A nurse is caring for a newborn with gastroschisis. Which nursing intervention should be the priority immediately after birth?

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.

Understanding the Priority: Initial Stabilization of a Newborn with Gastroschisis

The correct answer is 1. Cover the exposed bowel with warm, moist sterile saline gauze and plastic wrap. The immediate priority for a newborn with gastroschisis is to protect the exposed abdominal contents from contamination, trauma, and fluid and heat loss. This congenital anomaly is characterized by a full-thickness abdominal wall defect through which the bowel and other abdominal organs protrude freely, without a protective membrane ^[1]. Because the bowel is directly exposed to the external environment, the risk of rapid dehydration, hypothermia, and infection is critically high.

Why This Intervention is the Priority
The hallmark of gastroschisis is the absence of a protective sac around the herniated bowel ^[1]. This means the intestinal loops have been floating in amniotic fluid in utero and are completely unprotected after birth. The exposed viscera lose massive amounts of fluid and heat through evaporation. A sterile, non-adherent covering using warm, moist saline gauze and plastic wrap serves multiple life-sustaining purposes:
- Prevents Heat Loss: The large surface area of the exposed bowel leads to rapid evaporative heat loss, causing hypothermia. A plastic wrap creates a greenhouse effect, conserving warmth.
- Minimizes Fluid Loss: Evaporative water loss from the serosal surface of the bowel is profound and can quickly lead to hypovolemia and electrolyte imbalances. The moist saline gauze directly addresses this.
- Reduces Infection Risk: The sterile covering acts as a physical barrier against environmental pathogens, protecting the bowel from direct contamination.
- Protects Tissue Integrity: The gauze prevents the delicate bowel from drying out and suffering ischemic injury or mechanical trauma during handling and transport.

Analysis of Incorrect Options

2. Place the infant in a supine position to prevent further bowel protrusion
This is incorrect and potentially harmful. The standard of care is to position the infant on their right side or supine with the lower body slightly elevated. More critically, the exposed bowel must be supported to prevent stretching of the mesentery and compromise of vascular supply. Placing the infant flat without supporting the eviscerated organs can cause the bowel to fall to the side, leading to kinking of the mesenteric vessels, which can result in ischemia and necrosis. The priority is to maintain the bowel in a neutral, supported position, often achieved by placing the infant in a "bowel bag" or using a protective "silo" covering that suspends the organs.

3. Begin immediate oral feeding to prevent hypoglycemia
This is contraindicated. In gastroschisis, the bowel is not only externalized but often inflamed and edematous due to prolonged exposure to amniotic fluid. Peristalsis is absent or severely impaired, and there is a functional intestinal obstruction. Initiating oral feeding would lead to abdominal distension, vomiting, and a high risk of aspiration. The newborn is kept NPO (nothing by mouth), and an orogastric or nasogastric tube is placed to low intermittent suction to decompress the stomach and prevent aspiration of gastric contents. Nutritional support and glucose maintenance are provided parenterally via intravenous fluids.

4. Administer prophylactic antibiotics to prevent infection
While broad-spectrum prophylactic antibiotics are a critical component of the medical management plan for gastroschisis to reduce the risk of sepsis from the exposed bowel, this is not the immediate nursing priority in the delivery room or upon birth. The sequence of care begins with physical protection and stabilization of the defect. Antibiotic administration is initiated promptly, but it follows the immediate life-saving steps of airway management, thermoregulation, and covering the defect. The physical barrier provided by the sterile covering is the first line of defense against infection.

Connecting to Pathophysiology and Clinical Management
The embryologic origin of gastroschisis, where the bowel fails to return to the abdominal cavity after physiological herniation around the 10th to 12th week of gestation, explains the clinical presentation ^[1]. The exposed bowel is chemically irritated by amniotic fluid, leading to a characteristic inflammatory peel and matting of the intestinal loops. This pathophysiology directly informs the nursing priorities: protecting the bowel from further chemical and physical insult from the air, preventing massive insensible water loss that can exceed normal newborn requirements, and preparing for gradual reduction of the herniated contents. Modern management often involves placing a preformed silo or using sutureless repair techniques to slowly reduce the bowel into the abdominal cavity over several days, a process that relies on the initial proper stabilization and coverage of the defect [1,3]. In resource-limited settings, the principles of covering the defect, preventing hypothermia, and fluid resuscitation are the foundational skills taught to reduce high mortality rates associated with delays in care .