A 6-week-old infant with poor weight gain is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?

Choice A: Measuring urine output daily is not a specific statement for the nurse to include, as this is a general recommendation for all clients with urinary catheters and does not address the potential complications of a suprapubic catheter. This is a distractor choice.

Choice B: Observing urine color and clarity is not a relevant statement for the nurse to include, as this does not reflect the condition of the suprapubic catheter or its insertion site. This is another distractor choice.

Choice C: Inspecting genital area for signs of infection is an important statement for the nurse to include, as this can help detect and prevent urinary tract infection, peritonitis, or abscess formation, which are common risks associated with suprapubic catheters. Therefore, this is the correct choice.

Choice D: Palpating flank area for tenderness is not a necessary statement for the nurse to include, as this is not an accurate or reliable method to assess for kidney function or damage, which are unlikely to occur with a suprapubic catheter. This is another distractor choice.

Choice B This situation could lead to conflict, but the client is not actively posing an immediate danger. The nurse should still intervene, but it is not the highest priority.

Choice A is incorrect because the client with anorexia nervosa who is refusing to eat the evening snack is not in immediate danger. The nurse should monitor the client's nutritional status and weight, but this can be done later.

Choice C iThe client with bipolar disorder who is pacing may be exhibiting signs of agitation, restlessness, or escalating mania, which can quickly lead to aggression, impulsivity, or loss of control. This behavior requires immediate attention to ensure safety for both the client and others on the unit. Manic or agitated patients may become unpredictable, making early intervention crucial.

Choice D is incorrect because the client with major depression who refuses to participate in group is not in immediate danger. The nurse should encourage the client to join the group, but this can be done later.