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. A blood glucose level of 56 mg/dL indicates hypoglycemia, and the immediate priority is to raise the blood sugar level. Non-diet carbonated soda can provide a quick source of sugar.
Choice B reason: Documenting the reading is important but does not address the immediate need to correct the low blood sugar.
Choice C reason: While confirming the reading with a laboratory test is a good practice, it is not the first action to take when dealing with hypoglycemia.
Choice D reason: Administering insulin would be contraindicated as it would lower the blood sugar even further.

A. Adolescence B. Infant C. Preschool-age D. School-age

Correct Answer is C

Explanation

Choice A reason: Adolescents are capable of more complex thinking and are less likely to view illness as a punishment for misdeeds.

Choice B reason: Infants do not have the cognitive ability to associate illness with punishment.

Choice C reason: This is the correct choice. Preschool-age children often engage in magical thinking and may view illness as a punishment for misdeeds.

Choice D reason: School-age children are beginning to understand the biological causes of illness and are less likely to view it as a punishment.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse obtains a fingerstick blood glucose level using bedside lancet/glucose meter equipment from a client with a prescribed sliding scale insulin protocol. The meter indicates 56 mg/dL (3.12 mmol/L). At this time, which intervention should the nurse implement first?

Correct Answer is A

Explanation

When developing a plan of care for a hospitalized child, the nurse knows that children in which age group are most likely to view illness as a punishment for misdeeds?

Correct Answer is C

Explanation

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What notable sign most likely indicates increased intracranial pressure in an infant?

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