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 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.
Correct Answer is C
Explanation
Choice A reason: Infrequent diaper changes can contribute to diaper rash, but the presence of satellite lesions suggests a yeast infection rather than a simple irritant rash.
Choice B reason: Impetigo, caused by staphylococcal or streptococcal bacteria, typically presents with honey-colored crusts and is not usually associated with satellite lesions.
Choice C reason: The description of bright red scaly plaques and satellite lesions is characteristic of a yeast infection, specifically caused by Candida albicans.
Choice D reason: While urine and feces can irritate the skin and cause diaper rash, the specific clinical findings mentioned point more towards a yeast infection.
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