A 6-week-old infant with pyloric stenosis 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.
Instruct parents regarding care of the incisional area.
Monitor amount of intake and infant's response to feedings.
Initiate a continuous infusion of IV fluids per prescription.
The Correct Answer is D
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 B 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.
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: This is the correct answer because initiating a continuous infusion of IV fluids per prescription is essential to prevent dehydration and electrolyte imbalance in the infant. The infant may have significant fluid loss due to vomiting and poor intake.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect because 18% is the percentage of body surface area for the entire anterior trunk, not just the lower extremities.
Choice B reason: This is incorrect because 45% is the percentage of body surface area for the entire anterior and posterior trunk, plus the head and neck, not just the lower extremities.
Choice C reason: This is correct because 9% is the percentage of body surface area for the anterior surfaces of both lower extremities, according to the rule of nines.
Choice D reason: This is incorrect because 36% is the percentage of body surface area for the entire anterior and posterior surfaces of both lower extremities, not just the anterior surfaces.
Correct Answer is C
Explanation
Choice C reason: repositioning the infant every 2 hours can help expose different parts of the skin to the phototherapy light and increase the effectiveness of the treatment. The nurse should also check the skin for signs of irritation or burns.
Choice A reason: feeding the infant every 4 hours is not specific to home phototherapy. The infant may need more frequent feedings depending on their hunger cues and weight gain.
Choice B reason: performing diaper changes under the light is not necessary and may expose the infant's genitals to excessive light and heat. The nurse should advise the parents to cover the infant's eyes and genitals with protective shields during phototherapy.
Choice D reason: covering the infant with a receiving blanket can reduce the exposure of the skin to the phototherapy light and decrease the effectiveness of the treatment. The nurse should advise the parents to keep the infant unclothed or only in a diaper during phototherapy.
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