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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C, D, A, B
Explanation
C. Ask the client to lie on her back and with her knees flexed.
D. Position one hand around the top of the client's fundus and one hand just above the client's symphysis pubis.
A. Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus.
B. Observe the client's perineum for the passage of clots and the amount of bleeding.
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.
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