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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Fetal heart rate 152/min: Fetal heart rate is not typically considered an adverse effect of epidural analgesia. The focus of epidural analgesia is on providing pain relief for the mother rather than directly affecting the fetal heart rate.
B. Hypotension: Hypotension (low blood pressure) is a common adverse effect of epidural analgesia. Epidural anesthesia can cause vasodilation, leading to a decrease in blood pressure. The nurse should monitor the client's blood pressure closely and administer interventions as needed, such as IV fluids or medications to address hypotension.
C. Polyuria: Polyuria (excessive urination) is not a direct adverse effect of epidural analgesia. Epidural analgesia primarily affects pain sensation rather than urinary function.
D. Maternal temperature of 37.4 C (99.4 F): A slightly elevated maternal temperature is not a common adverse effect of epidural analgesia. However, the nurse should monitor for signs of infection or other complications and report any significant temperature changes to the healthcare provider.
Correct Answer is D
Explanation
A. This test determines if your baby is at risk for developing hypoglycemia after birth: The indirect Coombs' test is not related to assessing the risk of hypoglycemia in the baby. It specifically focuses on Rh sensitization.
B. The test will determine the amount of amniotic fluid around the fetus: The indirect Coombs' test does not assess the amount of amniotic fluid around the fetus. It is specifically aimed at detecting antibodies in the maternal blood.
C. The test studies blood flow in the fetus and placenta using ultrasound waves: This description is more indicative of a Doppler ultrasound or other tests that assess blood flow. The indirect Coombs' test is a blood test and does not involve ultrasound waves.
D. This test will detect the presence of Rh-positive antibodies in your blood
The indirect Coombs' test is performed during pregnancy to detect the presence of Rh antibodies in the maternal bloodstream. Rh antibodies can develop if an Rh-negative mother is carrying an Rh-positive baby, and there is a risk of hemolytic disease of the newborn (HDN) in subsequent pregnancies. The test helps identify if the mother has developed antibodies against Rh-positive blood, which could potentially affect the fetus.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today