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?

Monitor the rectal temperature every 4 hr

Administer broad-spectrum antibiotics

Cleanse the site with povidone-iodine

Prepare for surgical closure after 72 hr

Answer and Explanation

The Correct Answer is B

Rationale for A: Monitoring the rectal temperature is important, but every 4 hours may not be frequent enough to assess for signs of infection or other complications in a newborn with myelomeningocele.

Rationale for B: Administering broad-spectrum antibiotics is crucial to prevent infection, especially in cases of myelomeningocele where the protective covering of the spinal cord is compromised.

Rationale for C: Cleansing the site with povidone-iodine is not recommended as it can be irritating and potentially harmful to the delicate tissue surrounding the defect.

Rationale for D: Surgical closure is typically performed as soon as possible after birth, often within 24 hours, rather than delaying it for 72 hours.

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Correct Answer is B

Explanation

Hyperglycemia, or high blood sugar, can cause increased urination as the body tries to remove excess glucose from the blood. This can lead to dehydration and increased thirst.

A. Decrease in frequency of contractions B. BP 150/100 mm Hg C. Absent deep tendon reﬂexes D. Urinary output 35 mL/hr

Correct Answer is C

Explanation

Absent deep tendon reﬂexes are a sign of magnesium toxicity, which can occur with high levels of magnesium in the bloodstream. This can be a serious complication that requires immediate atention from the provider.

Option A, a decrease in frequency of contractions, is actually a desired eﬀect of magnesium sulfate in the management of preterm labor. It is not a cause for concern.

Option B, a blood pressure reading of 150/100 mm Hg, is high, but it is not necessarily related to the administration of magnesium sulfate. However, it should still be reported to the provider for appropriate management.

Option D, a urinary output of 35 mL/hr, is below the normal range but it may still be within an acceptable range for a client receiving magnesium sulfate. The provider should be notified if urinary output continues to decrease or if it falls below a certain threshold.

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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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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?