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 A
Explanation
Choice A rationale
Providing the patient with photos of the fetus can be a part of memory-making and is often a key component of care after a stillbirth. It allows parents to remember their baby and can aid in the grieving process.
Choice B rationale
While an autopsy can provide information about why a stillbirth occurred, it is not mandatory and should be discussed with the parents. The decision to perform an autopsy should be based on the parents’ wishes.
Choice C rationale
Limiting the amount of time the fetus is in the patient’s room is not necessarily beneficial. Some parents may want to spend time with their baby to say goodbye, which can be therapeutic.
Choice D rationale
Informing the patient that the law requires them to name the fetus is not accurate. The decision to name the fetus is a personal one and varies among individuals.
Correct Answer is D
Explanation
Choice A rationale
Expecting two to four wet diapers every 24 hours is not accurate for a newborn. Newborns typically have six or more wet diapers per day. This indicates that the baby is getting enough milk.
Choice B rationale
Feeding the newborn 5 to 10 minutes per breast is not sufficient. It is recommended that newborns be breastfed for 15 to 20 minutes on each breast during each feeding. This ensures that the baby gets both the foremilk, which quenches the baby’s thirst, and the hindmilk, which provides the necessary nutrients and helps the baby feel full.
Choice C rationale
Giving the newborn 30 ml (1 oz) of water between feedings is not recommended. Newborns do not need additional water - breast milk or formula provides all the hydration they need. Giving a newborn extra water can lead to water intoxication, which is a serious condition.
Choice D rationale
Allowing the baby to feed at least every 3 hours is correct. Newborns should be fed on demand, typically every 2 to 3 hours. This ensures that the baby gets enough nutrition for growth and development.
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