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 D
Explanation
Do not retract the foreskin to clean your baby’s penis during each diaper change.
The foreskin should not be retracted for cleaning during infancy.
Choice A is incorrect because you should clean around the umbilical cord stump with plain water and blot dry until it falls off naturally.
Choice B is incorrect because swaddling a baby tightly with their legs extended is not recommended.
Choice C is incorrect because a newborn should urinate at least six times a day.
Correct Answer is B
Explanation
A client who is 80% effaced and 8 cm dilated is in active labor and at risk for postpartum hemorrhage.
Choice A is not an answer because ectopic pregnancy occurs when a fertilized egg implants outside of the uterus and is not a risk for a client who is in active labor.
Choice C is not an answer because an incompetent cervix refers to a cervix that dilates prematurely during pregnancy and is not a risk for a client who is in active labor.
Choice D is not an answer because hyperemesis gravidarum refers to severe nausea and vomiting during pregnancy and is not a risk for a client who is in active labor.
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