An infant is born with an encephalocele. Which action by the nurse takes priority?
A.
Admit the baby to the NICU.
B.
Consult the palliative care team.
C.
Place warm sterile gauze on the defect.
D.
Prepare the infant for surgery.
ANS: C
The priority action is to place sterile gauze over the open defect to prevent infection. The infant will need surgery and admission to the NICU, but the first action to take is to protect the baby's safety. The mortality rate is fairly high, but the first choice would not be to consult the palliative care team, as surgery is usually attempted to repair the defect.
You might also like to view...
The nurse identifies which anticipated outcomes of using a continuous passive motion mechanical device on the postoperative client?
Select all that apply. 1. The client experiences decreased edema in the joint. 2. The client does not accumulate blood in the joint. 3. The client experiences decreased pain in the joint. 4. The client has no or reduced scar tissue formation in the joint. 5. The client is able to get out of bed quickly after surgery.
When examining the client's external ear, a nurse palpates painless nodules on the pinna. The nurse should inquire about history of which of the following?
A. An old injury to the external ear B. Gout, sun or chemical exposure, arthritis C. Superficial infections of the outer ear D. Considered to be a normal variant of aging
Which intervention by the nurse is most therapeutic when a patient loses a pool game on the unit and begins acting aggressively?
a. Having the other unit staff present to demonstrate both a unified presence as well as a show of force b. Saying to the patient, "Accompany me to your room so we can talk about what triggered your anger.". c. Stating, "The rules here are for everyone. If you cannot control your temper, you may need to leave the dayroom.". d. Setting limits on the behavior immediately, in front of other patients, to help communicate that the unit rules apply to everyone
Inhalant abuse is usually a problem among children and ___________.
Fill in the blank(s) with the appropriate word(s).