A nurse is 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?
Prepare for surgical closure after 72 hours.
Cleanse the site with povidone-iodine.
Monitor the rectal temperature every 4 hours.
Administer broad-spectrum antibiotics.
The Correct Answer is D
Choice A rationale
While surgical closure is a common treatment for myelomeningocele, it is not typically performed immediately after birth.
Choice B rationale
Cleansing the site with povidone-iodine is not typically the first step in caring for a newborn with a myelomeningocele.
Choice C rationale
Monitoring the rectal temperature every 4 hours is not specifically related to the care of a newborn with a myelomeningocele.
Choice D rationale
This is the correct answer. Administering broad-spectrum antibiotics can help prevent infection in a newborn with a myelomeningocele.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A heart rate of 89/min is within the normal range for adults, and would not typically be a cause for concern.
Choice B rationale
A blood pressure of 120/70 mm Hg is considered normal for adults.
Choice C rationale
Moderate lochia serosa is a normal part of the postpartum period.
Choice D rationale
This is the correct answer. Cool, clammy skin can be a sign of postpartum hemorrhage, a serious condition that requires immediate medical attention.
Correct Answer is B
Explanation
Choice A rationale
Oatmeal is a good source of dietary fiber, but it does not have the highest fiber content per cup compared to the other options. A cup of cooked oatmeal contains about 4 grams of fiber.
Choice B rationale
Lentils are an excellent source of dietary fiber. One cup of cooked lentils contains approximately 15.6 grams of fiber, which is significantly higher than the other options. This makes lentils a great choice for someone looking to increase their fiber intake, especially for those following a vegan diet.
Choice C rationale
Cabbage does contain fiber, but not as much as lentils or oatmeal. One cup of raw cabbage contains about 2.2 grams of fiber. While it’s a healthy vegetable to include in a diet, it’s not the best choice for someone specifically looking to increase their fiber intake.
Choice D rationale
Asparagus is another healthy vegetable that contains fiber, but not as much as the other options. One cup of cooked asparagus contains about 3.7 grams of fiber. While it’s a good choice for a balanced diet, there are better options for increasing fiber intake.
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