an infant is born with a gastroschisis care preoperatively should include which priority intervention
Logo

Nursing Elites

ATI RN

ATI Nursing Care of Children 2019 B

1. An infant is born with a gastroschisis. Care preoperatively should include which priority intervention?

Correct answer: D

Rationale: The correct priority intervention for an infant with gastroschisis is to cover the exposed abdominal contents with a sterile bowel bag. This action helps protect the intestines from injury, contamination, and dehydration before surgical repair. Choice A, placing the infant in the prone position, is not appropriate as it does not address the immediate need to protect the exposed intestines. Choice B, sterile water feedings, and Choice C, monitoring serum laboratory electrolytes, are not the priority interventions for this condition. Sterile water feedings may not provide the necessary protection for the exposed intestines, and monitoring electrolytes, while important, is secondary to the immediate need for protection and hydration of the exposed abdominal contents.

2. The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother staying in the room or leaving. This action should be considered which?

Correct answer: A

Rationale: It is appropriate to give a 10-year-old the choice of having a parent present or not during an exam, respecting the child's growing need for privacy.

3. The clinic nurse is assessing a child with a heavy ascariasis lumbricoides (common roundworm) infection. Which assessment findings should the nurse expect?

Correct answer: D

Rationale: A heavy roundworm infection can cause anemia, anorexia, irritability, and an enlarged abdomen due to the worms’ effects on nutrient absorption and intestinal function.

4. What intervention is contraindicated in a suspected case of appendicitis?

Correct answer: A

Rationale: Enemas are contraindicated in cases of suspected appendicitis because they can increase the risk of perforation. The pressure from the enema can exacerbate inflammation and potentially lead to the rupture of the appendix. Palpating the abdomen gently is essential for diagnosing appendicitis, as it helps identify the characteristic signs like rebound tenderness. Antibiotics are commonly used to treat the infection associated with appendicitis, and antipyretics are administered to manage fever, which is a common symptom of the condition. Therefore, enemas are the intervention to avoid in suspected appendicitis cases.

5. When checking the intravenous (IV) site on a child, the nurse should take which action?

Correct answer: C

Rationale: Looking at and palpating the IV site helps assess for signs of infiltration or infection, such as swelling, redness, or pain. Simply looking or asking the child may miss subtle signs, and removing all the tape unnecessarily disrupts the site.

Similar Questions

A child is admitted for minimal change nephrotic syndrome (MCNS). The nurse recognizes that the child’s prognosis is related to what factor?
A 12-year-old child had an appendectomy 18 hours ago. The nurse is monitoring the child for pain control. Which of the following tools is most appropriate for assessing the child’s pain?
Which are included in the evaluation step of the nursing process? (Select all that apply.)
What is often the initial sign of acute rheumatic fever in children?
A foster parent is talking to the nurse about the health care needs for the child who has been placed in the parent's care. Which statement best describes the health care needs of foster children?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses