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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The Babinski reflex, also known as the plantar reflex, is a normal reflex in infants
that occurs when the sole of the foot is stroked from heel to toe.
In response to this stimulus, the big toe moves upward or toward the top surface of the foot and the other toes fan out.
Choice A is not an answer because flexion of the forearm is not a response to stimulation of the foot.
Choice B is not an answer because downward curl of the toes is not a response
to stimulation of the foot.
Choice D is not an answer because extension of the leg is not a response to
stimulation of the foot.
Correct Answer is A
Explanation
Broccoli is a good source of calcium for vegans.
Choice B is incorrect because bananas are not mentioned as a good source of calcium for vegans.
Choice C is incorrect because avocados are not mentioned as a good source of calcium for vegans.
Choice D is incorrect because potatoes are not mentioned as a good source of calcium for vegans.
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