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 ["0.5"]
Explanation
Correct answer is 0.5 tablets
Explanation:
To determine how many tablets of metronidazole the nurse should administer per dose, we can use the following calculation:
Number of tablets per dose = Total prescribed dose/Strength of one tablet
Given that the total prescribed dose is 250mg and the strength of one tablet is 500mg, the calculation is:
Number of tablets per dose = 250 mg/ 500 mg
Number of tablets per dose=0.5
Therefore, the nurse should plan to administer 0.5 tablets per dose.
Correct Answer is B
Explanation
A. Urinary output 40 mL/hr: Decreased urinary output can be an indicator of inadequate fluid intake or other issues, but it is not a specific sign of hemorrhage.
B. Blood pressure 88/40 mm Hg: This is the correct answer. A low blood pressure, especially with a low diastolic pressure, can be indicative of hypovolemic shock, which may result from postpartum hemorrhage. Hemorrhage leads to a decrease in circulating blood volume, causing a drop in blood pressure.
C. Moderate rubra lochia: Lochia is the normal vaginal discharge experienced after childbirth, and moderate rubra lochia is considered within the expected range for the early postpartum period. It is not a specific sign of hemorrhage.
D. Heart rate 90/min: A heart rate of 90 beats per minute is within the normal range for a postpartum client and may not be a specific sign of hemorrhage. However, an increase in heart rate could be an early indicator of hypovolemia due to hemorrhage.
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