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.
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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Related Questions
Correct Answer is A
Explanation
A. Obtain a blood pressure reading before the client gets out of beD This intervention is important because the client is prescribed medications that may affect blood pressure, such as antidepressants and sedatives. Monitoring blood pressure before changes in position can help prevent orthostatic hypotension and related complications.
B. Measure and record the client's urinary output every day: While monitoring urinary output is important for overall assessment, it may not be the most immediate concern given the client's recent surgery and medication regimen.
C. Provide the client with teaching regarding a cardiac diet: While education on a cardiac diet is important for cardiovascular health, addressing immediate concerns related to medication effects and post-surgical recovery takes priority.
D. Obtain the client's vital signs every 4 hours when awake: While vital sign monitoring is essential, the timing of every 4 hours may not be necessary during sleep, and obtaining blood pressure readings before changes in position is more critical to prevent adverse events.
Correct Answer is B
Explanation
A. Explaining that the dosage has been changed is not appropriate without verifying the correct dosage first.
B. Withholding the medication until the dosage can be confirmed is the safest approach to prevent potential medication errors.
C. Informing the client that he may refuse the medication is an option, but it does not address the potential discrepancy in dosage.
D. Telling him to take the medication and then verifying the dosage at the next healthcare team meeting could result in a medication error and is not a safe practice
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