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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Not crying if parents return and leave again may indicate the child has moved past the initial protest stage but does not necessarily indicate despair.
Choice B reason: This is the correct choice. Lying quietly in bed can be a sign of the despair stage, where the child has given up hope of the parents' return and appears withdrawn.
Choice C reason: Screaming and crying when parents leave is characteristic of the protest stage, not the despair stage.
Choice D reason: Appearing happy and content with staff may indicate the child has reached the detachment stage, which follows despair and involves the child forming new attachments.
Correct Answer is ["B","E"]
Explanation
Choice A reason: Tripod positioning is a more severe sign, indicating increased work of breathing.
Choice B reason: This is one of the correct choices. Nasal flaring is a mild symptom of respiratory distress, indicating increased effort to breathe.
Choice C reason: Confusion is a more severe symptom, suggesting hypoxia affecting brain function.
Choice D reason: Cyanosis is a severe sign of respiratory distress, indicating poor oxygenation.
Choice E reason: This is one of the correct choices. Tachypnea, or rapid breathing, is a mild symptom of respiratory distress.
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