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?

Cleanse the site with povidone-iodine

Monitor the rectal temperature every 4 hours .

Prepare for surgical closure after 72 hours

Administer broad-spectrum antibiotics

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Administering broad-spectrum antibiotics.

Choice A rationale:

Cleansing the site with povidone-iodine is not recommended because it can be irritating and potentially harmful to the exposed neural tissue.

Choice B rationale:

Monitoring the rectal temperature every 4 hours is not appropriate as it can increase the risk of infection and trauma to the site. Axillary temperature monitoring is preferred.

Choice C rationale:

Preparing for surgical closure after 72 hours is incorrect. Surgical closure is typically performed within the first 24 to 48 hours to prevent infection and further damage to the neural tissue.

Choice D rationale:

Administering broad-spectrum antibiotics is crucial to prevent infection, especially since the cerebrospinal fluid is leaking, which increases the risk of meningitis and other infections.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale
A heart rate of 89/min is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
Cool, clammy skin can be a sign of shock or other serious conditions such as hypoperfusion or inadequate blood flow, which could be a sign of hemorrhage or other circulatory issues. This is a significant finding that should be reported to the provider immediately. Hypoperfusion can lead to inadequate oxygen supply to the body’s organs and tissues, which can result in organ failure and other serious complications. Therefore, any signs of hypoperfusion, including cool, clammy skin, should be reported to the provider immediately for further evaluation and treatment.
Choice C rationale
A blood pressure of 120/70 mm Hg is within the normal range for an adult, and would not typically be a cause for concern.
Choice D rationale
Moderate lochia serosa is a normal finding in a woman who is 3 days postpartum. Lochia serosa is the term for the pink or brownish discharge that occurs after lochia rubra, the bright red discharge that occurs immediately after childbirth. Lochia serosa typically begins about 3- 4 days after delivery and can continue for up to 10 days postpartum.

A. Drink herbal tea two times daily. B. Take daily hot baths. C. Maintain a healthy weight. D. Use a lubricant during intercourse.

Correct Answer is C

Explanation

Choice A rationale
While herbal teas can be a part of a healthy diet, there is no scientific evidence to suggest that drinking herbal tea twice daily can improve fertility. Some herbal teas may even contain substances that could potentially harm a developing fetus or interfere with fertility treatments. Therefore, it’s important for individuals trying to conceive to discuss any dietary supplements or herbal remedies with their healthcare provider.
Choice B rationale
Taking daily hot baths is not recommended as a fertility treatment. In fact, frequent hot baths or hot tub use can actually decrease fertility in men by affecting sperm production. For women, there is no evidence to suggest that hot baths can improve fertility.
Choice C rationale
Maintaining a healthy weight can improve fertility in both men and women. Being overweight or underweight can affect hormone production and make it more difficult to conceive.
Therefore, maintaining a healthy weight through a balanced diet and regular physical activity is one of the most effective non-pharmacological treatments for improving fertility.
Choice D rationale
Using a lubricant during intercourse can make sex more comfortable, but some lubricants can actually decrease fertility by affecting sperm motility. If a lubricant is needed, it’s important to choose a product that is labeled as "fertility-friendly"5.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 assessing a patient who is 3 days postpartum. Which of the following findings should the nurse report to the provider?”

Correct Answer is B

Explanation

A nurse is discussing fertility treatment options with a client and their partner. Which of the following non-pharmacological treatments should the nurse suggest?

Correct Answer is C

Explanation

A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client in a hands-and-knee position. Which should the nurse ask to evaluate the effectiveness of this intervention?

In a prenatal clinic, a nurse is caring for a group of clients. Which client should the nurse identify as having a contraindication for a contraction stress test?

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?

A nurse is collecting data from a client who is at 30 weeks of gestation. Which finding should the nurse identify as a manifestation of pyelonephritis?

A nurse is caring for a client who is 1 hour postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?

“A nurse is caring for a patient who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?”

A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first?

A nurse is caring for a client who is at 6 weeks of gestation and reports nausea and vomiting. Which of the following recommendations should the nurse make?

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?