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?
Administer broad-spectrum antibiotics.
Monitor the rectal temperature every 4 hr.
Cleanse the site with povidone-iodine.
Prepare for surgical closure after 72 hr.
The Correct Answer is A
The correct answer is choice A, administer broad-spectrum antibiotics.
Choice A rationale:
Administering broad-spectrum antibiotics is crucial for a newborn with a myelomeningocele that is leaking cerebrospinal fluid to prevent infection. The leaking of cerebrospinal fluid can increase the risk of meningitis, which is an infection of the membranes covering the brain and spinal cord. Broad-spectrum antibiotics are used as a prophylactic measure to reduce this risk.
Choice B rationale:
Monitoring the rectal temperature every 4 hours is important for detecting fever, which could indicate infection. However, it is not the most immediate action required for a newborn with a leaking myelomeningocele. The priority is to prevent infection through the administration of antibiotics.
Choice C rationale:
Cleansing the site with povidone-iodine is not recommended for a myelomeningocele because it can be toxic to the exposed neural tissue. Instead, the area should be covered with a sterile saline dressing to protect the site and prevent drying and further damage to the neural tissue.
Choice D rationale:
While surgical closure is necessary for a newborn with myelomeningocele, it is typically performed within 24 to 48 hours after birth, not after 72 hours. Early closure is essential to reduce the risk of infection and further damage to the exposed spinal cord and nerves.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Allowing parents to enter the nursery while wearing masks may be a preventive measure for some situations, but it is not a standard infection control procedure in a newborn nursery.
Choice B rationale:
Airborne precautions are not required for routine infection control in a newborn nursery. They are typically reserved for specific airborne-transmitted infections.
Choice C rationale:
Placing the newborn's foot on a sterile field during a heel stick is a procedure to maintain sterile technique but is not a general infection control instruction for the nursery.
Choice D rationale:
Placing newborn bassinets at least 3 feet apart is a crucial infection control measure in a newborn nursery. It helps prevent cross-contamination and the spread of infections among newborns. Proper spacing allows for better airflow and reduces the risk of contact transmission between infants.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should assess this client first as they are at 34 weeks of gestation and experiencing epigastric pain and headache. These symptoms could be indicative of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia requires immediate assessment and intervention to prevent further complications.
Choice B rationale:
Nausea and vomiting are common symptoms during the first trimester of pregnancy, and at 12 weeks of gestation, it is less likely to be a critical issue compared to potential preeclampsia.
Choice C rationale:
Painful urination may indicate a urinary tract infection, which can be important to assess and treat, but it is not as urgent as potential signs of preeclampsia in a client at 34 weeks of gestation.
Choice D rationale:
Cramping and spotting can be normal signs of impending labor, especially at 39 weeks of gestation. While it's important to assess this client, it is not the priority over potential preeclampsia in a client at 34 weeks of gestation with symptoms of epigastric pain and headache.
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