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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Increased urination, or polyuria, is a common clinical finding in clients with hyperglycemia. High levels of glucose in the blood can cause the kidneys to work harder to filter out the excess glucose, resulting in increased urine output.
Option A, dizziness, is a nonspecific symptom and can occur for a variety of reasons, including hypoglycemia, hyperglycemia, or dehydration.
Option C, sweating, is also a nonspecific symptom and can occur for a variety of reasons, including hypoglycemia, hyperglycemia, or anxiety.
Option D, double vision, is a symptom that can occur in severe cases of hyperglycemia or diabetic ketoacidosis. However, it is not a common or early symptom of hyperglycemia.
Correct Answer is B
Explanation
Retained placental fragments is a risk factor for postpartum hemorrhage. When placental fragments remain in the uterus, they prevent the uterus from contracting down and can cause significant bleeding. Pregnancy-induced hypertension, oligohydramnios, and meconium-stained fluid are not considered risk factors for postpartum hemorrhage.
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