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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Feeding the infant every 4 hours is not a specific instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. However, feeding the infant frequently is important to promote hydration and elimination of bilirubin through urine and stool.
Choice B reason: Performing diaper changes under the light is not a recommended instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. The nurse should instruct the parents to turn off the light and cover the infant's eyes with protective goggles or patches during diaper changes to prevent eye damage or irritation.
Choice D reason: Covering with a receiving blanket is not an appropriate instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. The nurse should instruct the parents to keep the infant unclothed except for a diaper and eye protection during phototherapy to maximize skin exposure to the light and increase its effectiveness.
Correct Answer is D
Explanation
Choice A: Mark an outline of the 'olive-shaped' mass in the right epigastric area. This is not a priority action, as it does not address the immediate needs of the infant. The 'olive-shaped' mass is a sign of pyloric stenosis, but it does not affect the infant's hydration or nutrition.
Choice B: Instruct parents regarding care of the incisional area. This is an important action, but not a priority before surgery. The parents need to know how to care for the incisional area after surgery, but this can be done later.
Choice C: Monitor amount of intake and infant's response to feedings. This is a relevant action, but not a priority before surgery. The infant with pyloric stenosis may have vomiting, dehydration, and electrolyte imbalance due to gastric outlet obstruction. Monitoring intake and output can help assess the severity of these problems, but it does not correct them.
Choice D: Initiate a continuous infusion of IV fluids per prescription. This is the priority action before surgery, as it can prevent or treat dehydration and electrolyte imbalance in the infant. IV fluids can also help maintain blood volume and perfusion during surgery.
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