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?

This is the method that the nurse should use to elicit the Moro reflex. The Moro reflex, or startle reflex, is an involuntary motor response that infants develop shortly after birth. It is a response to a sudden loss of support or extremely sudden stimulation¹. A loud noise above the newborn can trigger the Moro reflex by startling the infant. The Moro reflex involves three distinct components: spreading out the arms (abduction), pulling the arms in (adduction), and crying (usually)².

The other options are not correct because they do not elicit the Moro reflex.
a) Turn the newborn's head to one side.
This does not elicit the Moro reflex, but rather the tonic neck reflex. The tonic neck reflex occurs when the infant turns their head to one side and assumes a "fencing" posture, with the arm and leg on the same side extended and the opposite arm and leg flexed.

b) Touch the newborn's cheek with a finger.
This does not elicit the Moro reflex, but rather the rooting reflex. The rooting reflex occurs when the infant turns their head and opens their mouth in response to a touch on their cheek or mouth. This reflex helps the infant locate and latch onto a nipple for feeding³.
d) Tap the newborn's forehead with a finger.
This does not elicit the Moro reflex, but rather the glabellar reflex. The glabellar reflex occurs when the infant blinks in response to a tap on their forehead or bridge of their nose. This reflex helps protect the eyes from injury³.

A. Using povidone-iodine on the site of a myelomeningocele is not recommended as it can be irritating to the tissue and might not be safe for use on open neural tissue. The focus should be on preventing infection through other means.

B. Administering broad-spectrum antibiotics is crucial as the cerebrospinal fluid (CSF) leak increases the risk of infection, such as meningitis. Antibiotics help protect the newborn from potentially serious infections until surgical repair can be performed.

C. Surgical closure of a myelomeningocele is typically done as soon as possible, often within 24-48 hours after birth, to minimize the risk of infection and further damage to the exposed spinal cord.

D. While monitoring temperature is important, rectal temperature measurement is not recommended for a newborn with a myelomeningocele due to the risk of causing further complications. Axillary temperature measurement would be safer and less invasive.