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.
The Correct Answer is B
Rationale:
A. Administering broad-spectrum antibiotics is not indicated as the first-line intervention for a myelomeningocele that is leaking cerebrospinal fluid. Antibiotics may be initiated later if signs of infection develop.
B. Cleansing the site with povidone-iodine is essential to reduce the risk of infection and prevent contamination of the exposed neural tissue.
C. Monitoring the rectal temperature every 4 hours is important for assessing the newborn's overall health but is not specific to managing a myelomeningocele.
D. Surgical closure of the myelomeningocele may be necessary, but immediate care focuses on protecting the exposed neural tissue and preventing infection before surgical intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E","F","G"]
Explanation
Rationale:
A. Newborns with neonatal abstinence syndrome (NAS) are often irritable and hypersensitive to stimuli. Keeping the environment calm and quiet can help minimize their discomfort.
B. Naloxone is not routinely used in the management of NAS unless there is evidence of severe respiratory depression or opioid overdose, which is not indicated in this scenario.
C. Maternal opioid use and positive urine drug screens for methadone may contraindicate breastfeeding due to the potential transmission of opioids to the infant through breast milk. It's essential to consult with healthcare providers regarding the safest feeding option for the newborn.
D. Eye contact during feeding is essential for bonding between the parent and the newborn and should not be discouraged unless medically necessary.
E. Ballard newborn screening helps assess the newborn's gestational age and guide appropriate care for neonates with NAS, as they may require specialized management.
F. Daily weighing helps monitor the newborn's hydration status and overall well-being, which is crucial in managing NAS and ensuring adequate nutrition.
G. Swaddling can provide comfort to newborns with NAS by mimicking the womb environment and reducing their agitation.
Correct Answer is C
Explanation
Rationale:
A. Provide the newborn with 15 ml glucose water after each feeding: This action is not directly related to phototherapy for jaundice treatment.
B. Turn the newborn every 4 hours: While turning the newborn is important for preventing pressure ulcers, it is not specifically related to phototherapy.
C. Close the newborn's eyes before applying eyepatches:
Correct answer. It is important to protect the newborn's eyes from phototherapy light by using eye patches or covering their eyes with soft material to prevent damage to the retina.
D. Apply hydrating lotion to the newborn's skin prior to treatment: Hydrating lotion is not typically applied before phototherapy, as it may interfere with the effectiveness of the treatment or cause skin irritation.
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