A nurse is caring for a newborn with gastroschisis. Which nursing intervention should be the priority immediately after birth?
1Cover the exposed bowel with warm, moist sterile saline gauze and plastic wrap✓ 정답
2Place the infant in a supine position to prevent further bowel protrusion
3Begin immediate oral feeding to prevent hypoglycemia
4Administer prophylactic antibiotics to prevent infection
해설
The priority is to cover the exposed bowel with warm, moist sterile saline gauze and plastic wrap to prevent drying, heat loss, and contamination. Other options are less critical or contraindicated in the immediate postpartum period.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention for a newborn with gastroschisis. Gastroschisis is a congenital defect where the infant's intestines (and sometimes other organs) protrude through a hole in the abdominal wall, usually to the right of the umbilicus. The exposed bowel is not covered by a protective sac (unlike omphalocele), making it extremely vulnerable to Key Point!fluid loss, heat loss, and infection. The immediate priority is to protect this exposed viscera.
Answer Rationale: The correct answer is ① Cover the exposed bowel with warm, moist sterile saline gauze and plastic wrap. This intervention directly addresses the ABCs (Airway, Breathing, Circulation) of neonatal resuscitation and stabilization in this specific context. The warm, moist saline prevents the bowel from drying out and becoming necrotic. The plastic wrap (or a sterile bowel bag) placed over the moist gauze creates a barrier that minimizes evaporative heat and fluid loss, which are massive risks for the newborn. This is the standard, evidence-based first step before any other care or transport.
Distractor Analysis:
Watch out for confusion!② Place the infant in a supine position is incorrect and potentially harmful. Placing the infant supine can increase tension on the mesentery (the tissue that holds the bowel in place) and potentially compromise blood flow to the exposed intestines. The correct position is on the right side or with the bowel supported to prevent torsion or kinking.
③ Begin immediate oral feeding is contraindicated. The infant with gastroschisis will have a nasogastric (NG) or orogastric (OG) tube inserted to decompress the stomach and prevent vomiting and aspiration. Oral feeds are withheld until after surgical repair and the return of bowel function.
④ Administer prophylactic antibiotics is an important intervention but is not the immediate priority. While infection prevention is critical, the first action is always to protect the exposed organ system from the immediate physical threats of drying and hypothermia. Antibiotics would be administered after initial stabilization.
Related Concepts: It is crucial to differentiate gastroschisis from omphalocele. Omphalocele involves herniation covered by a peritoneal sac, which offers some protection. Gastroschisis has no sac, making the bowel directly exposed to amniotic fluid in utero and the environment after birth, leading to a thickened, inflamed appearance. The nursing priorities, while similar, emphasize even more urgent protection for gastroschisis.
Concept Summary
Condition
Definition
Key Feature
Immediate Nursing Priority
Gastroschisis
Bowel protrusion through a paraumbilical defect (usually right).
No protective sac. Exposed, matted, inflamed bowel.
Cover with warm, moist sterile saline gauze + plastic wrap to prevent heat/fluid loss.
Omphalocele
Abdominal contents herniate into the base of the umbilical cord.
Covered by a peritoneal sac. May contain liver.
Cover sac with warm, moist sterile dressings. Handle gently to prevent rupture.
Side-by-Side Comparison!
Feature
Gastroschisis
Omphalocele
Sac
Absent
Present (peritoneum + amnion)
Location
Usually to the right of the umbilicus
At the base of the umbilical cord
Contents
Usually intestines only (no liver)
Often includes liver and intestines
Associated Anomalies
Less common (mainly intestinal atresia)
Very common (e.g., cardiac, chromosomal like Trisomy 13/18)
Anatomy, Physiology & Pharmacology PointsPathophysiology: The defect in gastroschisis is due to a vascular disruption during fetal development. The exposed bowel loses fluid and heat through evaporation, leading to hypothermia and third-spacing of fluid (massive fluid shifts into the bowel wall and peritoneal cavity), causing Key Point!hypovolemia and electrolyte imbalances.
Pharmacology: Broad-spectrum IV antibiotics (e.g., ampicillin, gentamicin) are started early due to high infection risk from exposed bowel. The infant will also require IV fluids at 1.5-2 times maintenance to compensate for massive fluid losses.
Memory TipsGastroschisis = "Gauze" Priority: Think "Gastroschisis needs Gauze" first and foremost.
No Sac = More Urgent: Remember, if there's NO sac (gastroschisis), the bowel is naked and needs immediate protection from the environment.
Right Side & Right Side-Lying: The defect is usually on the right, so position the baby on its right side to support the bowel.
High-Frequency NCLEX Topics
This is a classic High Yield topic for pediatric and maternal-newborn nursing. The NCLEX loves to test priority actions for congenital anomalies. You must know the immediate post-birth care for conditions like gastroschisis, omphalocele, meningomyelocele, and choanal atresia. The principle is always: Protect the exposed tissue or structure first.
Watch Out for Question Variations!
The same concept can be tested in different ways:
Assessment Focus: "The nurse assesses a newborn with gastroschisis. Which finding requires immediate intervention?" (Answer: Dry, cracked appearance of the exposed bowel).
Planning Focus: "When planning care for a newborn with gastroschisis, which intervention should the nurse include first?" (Answer: Prepare warm, sterile saline-soaked gauze).
Parent Teaching: "A parent asks why their baby with gastroschisis cannot be held before surgery. What is the nurse's best response?" (Answer: "To prevent injury and heat loss from the exposed intestines, we need to keep the area protected and stable.").
Nursing Clinical Practice GuideClinical Scenario: You are the nurse in the delivery room. A full-term infant is born via vaginal delivery. Immediately, you see a mass of dark red, matted intestines protruding from a 3-4 cm defect to the right of the umbilicus. The infant is crying vigorously.
Nursing Intervention Strategy:
Immediate Action (Priority): While maintaining thermoregulation (dry the infant except the defect), gently cover the exposed bowel with sterile gauze soaked in warm 0.9% normal saline. Then, loosely cover this with a sterile plastic wrap or bowel bag. Do not attempt to reduce the bowel.
Positioning: Place the infant in a right lateral position or supine with the bowel supported by rolls to prevent tension and torsion.
Airway & Monitoring: Ensure a patent airway. Insert an orogastric (OG) tube to low intermittent suction to decompress the stomach and prevent aspiration.
IV Access & Fluids: Establish IV access (umbilical vein catheter often used) and begin IV fluids at high maintenance rates (e.g., D10W with electrolytes) to prevent hypovolemia.
Medications: Administer IV antibiotics as ordered. Provide pain management.
Preparation for Transfer/Surgery: Maintain the infant in a thermoneutral environment (isolette). Keep the infant NPO (nothing by mouth). Prepare for transfer to the NICU (Neonatal Intensive Care Unit) and eventual surgical repair.
Patient Safety and Precautions:
Never use dry gauze, as it will stick to and damage the bowel.
Never attempt to push the bowel back into the abdomen.
Monitor closely for signs of bowel ischemia: color change (purple/black), foul odor.
Strict aseptic technique is mandatory when handling the dressing to prevent sepsis.
Nursing Procedure & Medication FlowProcedure: Applying the Protective Dressing
Prepare a sterile field with warm sterile saline, sterile gauze, and sterile plastic wrap.
Using sterile gloves, gently apply the saline-soaked gauze directly over all exposed bowel.
Loosely cover the moist gauze with plastic wrap, creating a "humidified chamber." Secure the edges to the intact abdominal skin with a non-constrictive method.
Assess the bowel color and moisture every 15-30 minutes. Re-moisten gauze with sterile saline as needed to keep it damp.
Medication: IV Fluid Management
These infants often require 150-200 mL/kg/day of IV fluid (compared to a normal newborn's 80-100 mL/kg/day) due to massive third-spacing losses.
Monitor urine output (goal: >1-2 mL/kg/hr), serum electrolytes, and glucose closely to guide therapy.
A Word from Your Senior Nurse
"In the whirlwind of a delivery with a congenital anomaly, it's easy to feel overwhelmed. Remember your ABCs with a twist for the newborn: Airway, Breathing, and Cover that bowel! Your quick, calm action to protect that exposed intestine from drying and cooling is literally life- and bowel-saving. In clinical practice, you'll be part of a rapid-response team for these babies. Your knowledge of this priority intervention shows you're thinking like a true neonatal nurse—anticipating the biggest threats and acting to prevent them. That's the kind of critical thinking the NCLEX rewards and, more importantly, that your tiny patients need."
Gastroschisis — A congenital abdominal wall defect where intestines protrude through a hole usually to the right of the umbilicus, without a protective sac.
Omphalocele — A congenital defect where abdominal organs herniate into the base of the umbilical cord and are covered by a peritoneal sac.
Third-Spacing — The shift of intravascular fluid into interstitial spaces or body cavities (like the bowel wall in gastroschisis), leading to hypovolemia.
Orogastric (OG) Tube — A tube inserted through the mouth into the stomach, used in newborns with gastroschisis for decompression to prevent vomiting and aspiration.
Hypothermia — A dangerously low body temperature; a major risk for newborns with gastroschisis due to evaporative heat loss from exposed viscera.