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 A

Explanation

Transmission can occur through bodily ﬂuids, including urine, saliva, blood, breast milk, and cervical secretions. Therefore, pregnant women can acquire CMV by close contact with young children who are shedding the virus, or by exposure to contaminated body ﬂuids in healthcare settings or through sexual activity.

A. Eversion of the great toe B. Flexion of the forearm C. Downward curl of the toes D. Extension of the leg

Correct Answer is A

Explanation

The Babinski reﬂex is a normal reﬂex present in newborns and infants up to about 2 years old. It is elicited by stroking the lateral aspect of the sole of the foot from the heel towards the toes. A positive Babinski reﬂex is characterized by dorsiﬂexion (upward movement) of the big toe and fanning out of the other toes. This is also known as an extensor response.

Therefore, option a, eversion of the great toe, is the expected finding for a positive Babinski reﬂex. Options b, c, and d are not consistent with a positive Babinski reﬂex.

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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

A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?

Correct Answer is A

Explanation

A nurse is performing an assessment of a newborn’s Babinski reﬂex. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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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