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 A

Explanation

Choice A reason: This is the correct choice. An 8-year-old is typically capable of understanding and using PCA effectively, especially after a major surgery like spinal fusion.
Choice B reason: A 6-year-old may not fully understand how to use PCA and could be at risk for under or overdosing.
Choice C reason: While a 10-year-old could use PCA, the presence of a concussion may impair their ability to use it properly.
Choice D reason: A 16-year-old with Down Syndrome may have cognitive impairments that could hinder the safe use of PCA.

A. Explain body changes that will take place. B. Maintain the child’s normal routines. C. Allow the child to talk about the illness. D. Encourage friends to visit.

Correct Answer is B

Explanation

Choice A reason: While it is important to prepare the child for changes, maintaining normalcy is more immediately beneficial.
Choice B reason: This is the correct choice. Maintaining normal routines provides a sense of stability and normalcy, which is comforting during a stressful time.
Choice C reason: Allowing the child to talk about the illness is important, but it may not be as comforting as maintaining normal routines.
Choice D reason: Encouraging friends to visit can provide support, but it is not as impactful on daily comfort as maintaining normal routines.

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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

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