, including tachycardia and hypotension, which are early indicators of blood loss. The scenario is consistent with placenta previa, a condition where the placenta covers the cervical os, causing painless bright red vaginal bleeding. Rapid fluid resuscitation via large-bore IV access is critical to maintain maternal perfusion, prevent shock, and prepare for possible blood transfusion. Establishing IV access is the first-line, priority intervention according to the ABC (Airway, Breathing, Circulation) principle, since maternal circulation directly affects fetal oxygenation.

C. Insert an indwelling urinary catheter is incorrect as the first action because while a catheter may be needed to monitor urine output during resuscitation or surgery, it does not immediately stabilize maternal circulation. Catheterization is secondary to initiating IV fluids to manage blood loss.

D. Prepare the abdominal and perineal areas is incorrect because surgical preparation is important for emergent cesarean delivery, but it is not the initial priority. The client’s hemodynamic stability must be addressed first to reduce maternal and fetal risk during surgery.

Rationale:

A. Plan to administer a plain water enema and maintain contact precautions is incorrect because pyloric stenosis is not an infectious condition and does not require contact precautions. Enemas, especially plain water enemas, are contraindicated in infants due to the risk of causing severe electrolyte imbalance and water intoxication. This intervention does not address the underlying problem of vomiting and dehydration.

B. Monitor the infant for dehydration and electrolyte imbalance is correct because infants with pyloric stenosis experience projectile, non-bilious vomiting, which leads to significant loss of fluids and gastric electrolytes. This commonly causes metabolic alkalosis, hyponatremia, and hypokalemia. The infant in the scenario already shows signs of dehydration, including dry mucous membranes and a depressed anterior fontanel, making fluid and electrolyte monitoring the top priority. Restoring hydration and correcting electrolyte disturbances are essential before any surgical intervention (pyloromyotomy).

C. Measure the infant's head circumference and weigh the infant is incorrect because although weight monitoring is part of routine assessment, head circumference measurement is not a priority in the context of acute dehydration from pyloric stenosis. The immediate concern is stabilizing fluid and electrolyte status.

D. Offer the infant small, frequent feedings of thickened liquids is incorrect because infants with pyloric stenosis are typically NPO until after surgical correction. Continuing oral feedings would worsen vomiting and further dehydrate the infant. Feeding modifications are not an appropriate intervention at this stage.