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: Observing insertion site is an essential assessment for a client who has a suprapubic catheter. The insertion site is located in the lower abdomen, where urine drains from an opening in the bladder through a catheter into a drainage bag. The nurse should inspect the site for signs of infection, inflammation, bleeding, or leakage. The nurse should also clean the site with soap and water and apply a sterile dressing as needed.

Choice B reason: Palpating flank area is not a relevant assessment for a client who has a suprapubic catheter. The flank area is located on the sides of the back, where the kidneys are located. Palpating the flank area can detect tenderness or pain that may indicate kidney infection or stones, but it does not provide information about the suprapubic catheter or its function.

Choice C reason: Measuring abdominal girth is not a relevant assessment for a client who has a suprapubic catheter. The abdominal girth is the circumference of the abdomen at the level of the umbilicus. Measuring abdominal girth can detect changes in fluid balance, ascites, or bowel obstruction, but it does not provide information about the suprapubic catheter or its function.

Choice D reason: Assessing perineal area is not a relevant assessment for a client who has a suprapubic catheter. The perineal area is located between the anus and the genitals. Assessing perineal area can detect signs of infection, irritation, or injury in the genital or anal regions, but it does not provide information about the suprapubic catheter or its function.

Choice A reason: Client’s healthcare power of attorney. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The healthcare power of attorney is a legal document that designates who can make medical decisions for the client if they are unable to do so themselves.

Choice B reason: Currently prescribed medications. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The currently prescribed medications are a part of the background information that can help explain the client’s medical history and potential causes of confusion.

Choice C reason: Fall at home as reason for admission. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The fall at home is a part of the background information that can help explain the client’s reason for admission and potential injuries.

Choice D reason: Increasing confusion of the client. This is the first information that the nurse should provide, as it addresses the current situation or problem of the client. The increasing confusion of the client is a part of the assessment information that can help identify the urgency and severity of the issue and guide further interventions.