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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Assessing DTRs when the client has ankle edema is important, but it is not the most critical time. Ankle edema can be a common occurrence in pregnancy due to increased fluid volume and changes in blood flow.

B. Elevated blood pressure in a pregnant client can be a sign of preeclampsia, a serious condition that can lead to complications for both the mother and the baby. Assessing DTRs can help in
detecting hyperreflexia, which is a sign of preeclampsia. Therefore, it is most important to assess DTRs when there is an elevated blood pressure.

C. While assessing DTRs during admission to labor and delivery is a standard procedure to monitor the client's neurological status, it is not as critical as assessing them when there is an elevated blood pressure.

D. Assessing DTRs within the first trimester of pregnancy is not typically a priority unless there are specific clinical indications or concerns. Elevated blood pressure is a more immediate
concern that requires prompt assessment of DTRs

A. Determine if the mother has recently experienced a fall. B. Review the client's current food and medication allergies. C. Encourage increased intake of high protein foods. D. Instruct the daughter to check her mother's temperature. E. Ask if the mother is experiencing any pain with

Correct Answer is ["A","B","D","E"]

Explanation

A. Confusion can be a sign of a concussion or other injury resulting from a fall, which is a common risk for individuals with Parkinson's disease.
B. Reviewing the client's current food and medication allergies is important as allergies can contribute to confusion if the client is exposed to an allergen.
C. Encouraging increased intake of high protein foods is generally recommended for individuals with Parkinson's disease, but it is not directly related to the acute onset of confusion.
D. Checking the mother's temperature is a direct action to assess for infection, which can be a cause of acute confusion, especially in older adults.
E. Pain with urination could indicate a urinary tract infection, which is another common cause of confusion in the elderly. It is important to assess for this possibility.

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A6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy, Which pre- operative nursing action has highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

Correct Answer is B

Explanation

The daughter of an older woman who has Parkinson's disease, calls the clinic and reports that her mother has been confused for the past week. Which action(s) should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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