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?

Prepare for surgical closure after 72 hr.

Administer broad-spectrum antibiotics.

Cleanse the site with povidone-iodine.

Monitor the rectal temperature every 4 hr.

Answer and Explanation

The Correct Answer is B

The correct answer is. Administering broad-spectrum antibiotics.

Cleansing the site with povidone-iodine is not recommended because it can be irritating and potentially harmful to the exposed neural tissue.

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.

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.

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 C

Explanation

This can be a sign of magnesium toxicity and should be reported to the provider.

Choice A is incorrect because magnesium sulfate is used to treat hypertension associated with preeclampsia.

Choice B is incorrect because a respiratory rate of 16/min is within normal range.

Choice D is incorrect because hyperglycemia is not a known adverse reaction to magnesium sulfate.

A. Facial petechiae. B. Erythema toxicum. C. Periauricular papillomas. D. Telangiectatic nevi. E. Telangiectatic nevi.

Correct Answer is A

Explanation

A nuchal cord occurs when the umbilical cord wraps around the fetal neck completely or for 360 degrees.

In some cases, a tight nuchal cord can cause conjunctival hemorrhage and petechiae.

Choice B) is not correct because erythema toxicum is a common rash seen in newborns and is not related to a nuchal cord.

Choice C) is not correct because periauricular papillomas are benign skin growths near the ear and are not related to a nuchal cord.

Choice D) is not correct because telangiectatic nevi, also known as stork bites or salmon patches, are common birthmarks seen in newborns and are not related to a nuchal cord.

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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 is caring for a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

Correct Answer is C

Explanation

A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider?

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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?