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?

Administer broad-spectrum antibiotics.

Cleanse the site with povidone-iodine.

Monitor the rectal temperature every 4 hr.

Prepare for surgical closure after 72 hr.

Answer and Explanation

The Correct Answer is A

A. Administering broad-spectrum antibiotics is important because a leaking myelomeningocele increases the newborn’s risk for infection, including meningitis. Early prophylactic antibiotic therapy helps prevent serious complications.

B. Cleansing the site with povidone-iodine is not recommended because antiseptics can irritate neural tissue and worsen leakage. The sac should be kept sterile and moist using a saline-soaked sterile dressing instead.

C. Monitoring rectal temperature is contraindicated because rectal manipulation can risk trauma to the myelomeningocele sac. Noninvasive temperature monitoring, such as axillary measurement, is safer.

D. Surgical closure should be performed as soon as possible, ideally within 24–48 hours after birth, rather than waiting 72 hours, to reduce the risk of infection and further neurologic damage.

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Correct Answer is D

Explanation

Rationale:

A. Limiting the length of breastfeeding to 5 minutes per breast is not recommended and may lead to inadequate milk transfer and supply issues.

B. Instructing the client to wait 4 hours between daytime feedings may result in insufficient milk intake for the newborn and could impact breastfeeding success.

C. Offering supplemental formula between feedings may interfere with establishing breastfeeding and could decrease the client's milk supply.

D. Assessing the newborn's latch while breastfeeding is the appropriate action for addressing sore nipples. Poor latch is a common cause of nipple soreness in breastfeeding mothers. Ensuring the newborn has a proper latch can help alleviate discomfort and prevent further nipple trauma.

A. Peripheral edema 2+ bilateral lower extremities B. Blood pressure 136/6 mm Hg C. Lateral deviation of the uterus D. Pain rating of 3 on a scale of 0 to 10 E. Deep tendon reflexes 1+ F. Breasts soft G. Large amount of lochia rubra H. Uterine tone soft

Correct Answer is ["C","G","H"]

Explanation

A. Peripheral edema 2+ bilateral lower extremities - Peripheral edema is common postpartum and does not typically require immediate follow-up unless it is associated with other concerning signs or symptoms.
B. Blood pressure 136/6 mm Hg - The blood pressure provided appears to be incorrect, as the diastolic pressure is unusually low. However, given the options provided, blood pressure is not explicitly mentioned in the scenario as a critical factor requiring immediate follow-up.
C. Lateral deviation of the uterus - Lateral deviation of the uterus suggests uterine atony, a potential complication of postpartum hemorrhage, requiring immediate follow-up and intervention to prevent further complications.
D. Pain rating of 3 on a scale of 0 to 10 - While increased pain should be addressed, it does not necessarily indicate an emergency situation requiring immediate follow-up compared to other findings such as uterine deviation or excessive bleeding.
E. Deep tendon reflexes 1+ - This finding is within normal limits and does not require immediate follow-up.
F. Breasts soft - Soft breasts are expected in the postpartum period and do not typically require immediate follow-up unless associated with other concerning signs or symptoms.

G. Large amount of lochia rubra - A large amount of bright red lochia could indicate postpartum hemorrhage, necessitating immediate follow-up and intervention to prevent further complications.
H. Uterine tone soft - Soft uterine tone suggests uterine atony, which is a potential complication requiring immediate follow-up and intervention to prevent excessive bleeding.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is ["C","G","H"]

Explanation

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