A nurse is formulating a care plan for an infant diagnosed with spina bifida who is scheduled for a surgical closure of the myelomeningocele sac.

Which of the following interventions should be incorporated into the care plan?

Choice A rationale
A client who has a cesarean incision that is well-approximated with no drainage is not at the greatest risk for developing a puerperal infection. While any surgical incision can potentially become infected, if the incision is healing well with no signs of infection, the risk is relatively low.
Choice B rationale
A client who does not wash her hands between perineal care and breastfeeding is increasing her risk of infection, but this is not the greatest risk factor for developing a puerperal infection. Good hand hygiene is important to prevent the spread of germs, but other factors pose a greater risk for puerperal infection.
Choice C rationale
A client who has an episiotomy that is erythematous and has extended into a third-degree laceration is at the greatest risk for developing a puerperal infection. An episiotomy is a surgical cut made at the opening of the vagina during childbirth to aid a difficult delivery and prevent rupture of tissues. If the episiotomy extends and becomes a third-degree laceration, it involves the vaginal tissue, perineal skin, and the muscle of the perineum, and can extend into the anal sphincter, the muscle that surrounds the anus. This type of wound provides a medium for bacterial growth, increasing the risk of infection.
Choice D rationale
A client who is not breastfeeding and is using measures to suppress lactation is not at the greatest risk for developing a puerperal infection. While breastfeeding can help reduce the risk of certain types of infections, not breastfeeding does not significantly increase the risk of puerperal infection.

Choice A rationale
Erythema toxicum is a common rash seen in newborns, characterized by blotchy red spots on the skin with overlying white or yellow papules or pustules. It does not present as small white nodules on the roof of the mouth.
Choice B rationale
Mongolian spots are a type of birthmark that are flat, blue, or blue-gray. They appear at birth or in the first or second week of life. They look similar to bruises and are most often found on the buttocks or lower back, but are never found on the roof of the mouth.
Choice C rationale
Epstein pearls are small, harmless white or yellow nodules that may appear along your newborn baby’s gums or on the roof of their mouth. They are common and usually go away within three months after birth.
Choice D rationale
Milia spots are tiny white bumps that appear across a baby’s nose, chin or cheeks. Milia are common in newborns but can occur at any age. Unlike Epstein pearls, they do not appear on the roof of the mouth.