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 A

Explanation

An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening during delivery. A midline episiotomy is an incision made in the midline of the perineum, which has been associated with a higher risk of infection than a mediolateral episiotomy.

Option B is incorrect because meconium-stained fluid does not necessarily place the postpartum client at increased risk for infection. However, it can indicate that the fetus was stressed during delivery and may require additional monitoring after birth.

Option C is also incorrect because gestational hypertension, while it can lead to complications during pregnancy and delivery, does not necessarily place the postpartum client at increased risk for infection.

Option D is also incorrect because placenta previa is a condition in which the placenta is low-lying and can partially or completely cover the cervix. It can cause bleeding during pregnancy and delivery but does not necessarily place the postpartum client at increased risk for infection.

A. Instruct the client to stop taking the antiretroviral medications at 32 weeks of gestation. B. Use a fetal scalp electrode during labor and delivery. C. Bathe the newborn before initiating skin-to-skin contact. D. Administer a pneumococcal immunization to the newborn within 4 hr following

Correct Answer is C

Explanation

The purpose of bathing the newborn before initiating skin-to-skin contact is to decrease the risk of transmission of the virus from the mother to the newborn. Instructing the client to stop taking the antiretroviral medications at 32 weeks of gestation is incorrect as these medications should be taken throughout pregnancy to decrease the risk of transmission to the fetus.

Using a fetalscalp electrode during labor and delivery is also not an appropriate action as it increases the risk of transmission of the virus to the newborn. Administering a pneumococcal immunization to the newborn within 4 hours following birth is not specific to HIV positive newborns and is not related to preventing transmission of the virus.

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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 reviewing the electronic medical record of a postpartum client. The nurse should identify which of the following factors places the client at risk for an infection?

Correct Answer is A

Explanation

A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

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