A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation.
Which of the following actions should the nurse take
Diagnostic results
Escherichia coli infection resulting in necrotizing enterocolitis Hgb 10g/dL
Platelet count 50,000 mm
WBC count 4,000 mm3
The Correct Answer is A
The nurse should insert an orogastric decompression tube with low wall suction. The newborn has Escherichia coli infection resulting in necrotizing enterocolitis, which can cause abdominal distention, decreased activity level, and bloody stools. The newborn also has a superficial rash on the abdominal wall, which may indicate a bacterial infection. The presence of a fist clenching, thrashing, and crying during light palpation of the
abdomen may indicate pain caused by bowel distention. An orogastric decompression tube with low wall suction can help decompress the bowel and relieve abdominal distention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Monitor the rectal temperature every 4 hr: Rectal temperature measurement is contraindicated in this newborn due to the risk of trauma to the spinal cord or irritation of the leaking sac. Axillary temperature monitoring is a safer alternative.
B. Administer broad-spectrum antibiotics: Broad-spectrum antibiotics help prevent infection from organisms entering through the exposed or leaking sac. This is a priority intervention to ensure the safety of the newborn.
C. Cleanse the site with povidone-iodine: Povidone-iodine is not recommended for cleansing the sac, as it can cause irritation or toxicity. Instead, the sac should be kept clean and moist with a sterile, saline-soaked dressing.
D. Prepare for surgical closure after 72 hr: Surgical closure of the defect is typically performed within 24 to 48 hours after birth to minimize infection risk and prevent further damage to neural tissue. Waiting beyond this window is not standard practice for a leaking myelomeningocele.
Correct Answer is A
Explanation
The nurse should inform the client that it is common for yellow discharge to form at the circumcision site during the first 24 to 72 hours following the procedure. This is due to the accumulation of exudate, which is a normal part of the healing process. The nurse does not need to obtain a sample of the discharge for laboratory testing. The povidone-iodine solution should not be applied to the circumcision site, as it can be caustic and delay healing. Wiping the discharge away gently with a washcloth and warm water may irritate the wound and cause additional trauma.
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