A nurse is caring for a client who is 1 hr postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?

Rationale:

A. Administering broad-spectrum antibiotics is not indicated as the first-line intervention for a myelomeningocele that is leaking cerebrospinal fluid. Antibiotics may be initiated later if signs of infection develop.

B. Cleansing the site with povidone-iodine is essential to reduce the risk of infection and prevent contamination of the exposed neural tissue.

C. Monitoring the rectal temperature every 4 hours is important for assessing the newborn's overall health but is not specific to managing a myelomeningocele.

D. Surgical closure of the myelomeningocele may be necessary, but immediate care focuses on protecting the exposed neural tissue and preventing infection before surgical intervention.

Rationale:

A. Polycythemia, an elevated red blood cell count, is not typically associated with forceps- assisted birth.

B. Facial palsy, or facial nerve injury, can occur as a complication of forceps-assisted birth due to pressure on the facial nerves during delivery.

C. Bronchopulmonary dysplasia is a lung condition primarily associated with premature birth and prolonged mechanical ventilation, not forceps-assisted birth.

D. Hypoglycemia may occur in newborns for various reasons but is not specifically associated with forceps-assisted birth unless there are other complicating factors such as maternal diabetes.