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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Consuming foods served at cool temperatures can help alleviate nausea and vomiting during early pregnancy. Cold foods often have less aroma compared to hot foods, which can make them more tolerable for someone experiencing nausea.
Choice B rationale
Brushing teeth after each meal is a good oral hygiene practice, but it does not directly help with managing nausea and vomiting during early pregnancy.
Choice C rationale
Eating three large meals per day is not recommended for managing nausea and vomiting during early pregnancy. Instead, eating small, frequent meals throughout the day can help keep the stomach from becoming empty, which can exacerbate nausea.
Choice D rationale
Drinking plenty of water when feeling nauseated can help prevent dehydration, which can occur as a result of vomiting. However, it may not directly alleviate the feeling of nausea.
Correct Answer is D
Explanation
Choice A rationale
Applying triple antibiotic ointment on the baby’s umbilical cord is not typically recommended. The American Academy of Pediatrics advises against applying any antiseptic or antibiotic ointment to the umbilical cord stump in most cases.
Choice B rationale
Giving a newborn an immersion bath daily is not recommended. Newborns do not need daily baths, and excessive bathing can dry out their skin.
Choice C rationale
Swaddling a baby with their legs in an extended position is not recommended. This position can increase the risk of developmental dysplasia of the hip.
Choice D rationale
Offering a pacifier during naps or at bedtime can be part of a safe sleep routine for a newborn, once breastfeeding is well established.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.