A 6-week-old infant with poor weight gain 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.

Maintain 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

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: This is the correct answer because maintaining a continuous infusion of IV fluids per prescription is essential to prevent dehydration and electrolyte imbalance in the infant. The infant may have significant fluid loss due to vomiting and poor intake.

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.

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Correct Answer is C

Explanation

Choice A reason: Straining all urine is not a relevant instruction for the nurse to provide, as this is not related to prostatitis. This is a distractor choice.

Choice B reason: Maintaining contact isolation is not a necessary instruction for the nurse to provide, as prostatitis is not a contagious condition. This is another distractor choice.

Choice C reason: Avoiding urinary catheterization is an important instruction for the nurse to provide, as this can introduce bacteria into the urinary tract and worsen the infection. Therefore, this is the correct choice.

Choice D reason: Restricting oral fluid intake is not an appropriate instruction for the nurse to provide, as this can lead to dehydration and reduced urine output, which can increase the risk of urinary stasis and infection. This is another distractor choice.

A. Feed the infant every 4 hours. B. Perform diaper changes under the light. C. Reposition the infant every 2 hours. D. Cover with a receiving blanket.

Correct Answer is C

Explanation

Choice C reason: repositioning the infant every 2 hours can help expose different parts of the skin to the phototherapy light and increase the effectiveness of the treatment. The nurse should also check the skin for signs of irritation or burns.

Choice A reason: feeding the infant every 4 hours is not specific to home phototherapy. The infant may need more frequent feedings depending on their hunger cues and weight gain.

Choice B reason: performing diaper changes under the light is not necessary and may expose the infant's genitals to excessive light and heat. The nurse should advise the parents to cover the infant's eyes and genitals with protective shields during phototherapy.

Choice D reason: covering the infant with a receiving blanket can reduce the exposure of the skin to the phototherapy light and decrease the effectiveness of the treatment. The nurse should advise the parents to keep the infant unclothed or only in a diaper during phototherapy.

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A 6-week-old infant with poor weight gain is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is C

Explanation

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