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: The diaphragm should be used with a spermicide, not a vaginal lubricant. Spermicide is necessary to kill sperm and increase the effectiveness of the diaphragm.
b: The diaphragm can be inserted up to 6 hours before intercourse, making it a convenient option for contraception. It should be left in place for at least 6 hours after intercourse but not more than 24 hours to ensure effectiveness.
c: The diaphragm should not be removed 2 to 4 hours after intercourse. It must remain in place for at least 6 hours after intercourse to provide effective contraception.
d:Washing the diaphragm with detergent soap can damage the latex and increase the risk of deterioration. It should be washed with mild soap and water or with a special cleanser recommended by the healthcare provider.
Correct Answer is B
Explanation
A. Weak cry: A weak cry is not a specific manifestation associated with newborns exposed to methadone. Methadone-exposed newborns may show signs of neonatal abstinence syndrome (NAS), but a weak cry is not a primary characteristic.
B. Poor feeding: This is the correct answer. Poor feeding is a common manifestation of neonatal abstinence syndrome (NAS) in newborns exposed to opioids, including methadone. NAS can cause gastrointestinal symptoms, including feeding difficulties.
C. Respiratory rate of 30/min: While respiratory issues can be part of the neonatal abstinence syndrome, a specific respiratory rate of 30/min is not universally characteristic. NAS symptoms can vary among infants.
D. Absent Moro reflex: The Moro reflex is not typically affected in infants exposed to methadone. NAS symptoms often involve central nervous system irritability, but the Moro reflex is a complex primitive reflex that may remain intact.
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