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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Bronchopulmonary dysplasia is a chronic lung disease that affects newborns and infants, but it is not a complication of forceps-assisted birth. It’s more common in premature babies who have been treated with oxygen and positive-pressure ventilation.
Choice B rationale
Polycythemia, a condition characterized by an increased number of red blood cells, is not a complication of forceps-assisted birth. It can occur due to various reasons, including high altitude and certain genetic disorders.
Choice C rationale
Facial palsy can occur as a complication of forceps-assisted birth. The pressure exerted by the forceps can cause damage to the facial nerve, leading to temporary or permanent facial weakness or paralysis.
Choice D rationale
Hypoglycemia, or low blood sugar, is not a complication of forceps-assisted birth. It’s more commonly seen in babies of mothers with diabetes, premature babies, and babies who are small for their gestational age.
Correct Answer is D
Explanation
Choice A rationale
A heart rate of 89/min is within the normal range for adults, and would not typically be a cause for concern.
Choice B rationale
A blood pressure of 120/70 mm Hg is considered normal for adults.
Choice C rationale
Moderate lochia serosa is a normal part of the postpartum period.
Choice D rationale
This is the correct answer. Cool, clammy skin can be a sign of postpartum hemorrhage, a serious condition that requires immediate medical attention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.