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 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.

Choice A: Think about reasons the episodes occur. This is not the best instruction, as it may increase the anxiety level of the client. Thinking about reasons may trigger negative thoughts, emotions, or memories that can worsen the anxiety. The nurse should teach the client to focus on coping skills rather than causes.

Choice B: Center attention on positive upbeat music. This is not the best instruction, as it may not be effective for all clients. Listening to positive upbeat music may help distract or soothe some clients, but it may also irritate or annoy others. The nurse should teach the client to choose music that matches their mood and preference.

Choice C: Practice using muscle relaxation techniques. This is the best instruction, as it can reduce the physical symptoms of anxiety. Muscle relaxation techniques involve tensing and relaxing different muscle groups in a systematic way, which can lower blood pressure, heart rate, and breathing rate. The nurse should teach the client how to perform muscle relaxation techniques and practice them regularly.

Choice D: Find outlets for more social interaction. This is not the best instruction, as it may not be feasible or helpful for all clients. Finding outlets for more social interaction may help some clients feel supported or connected, but it may also stress or overwhelm others. The nurse should teach the client to seek social support that is appropriate and comfortable for them.