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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Scant, bright red spotting during early pregnancy can be a normal finding known as implantation bleeding, which occurs when the embryo attaches to the uterus. It is generally not a cause for concern unless it becomes heavy and is accompanied by severe pain.

Choice B rationale:

Elevated hCG (human chorionic gonadotropin) levels during the first trimester are a normal part of a healthy pregnancy. hCG levels peak around 10-12 weeks of gestation and then gradually decrease. A consistent increase in hCG levels is usually a positive sign of a progressing pregnancy.

Choice C rationale:

Cervical dilation during the first trimester, especially when the client is only at 12 weeks of gestation, is not normal and may indicate an imminent spontaneous abortion (miscarriage). This finding should be reported promptly to the healthcare provider for further assessment and management.

Choice D rationale:

Slight abdominal cramps can be a normal symptom during early pregnancy as the uterus undergoes changes and expands. However, unless they are severe and accompanied by other concerning signs such as heavy bleeding, they are not necessarily indicative of an imminent spontaneous abortion.

A. Measure the abdominal circumference at the level of the newborn's umbilicus every 12 hr. B. Insert an orogastric decompression tube with low wall suction. C. Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr. D. Administer nitric oxide inhalation therapy to the newborn.

Correct Answer is A

Explanation

Choice A rationale:

Measuring the abdominal circumference at the level of the newborn's umbilicus every 12 hr is a critical action in this scenario. The newborn has necrotizing enterocolitis (NEC), a serious gastrointestinal condition, and measuring abdominal circumference can help monitor for changes in abdominal distention, which is a sign of NEC progression.

Choice B rationale:

Inserting an orogastric decompression tube with low wall suction may not be the most appropriate action for a newborn with NEC. While decompression tubes can be used in some cases of NEC, their insertion should be guided by specific clinical indications, and not all cases require them.

Choice C rationale:

Providing the newborn with an iron-rich formula containing vitamin B12 every 2 hr is not indicated for NEC. NEC requires specialized medical management and treatment, which may include bowel rest and other interventions, but providing iron-rich formula is not one of them.

Choice D rationale:

Administering nitric oxide inhalation therapy is not relevant to the management of NEC. Nitric oxide inhalation therapy is used for respiratory conditions, particularly persistent pulmonary hypertension of the newborn, and does not address the gastrointestinal issues seen in NEC.

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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

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