A nurse in planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

Monitor the rectal temperature every 4 hr.

Administer broad-spectrum antibiotics

Prepare for surgical closure after 72 hr.

Cleanse the site with povidone-iodine

Answer and Explanation

The Correct Answer is B

Correct Answer: B

B. Administer broad-spectrum antibiotics
Newborns with a leaking myelomeningocele are at a high risk for infection, especially meningitis, due to the exposure of cerebrospinal fluid (CSF). Administering broad-spectrum antibiotics helps reduce the risk of infection until the defect is surgically closed.

Incorrect answers:

A. Monitor the rectal temperature every 4 hr. Taking rectal temperatures is contraindicated in a newborn with a myelomeningocele due to the risk of trauma to the rectum and potential introduction of bacteria near the exposed spinal cord and CSF. Axillary temperatures should be used instead.

C. Prepare for surgical closure after 72 hr. Surgical repair of a myelomeningocele is typically performed within the first 24–48 hours of life to reduce the risk of infection and prevent further nerve damage.

D. Cleanse the site with povidone-iodine. Povidone-iodine is not appropriate for cleansing the exposed myelomeningocele site because it can be too harsh and toxic to neural tissue.

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Correct Answer is B

Explanation

A. Hot flashes: Hot flashes are not a typical adverse effect of terbutaline. Hot flashes are more commonly associated with hormonal changes, such as those that occur during menopause.

B. Heart palpitations: This is the correct answer. Terbutaline can stimulate beta-2 receptors in the heart, leading to increased heart rate and palpitations. Clients receiving terbutaline should be monitored for cardiac side effects.

C. Shortness of breath: While terbutaline is used to relax smooth muscles, it can also affect beta-2 receptors in the respiratory system. However, shortness of breath is not a common adverse effect and may indicate other respiratory issues.

D. Bradycardia: Bradycardia, or a slow heart rate, is not a typical adverse effect of terbutaline. The medication is more likely to increase heart rate due to its beta-2 adrenergic agonist properties.

A. Fetal heart rate B. Fundal height C. Hgb D. Hct E. Platelet count F. Vaginal bleeding G. WBC count

Correct Answer is ["A","F"]

Explanation

In the context of a client at 32 weeks of gestation with complete placenta previa, the following assessment findings require immediate follow-up:

A. Fetal heart rate:

Explanation: An elevated fetal heart rate (174/min) may be indicative of fetal distress. This finding requires immediate follow-up to assess the well-being of the fetus.

F. Vaginal bleeding:

Explanation: A moderate amount of bright red vaginal bleeding is a concerning sign, especially in the context of complete placenta previa. It indicates active bleeding, and immediate follow-up is necessary to assess the severity of the situation and the well-being of both the mother and the fetus.

C & D. Hemoglobin (Hgb) and Hematocrit (Hct):

Explanation: Hemoglobin and hematocrit levels are important indicators of blood loss. Given the vaginal bleeding, these values need immediate follow-up to assess the extent of maternal blood loss and the potential need for blood transfusion.

The following assessment findings do not require immediate follow-up in the given context:

B. Fundal height:

Explanation: Fundal height (33cm) is typically measured to assess fetal growth. While it's important to monitor, it may not be an immediate concern unless there are other signs of fetal distress.

E. Platelet count:

Explanation: While platelet count is important, it may not require immediate follow-up unless there is evidence of severe bleeding and a potential risk of disseminated intravascular coagulation (DIC). In this scenario, attention to Hgb and Hct is more urgent.

G & H. White Blood Cell (WBC) count and Red Blood Cell (RBC) count:

Explanation: WBC count and RBC count may be monitored but do not require immediate follow-up unless there are signs of infection or other complications not evident in the given information.

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A nurse in planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving terbutaline to treat preterm labor. Which of the following findings should the nurse identify as a potential adverse effect of this medication?

Correct Answer is B

Explanation

A nurse is caring for a client who is at 32 weeks of gestation and has complete placenta previa Exhibits Which of the following assessment findings requires immediate follow-up) Select all that apply

Correct Answer is ["A","F"]

Explanation

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