A baby is born with bladder exstrophy. Immediate care for this infant will include which intervention?
1. Measuring intake and output
2. Inserting a Foley catheter
3. Covering the defect with sterile plastic wrap
4. Palpating the bladder mass to ensure urine is expelled
3
Rationale 1: Because the bladder constantly drains onto the skin of the abdomen, measuring output is not possible.
Rationale 2: The bladder is open to the abdomen. A Foley catheter cannot be inserted.
Rationale 3: This reduces the contamination of the bladder, which should be sterile.
Rationale 4: The bladder is very sensitive and palpation would cause unnecessary pain.
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