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?

Monitor the rectal temperature every 4 hr.

Administer broad-spectrum antibiotics.

Cleanse the site with povidone-iodine.

Prepare for surgical closure after 72hr.

Answer and Explanation

The Correct Answer is C

The priority action in this scenario is to prevent infection. Cleansing the site with povidone-iodine can help reduce the risk of infection. Rectal temperature monitoring and administration of antibiotics may be necessary if infection is suspected, but preventing infection is the priority. Surgical closure may be necessary, but this is not an immediate concern.

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Correct Answer is A

Explanation

An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening during delivery. A midline episiotomy is an incision made in the midline of the perineum, which has been associated with a higher risk of infection than a mediolateral episiotomy.

Option B is incorrect because meconium-stained fluid does not necessarily place the postpartum client at increased risk for infection. However, it can indicate that the fetus was stressed during delivery and may require additional monitoring after birth.

Option C is also incorrect because gestational hypertension, while it can lead to complications during pregnancy and delivery, does not necessarily place the postpartum client at increased risk for infection.

Option D is also incorrect because placenta previa is a condition in which the placenta is low-lying and can partially or completely cover the cervix. It can cause bleeding during pregnancy and delivery but does not necessarily place the postpartum client at increased risk for infection.

A. "You should store your diaphragm in sterile water after each use." B. "You should keep the diaphragm in place for at least 4 hours after intercourse." C. "You should use an oil-based vaginal lubricant when inserting your diaphragm." D. "You should have your provider refit you for a new diaphragm."

Correct Answer is D

Explanation

The size and shape of the cervix and vagina can change after childbirth, which can affect the fit and effectiveness of the diaphragm. The nurse should instruct the client to see her healthcare provider to be refitted for a new diaphragm.

Option A is incorrect because storing the diaphragm in sterile water is not necessary or recommended. The diaphragm should be cleaned with soap and water and allowed to air dry.

Option B is incorrect because the diaphragm should be removed no sooner than 6 hours after intercourse and can be left in place for up to 24 hours.

Option C is incorrect because oil-based vaginal lubricants can damage latex diaphragms, so water-based lubricants should be used instead.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is D

Explanation

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