A nurse in 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?
Monitor the rectal temperature every 4 hr.
Administer broad-spectrum antibiotics
Prepare for surgical closure after 72 hr.
Cleanse the site with povidone-iodine
The Correct Answer is B
Correct Answer: B
B. Administer broad-spectrum antibiotics
Newborns with a leaking myelomeningocele are at a high risk for infection, especially meningitis, due to the exposure of cerebrospinal fluid (CSF). Administering broad-spectrum antibiotics helps reduce the risk of infection until the defect is surgically closed.
Incorrect answers:
A. Monitor the rectal temperature every 4 hr. Taking rectal temperatures is contraindicated in a newborn with a myelomeningocele due to the risk of trauma to the rectum and potential introduction of bacteria near the exposed spinal cord and CSF. Axillary temperatures should be used instead.
C. Prepare for surgical closure after 72 hr. Surgical repair of a myelomeningocele is typically performed within the first 24–48 hours of life to reduce the risk of infection and prevent further nerve damage.
D. Cleanse the site with povidone-iodine. Povidone-iodine is not appropriate for cleansing the exposed myelomeningocele site because it can be too harsh and toxic to neural tissue.
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Related Questions
Correct Answer is B
Explanation
A. I will receive a series of three immunizations, and each one will be a month apart: This statement is not accurate for rubella immunization. The MMR vaccine is usually administered as a single injection.
B. I should avoid becoming pregnant for at least 1 month following the immunization
Rubella immunization is typically administered as the measles, mumps, and rubella (MMR) vaccine. The statement indicating understanding reflects awareness of the importance of avoiding pregnancy for a certain period after receiving the rubella immunization due to potential risks to the developing fetus.
C. I should avoid breastfeeding for 2 weeks following the immunization: Breastfeeding is not a contraindication after receiving the rubella immunization. In fact, breastfeeding is generally not affected, and mothers can continue to breastfeed.
D. I will report joint pain that develops after the immunization to my provider immediately: Joint pain is a potential side effect of the rubella vaccine. Reporting joint pain to the provider is essential for monitoring and addressing any adverse reactions.
Correct Answer is C
Explanation
A. Painful intercourse: Painful intercourse can have various causes, but it is not typically associated with serious complications related to oral contraceptives. It may be addressed with the healthcare provider during a routine follow-up.
B. Vaginal itching: Vaginal itching may be due to various reasons, including infections, but it is not typically a direct side effect of oral contraceptives. However, if the itching is persistent or severe, the client should report it to the provider for appropriate evaluation.
C. Persistent headaches: Persistent headaches can be a concerning side effect associated with the use of oral contraceptives. It may indicate an increased risk of vascular events, such as stroke or thrombosis. Clients experiencing persistent headaches while on oral contraceptives should report this symptom to the healthcare provider immediately for further evaluation.
D. Breast tenderness: Breast tenderness is a common side effect of hormonal contraceptives, and it is not typically an emergency or a sign of serious complications. However, if the breast tenderness is severe or associated with other concerning symptoms, the client should contact the provider for guidance.
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