an infant is born with a gastroschisis care preoperatively should include which priority intervention
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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. A school-age child with cancer is being prepared for a procedure. The child says, “I have had one of these before. They hurt.” The nurse bases her response on what knowledge related to pain in this patient?

Correct answer: D

Rationale: The correct answer is D. Pain is frequently reported by children with cancer, with around 84% experiencing it. Most children report moderate to severe pain, with about half finding it highly distressing. There is no evidence to suggest that children often misrepresent their pain experiences. Pain tolerance is not solely based on age but is a complex phenomenon. Children do not become accustomed to painful procedures, as each experience of pain is unique.

3. A parent of a school-age child tells the school nurse that the parents are going through a divorce. The child has not been doing well in school and sometimes has trouble sleeping. The nurse should recognize this as what?

Correct answer: B

Rationale: Poor academic performance and sleep disturbances are common reactions in children going through their parents' divorce, reflecting stress and adjustment challenges.

4. Which is described as an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid?

Correct answer: D

Rationale: A vesicle is an elevated, circumscribed lesion filled with serous fluid, typically less than 1 cm in diameter.

5. What do the clinical manifestations of minimal change nephrotic syndrome include?

Correct answer: D

Rationale: Minimal change nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, and edema due to the loss of protein in the urine. Hematuria, bacteriuria, and weight loss are not typical features of this condition.

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