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.

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Correct Answer is A

Explanation

Choice A rationale
Providing the client with a cool sitz bath can help soothe the perineal area, reduce inflammation, and promote healing after a fourth-degree laceration.
Choice B rationale
Administering methylergonovine IM is typically used for the prevention and treatment of postpartum or post-abortion hemorrhage caused by uterine atony or subinvolution. It would not directly address the care of a fourth-degree perineal laceration.
Choice C rationale
Applying a moist, warm compress to the perineum can provide some relief from discomfort, but a cool compress or sitz bath is typically recommended initially after a perineal laceration to help reduce swelling.
Choice D rationale
Applying povidone-iodine to the client’s perineum after she voids is not typically part of the care for a fourth-degree perineal laceration. The area should be kept clean, but routine application of antiseptics is not usually necessary.

A. Chills B. Breast tenderness C. Tinnitus D. Urinary frequency

Correct Answer is B

Explanation

Choice A rationale
Chills are not a common side effect of clomiphene citrate.
Choice B rationale
Breast tenderness is a common side effect of clomiphene citrate. This is due to the hormonal changes induced by the medication.
Choice C rationale
Tinnitus, or ringing in the ears, is not a common side effect of clomiphene citrate.
Choice D rationale
Urinary frequency is not a common side effect of clomiphene citrate.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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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?