A nurse is 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?
Prepare for surgical closure after 72 hours.
Cleanse the site with povidone-iodine.
Monitor the rectal temperature every 4 hours.
Administer broad-spectrum antibiotics.
The Correct Answer is D
Choice A rationale
While surgical closure is a common treatment for myelomeningocele, it is not typically performed immediately after birth.
Choice B rationale
Cleansing the site with povidone-iodine is not typically the first step in caring for a newborn with a myelomeningocele.
Choice C rationale
Monitoring the rectal temperature every 4 hours is not specifically related to the care of a newborn with a myelomeningocele.
Choice D rationale
This is the correct answer. Administering broad-spectrum antibiotics can help prevent infection in a newborn with a myelomeningocele.
Nursing Test Bank
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
The use of an oil-based vaginal lubricant when inserting a diaphragm is not recommended. Oil- based lubricants can damage the material of the diaphragm, reducing its effectiveness as a contraceptive method.
Choice B rationale
Keeping the diaphragm in place for at least 4 hours after intercourse is a standard recommendation. However, it does not address the specific needs of a postpartum woman. After childbirth, the size and shape of a woman’s vagina can change, potentially affecting the fit of the diaphragm.
Choice C rationale
The provider should refit the client for a new diaphragm. After childbirth, the size and shape of a woman’s vagina can change, potentially affecting the fit of the diaphragm. A poorly fitting diaphragm may not provide effective contraception.
Choice D rationale
Storing the diaphragm in sterile water after each use is not a standard recommendation. The diaphragm should be cleaned with mild soap and water, dried, and stored in a cool, dry place.
Correct Answer is A
Explanation
Choice A rationale
This is the correct answer. Sore nipples are a common issue for breastfeeding women, often due to the baby not latching well. Assessing the newborn’s latch can help identify and correct any issues, potentially alleviating the mother’s discomfort.
Choice B rationale
Limiting the length of breastfeeding to 5 minutes per breast is not typically recommended as it may not provide enough feeding time for the baby and could potentially exacerbate nipple soreness.
Choice C rationale
Waiting 4 hours between daytime feedings is not typically recommended. Newborns typically need to feed every 2-3 hours.
Choice D rationale
Offering supplemental formula between the newborn’s feedings is not typically the first step in addressing sore nipples in a breastfeeding mother. It’s more important to address the underlying issue, such as improving the baby’s latch.
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