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?

Choice A Reason:

Instruct the client to empty their bladder: Emptying the bladder before the examination allows for better visualization and palpation of the uterus and fetal parts. A full bladder can interfere with the ability to assess the position, presentation, and engagement of the fetus accurately.

Choice B Reason:

Position the client supine with knees flexed and place a small, rolled towel under one of their hips: Positioning the client supine with knees flexed helps relax the abdominal muscles and provides better access to the uterus for palpation. Placing a small, rolled towel under one hip helps tilt the pelvis slightly, which can improve visualization and palpation of the uterine fundus.

Choice C Reason:

Palpate the fetal part positioned above the symphysis pubis: Palpating the fetal part above the symphysis pubis (typically the fetal head) allows the healthcare provider to determine the presenting part, engagement, and degree of descent of the fetus. This step provides valuable information about the fetal position and presentation.

Choice E Reason:

Palpate the fetal parts along both sides of the uterus: Palpating the fetal parts along both sides of the uterus helps the healthcare provider identify the fetal back and limbs. This step provides further confirmation of the fetal position and presentation and helps assess fetal lie and attitude.

Choice D Reason:

Palpate the fetal part positioned in the fundus: Palpating the fetal part in the fundus (typically the buttocks or head) confirms the findings from the previous steps and helps determine the presenting part and its relationship to the maternal pelvis. This step provides additional information about the fetal position, presentation, and engagement, which is crucial for assessing fetal well-being and planning for labor and delivery.

Explanation

Choice A Reason:

"Put a soft mattress in your baby's crib." This incorrect. Soft mattresses increase the risk of sudden infant death syndrome (SIDS) and suffocation. It's important to use a firm mattress in the baby's crib to reduce the risk of these adverse events.

Choice B Reason:

"Wash your baby's face with plain water." This is correct instruction to include in the teaching about home safety for a newborn. Washing the baby's face with plain water is a safe and appropriate way to keep the baby clean without the risk of irritation or allergic reactions that can occur with the use of soaps or cleansers in the early days of life.

Choice C Reason:

"Place a bumper pad in your baby's crib." This is incorrect. Bumper pads pose a suffocation and entrapment hazard for infants, and they have been associated with an increased risk of SIDS. Current guidelines recommend against the use of bumper pads in cribs to ensure the safety of the baby.

Choice D Reason:

"Bathe your baby immediately after a feeding." This is incorrect. Bathing a baby immediately after a feeding is not recommended because it may lead to discomfort, vomiting, or spitting up. It's best to wait for at least 30 minutes to an hour after a feeding before bathing the baby to allow time for digestion and to reduce the risk of regurgitation during the bath.