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?

Monitor the rectal temperature every 4 hr.

Administer broad-spectrum antibiotics.

Cleanse the site with povidone-iodine.

Prepare for surgical closure after 72hr.

Answer and Explanation

The Correct Answer is C

The priority action in this scenario is to prevent infection. Cleansing the site with povidone-iodine can help reduce the risk of infection. Rectal temperature monitoring and administration of antibiotics may be necessary if infection is suspected, but preventing infection is the priority. Surgical closure may be necessary, but this is not an immediate concern.

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Correct Answer is B

Explanation

Methicillin-resistant Staphylococcus aureus (MRSA) is a type of bacteria that can be spread through contact with contaminated objects or people. Contact isolation precautions are used to prevent the spread of infectious organisms that are spread by direct or indirect contact. This includes wearing gloves and a gown when entering the client's room and removing them before leaving the room, as well as using dedicated equipment and ensuring proper disinfection of surfaces.

Droplet isolation precautions are used to prevent the spread of organisms that are spread by droplets from coughing, sneezing, or talking. Airborne isolation precautions are used to prevent the spread of organisms that can remain suspended in the air and travel long distances, such as tuberculosis. Protective environment precautions are used for clients who have compromised immune systems, such as those who have undergone a bone marrow transplant, and involve using special air filtration systems and limiting visitors to reduce the risk of infection.

A. "This medication stabilizes the fetal heart rate." B. "This medication prevents seizures." C. "This medication increases cardiac output." D. This medication improves tissue perfusion."

Correct Answer is B

Explanation

Magnesium sulfate is used to prevent seizures in clients with preeclampsia. It works by relaxing the smooth muscles and blocking neuromuscular transmission. While magnesium sulfate can indirectly improve fetal heart rate and tissue perfusion by preventing seizures, it does not directly stabilize the fetal heart rate or increase cardiac output.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?

Correct Answer is B

Explanation

A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks of gestation and has preeclampsia. Which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

A nurse is conducting a class for a group of clients about birth control. Which of the following information should the nurse include in the teaching?

A nurse is providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider?

A nurse is caring for a client who is in the latent phase of the first stage of labor and is in pain. Which of the following nursing interventions are appropriate to reduce pain? (Select all that apply.)

A nurse is caring for a client who received epidural analgesia during labor and is 4 hr postpartum. Which of the following client reports should the nurse address first?

A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?

A nurse is caring for a client who has pre-gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?