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 D
Explanation
Choice A rationale
While a sleep sack can keep a baby warm, it should not be used in a car seat because it can interfere with the harness and affect its effectiveness.
Choice B rationale
A car seat challenge test is usually performed on premature babies or those with medical conditions. It is not routinely required for a newborn delivered at 38 weeks of gestation.
Choice C rationale
The American Academy of Pediatrics recommends that children remain in a rear-facing car seat until they reach the highest weight or height allowed by their car safety seat’s manufacturer, which is typically around 2 years of age.
Choice D rationale
The car seat should indeed be positioned at a 45-degree angle. This position helps to keep the baby’s airway open and protects them in the event of a crash.
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.
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