An infant has been admitted to the Neonatal Intensive Care Unit (NICU) with congenital gastroschisis. Which intervention should the nurse perform first upon admission to the unit?

Place the infant flat and prone.

Wrap the infant in a warm blanket and allow the father to hold the infant briefly.

Cover the defect with warm, moist gauze and plastic.

Encourage breastfeeding to promote maternal bonding.

Answer and Explanation

The Correct Answer is C

Choice A reason: Placing the infant flat and prone is not the first priority in the care of an infant with gastroschisis.
Choice B reason: While providing warmth and promoting bonding are important, they are not the immediate priority upon admission for an infant with gastroschisis.
Choice C reason: This is the correct choice. The exposed abdominal organs in gastroschisis must be protected immediately to prevent heat and fluid loss and to reduce the risk of infection.
Choice D reason: Breastfeeding is important for bonding and nutrition but is not the first intervention for an infant with gastroschisis.

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Correct Answer is B

Explanation

Choice A reason: Developing friendships is important, but it is not as critical as walking in the early stages of a toddler's development.
Choice B reason: This is the correct choice. Walking is a significant developmental milestone for toddlers and is essential for their physical autonomy.
Choice C reason: Self-feeding is an important skill, but it typically develops after the child has learned to walk.
Choice D reason: Potty-training is a key milestone, but it usually occurs after the child has achieved the ability to walk.

A. Risk for Altered Tissue Perfusion B. Impaired Physical Mobility C. Risk for Altered Nutrition: Less than Body Requirements D. Risk for Fluid Imbalance

Correct Answer is A

Explanation

Choice A reason: A third-degree circumferential burn can compromise blood flow, posing an immediate risk for altered tissue perfusion, which can lead to tissue necrosis and limb loss.

Choice B reason: While impaired physical mobility is a concern, it is not as immediately life-threatening as altered tissue perfusion.

Choice C reason: Nutritional needs are important for healing, but the immediate threat to life from a third-degree burn is the risk for altered tissue perfusion.

Choice D reason: Fluid imbalance is a significant concern due to the potential for burn-induced edema and dehydration; however, the most immediate life-threatening issue is altered tissue perfusion.

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An infant has been admitted to the Neonatal Intensive Care Unit (NICU) with congenital gastroschisis. Which intervention should the nurse perform first upon admission to the unit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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