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: This is the correct choice. Hard candy can help relieve the sensation of thirst without causing fluid overload.
Choice B reason: Measuring capillary glucose is not directly related to managing thirst in SIADH.
Choice C reason: Withholding diuretics without medical advice could be harmful and is not related to managing thirst.
Choice D reason: Providing additional oral fluids may exacerbate fluid retention in SIADH and is not recommended.
Correct Answer is C
Explanation
Choice A reason: Applying a warm, moist pack is not the most appropriate action as it may increase swelling and does not address the underlying cause of the edema.
Choice B reason: While it is important to report significant changes to the healthcare provider, mild edema post-surgery can be expected and managed with elevation.
Choice C reason: Elevating the legs on pillows can help reduce edema by promoting venous return and decreasing swelling.
Choice D reason: Encouraging movement of the toes is beneficial for circulation and preventing stiffness, but it is not the primary intervention for edema. Elevation is more effective in this scenario.
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