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 D
Explanation
A. Human papillomavirus (HPV): The HPV vaccine is generally not administered during pregnancy. It is recommended for routine vaccination before sexual activity begins to provide protection against certain types of HPV that can lead to cervical cancer and genital warts.
B. Varicella (chickenpox): The varicella vaccine is also typically not administered during pregnancy. If a woman is not immune to varicella and is planning pregnancy, vaccination is recommended before conception.
C. Rubella : The rubella vaccine is crucial for individuals who have not been immunized against rubella during childhood, especially in the context of pregnancy. Rubella (German measles) is a viral infection that can cause serious congenital abnormalities, known as congenital rubella syndrome, if a pregnant woman becomes infected. Administering the rubella vaccine during pregnancy is not appropriate, but vaccination before conception or in the postpartum period is recommended to prevent future rubella infections.
D.The tetanus vaccine is safe to administer during pregnancy, typically given as part of the Tdap (tetanus, diphtheria, and pertussis) vaccine. It is recommended during pregnancy, preferably between 27 and 36 weeks of gestation, to protect the newborn from pertussis.
Correct Answer is C
Explanation
A. Administer oxygen via face mask at 10 L/min: While oxygen administration may be necessary for a client experiencing excessive bleeding, the first action should be to assess the extent of blood loss. Administering oxygen is not the priority at this point.
B. Prepare the client to receive plasma expander: Plasma expanders, such as intravenous fluids, may be part of the treatment for postpartum hemorrhage, but the immediate priority is to assess the client's blood loss and determine the need for blood products. Fluid replacement alone may not address the underlying issue.
C. Collect hemoglobin and hematocrit levels: This is the correct first action. Hemoglobin and hematocrit levels provide crucial information about the extent of blood loss and the need for further interventions, such as blood transfusions. This information helps guide the overall management of the client.
D. Insert an indwelling urinary catheter: While assessing urinary output is important, it is not the first priority when a client is saturating perineal pads every 10 to 15 minutes. The immediate concern is to assess and manage the excessive bleeding, and obtaining hemoglobin and hematocrit levels is a crucial step in this process.
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