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 72 hr
The Correct Answer is B
A. Monitor the rectal temperature every 4 hr: Rectal temperature measurement is contraindicated in this newborn due to the risk of trauma to the spinal cord or irritation of the leaking sac. Axillary temperature monitoring is a safer alternative.
B. Administer broad-spectrum antibiotics: Broad-spectrum antibiotics help prevent infection from organisms entering through the exposed or leaking sac. This is a priority intervention to ensure the safety of the newborn.
C. Cleanse the site with povidone-iodine: Povidone-iodine is not recommended for cleansing the sac, as it can cause irritation or toxicity. Instead, the sac should be kept clean and moist with a sterile, saline-soaked dressing.
D. Prepare for surgical closure after 72 hr: Surgical closure of the defect is typically performed within 24 to 48 hours after birth to minimize infection risk and prevent further damage to neural tissue. Waiting beyond this window is not standard practice for a leaking myelomeningocele.
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Related Questions
Correct Answer is C
Explanation
A. Rust-stained urine: This is a common finding in newborns and is due to urate crystals in the urine. It is benign and typically resolves as the infant's kidney function matures.
B. Transient circumoral cyanosis: This is a common finding in newborns, particularly during crying or feeding, and it usually resolves on its own. It does not typically indicate a serious condition.
C. A single palmar crease (also known as a simian crease) can be a normal variant, but it is often associated with certain congenital anomalies or chromosomal disorders, such as Down syndrome. The nurse should report this finding to the provider for further evaluation and possible genetic testing.
D. Subconjunctival hemorrhage: This can occur during delivery due to the pressure of vaginal birth. It is harmless and usually resolves within a few weeks without treatment.
Correct Answer is B
Explanation
The correct answer is choice B, "Allow the baby to feed at least every 3 hr." The nurse should instruct the client who is breastfeeding her newborn to allow the baby to feed at least every 3 hr, which can help to establish an adequate milk supply. The client should also be instructed to feed the newborn on demand, offer both breasts at each feeding, and continue to breastfeed for as long as the baby is interested. The nurse should advise the client to expect at least six to eight wet diapers every 24 hr and monitor the newborn for signs of dehydration, such as a decrease in urine output, dry mucous membranes, or lethargy.
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