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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A 7-year-old child may have some difficulty with separation but is typically able to understand the reason for hospitalization better than younger children.
Choice B reason: A 5-month-old infant may show signs of distress but does not have the same understanding of separation as an older child.
Choice C reason: This is the correct choice. A 4-year-old child is at a developmental stage where separation from family can cause significant distress and difficulty.
Choice D reason: A 15-month-old toddler may experience separation anxiety, but it is generally more intense in preschool-aged children.
Correct Answer is B
Explanation
Choice A reason: Discussing the child's previous history of injury is important, but it does not address the immediate concern of pain management.
Choice B reason: Consulting with a practitioner to determine safe analgesia options is crucial for managing pain while also monitoring the child's variable consciousness levels.
Choice C reason: While it is true that analgesia can mask neurological symptoms, it is essential to manage pain effectively, and the healthcare team can monitor for changes in consciousness.
Choice D reason: Teaching the family about specific medications like benzodiazepines is not the most immediate concern and should be left to the practitioner's discretion based on the child's condition. Pain management and safety are the priorities.
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