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 D

Explanation

The nonstress test is a screening tool that assesses fetal well-being. It is performed by monitoring the fetal heart rate (FHR) and uterine contractions (UC) while the client is at rest. The test is considered reactive if there are two or more accelerations of the FHR that reach a certain level above the baseline and last for at least 15 seconds over a 20-min period.

The presence of irregular contractions that are not felt by the client is a finding that is concerning because it could be a sign of uterine hyperstimulation, which can lead to fetal distress. Further diagnostic testing may be needed to assess fetal well-being in this situation.

Option A indicates that the client felt fetal movements during the testing period. This is a reassuring finding because fetal movements are a sign of fetal well-being.

Option B indicates that there were no late decelerations in the FHR with uterine contractions. This is a reassuring finding because late decelerations are a sign of fetal compromise.

Option C indicates that there was an acceleration of the FHR in response to fetal movement. This is a reassuring finding because it indicates that the fetus is capable of responding to stimuli.

A. Human papillomavirus B. Varicella C. Diphtheria-acellular pertussis D. Inactivated influenza E. Measles, mumps, and rubella

Correct Answer is ["C","D"]

Explanation

The nurse should plan to immunize the client with the following vaccines: Inactivated influenza: The Centers for Disease Control and Prevention (CDC) recommends that all pregnant women receive the influenza vaccine during any trimester of pregnancy, as pregnant women are at an increased risk of severe illness from the flu.

Diphtheria-acellular pertussis: The CDC recommends that pregnant women receive the Tdap vaccine (which includes protection against tetanus, diphtheria, and acellular pertussis) during each pregnancy, ideally between 27 and 36 weeks of gestation. This is to protect both the mother and the newborn from pertussis (whooping cough).

The following vaccines are not recommended:

Measles, mumps and rubella vaccine should not be given during pregnancy.

The HPV vaccine is not routinely recommended during pregnancy, and if the client becomes pregnant while receiving the HPV vaccine series, vaccination should be delayed until after the pregnancy.

The varicella vaccine (which protects against chickenpox) is not recommended during pregnancy, and if the client is not immune to chickenpox, the vaccine should be given after the pregnancy is over.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

Correct Answer is D

Explanation

A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to immunize the client with which of the following vaccines? (Select all that apply.)

Correct Answer is ["C","D"]

Explanation

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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?

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