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 B
Explanation
A. Select a 21-gauge needle to perform the procedure: The size of the needle used for a heel stick typically ranges between 23 and 25 gauge. A 21-gauge needle is larger and may cause more discomfort to the newborn.
B. Puncture the lateral side of the heel for the procedure: The lateral (outer) side of the heel is the recommended site for a heel stick in a newborn. This area is less sensitive, and puncturing the lateral side helps avoid injury to the medial (inner) side where important structures are located.
C. Apply an alcohol pad to the site after the procedure: Applying an alcohol pad after the procedure is not necessary and may cause unnecessary discomfort to the newborn. The puncture site can be gently blotted with a gauze pad if needed.
D. Place a cool cloth at the site for 15 minutes before the procedure: Placing a cool cloth before the procedure is not recommended. Cooling the site may cause vasoconstriction, making it more difficult to obtain an adequate blood sample. It's generally better to warm the heel, for example, by using a warm cloth, to promote blood flow.
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