The nurse is caring for an infant recovering from surgery for pyloric stenosis. Which nursing diagnosis should the nurse use to guide care during the immediate postoperative period?
A) Anxiety related to new feeding method used postoperatively
B) Ineffective tissue perfusion related to pressure on heart chambers
C) Excess fluid volume related to increased fluid intake prescribed postoperatively
D) Risk for infection of incision line, related to disruption of skin barrier during surgery
D
Feedback:
Because the incision line for a pyloric stenosis repair is near the diaper area, the child is at risk for developing a surgical infection. The diagnosis risk for infection of incision line is the most appropriate during the immediate postoperative period. Anxiety might be appropriate after the immediate postoperative period has passed. There is no enough information to determine if the infant is being given excessive fluid or if the infant is experiencing ineffective tissue perfusion.
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