A6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy, Which pre- operative nursing action has highest priority?

Mark an outline of the "olive-shaped mass in the right epigastric area

Initiate 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.

Answer and Explanation

The Correct Answer is B

A. Marking an outline of the "olive-shaped mass" in the right epigastric area is important for diagnosis, but not a priority pre-operatively.
B. Initiating a continuous infusion of IV fluids is crucial to ensure the infant is properly hydrated before the procedure, as pyloric stenosis can cause severe dehydration.
C. Monitoring the amount of intake and the infant's response to feedings is part of ongoing care, but immediate pre-operative hydration takes precedence.
D. Instructing parents regarding care of the incisional area is necessary post-operatively, not before the surgery.

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Correct Answer is A

Explanation

A. Reinforce the need for adequate hydration: Adequate hydration is essential for liquefying secretions in the lungs, especially in clients with COPD who may have increased mucus production. Proper hydration also supports cardiovascular function, particularly in clients with peripheral vascular disease.

B. Provide typed instructions for healthy diet selections: While diet is important for overall health, hydration is the priority in this scenario due to the client's respiratory and vascular conditions.

C. Explain a daily regimen: While educating the client about a daily regimen is important, ensuring adequate hydration takes precedence in this situation.

D. Demonstrate specific strengthening exercises: While exercise is beneficial for clients with COPD and PVD, ensuring proper hydration is more critical for respiratory and cardiovascular function in this scenario.

A. Obtain a capillary glucose level. B. Feed 30 mL of 10% dextrose in water. C. Wrap tightly in a warm blanket. D. Encourage the mother to breastfeed.

Correct Answer is A

Explanation

A. Obtain a capillary glucose level: The symptoms of jitteriness and tachypnea in a newborn could be indicative of hypoglycemia, so the first action should be to assess the glucose level to determine if hypoglycemia is the cause.

B. Feed 30 mL of 10% dextrose in water: While providing dextrose may be necessary if hypoglycemia is confirmed, assessing the glucose level should be done first to guide appropriate treatment.

C. Wrap tightly in a warm blanket: While keeping the newborn warm is important, it is not the first action to take in this scenario where the newborn is displaying signs of possible hypoglycemia.

D. Encourage the mother to breastfeeD Breastfeeding may help increase the newborn's glucose level, but the priority is to assess the glucose level first to determine if hypoglycemia is present.

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A6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy, Which pre- operative nursing action has highest priority?

Nursing Test Bank

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