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: Fasciitis, inflammation of the fascia, could cause pain and possibly edema, but it typically does not cause fever.
Choice B reason: Compartment syndrome is a serious condition where increased pressure within the muscles can lead to muscle and nerve damage as well as problems with blood flow. Pain, edema, and fever could be signs of this condition, especially in a limb that is in traction.
Choice C reason: Osteochondrosis refers to a group of disorders that affect the growth of bones in children and adolescents. While it can cause pain, it does not typically cause edema or fever.
Choice D reason: Osteomyelitis, an infection in the bone, could cause pain, edema, and fever. However, the acute onset of symptoms in a limb under traction is more indicative of compartment syndrome. Osteomyelitis typically has a more gradual onset.
Correct Answer is C
Explanation
Choice A reason: Fever is a concern, but it is not the most immediate sign of dehydration.
Choice B reason: While loose stools are a symptom of diarrhea, the frequency mentioned does not necessarily indicate an emergency.
Choice C reason: This is the correct choice. Lack of a wet diaper for 8 hours can indicate dehydration, which is an emergency in infants.
Choice D reason: Longer naps may not be directly related to diarrhea and do not warrant immediate contact with a pediatrician.
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