Author Question: An infant is born with an encephalocele. Which action by the nurse takes priority? A. Admit the ... (Read 71 times)

penguins · **on:** Jun 28, 2018

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.

Question 2

A postterm newborn is being treated for persistent pulmonary hypertension. Which assessment finding best indicates that a priority outcome has been met?

A.
Blood pressure in normal range for age
B.
Maintains temperature
C.
Oxygen saturation 95
D.
Weight gain

pami445 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

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.

Answer to Question 2

ANS: C
A priority outcome for this patient is maintenance of oxygen saturation in the normal range. The other assessment findings are good but do not relate to the primary outcome.