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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Blood pressure of 136/88 mm Hg should be monitored, but it is not a finding that the nurse needs to urgently report to the provider following the administration of butorphanol. The blood pressure reading is slightly elevated but might be attributed to pain or anxiety during labor.
Choice B rationale:
Moderate fetal heart rate variability is a reassuring sign of fetal well-being and is an expected finding during labor. It does not require immediate reporting to the provider.
Choice C rationale:
C. Respiratory rate 100/min: A respiratory rate of 100/min is indicative of tachypnea, which could suggest maternal distress, hypoxemia, or an adverse reaction to the medication. While opioids typically depress respiration, this finding is abnormal and warrants immediate evaluation to rule out complications such as maternal anxiety, pain, or hypoxia.
Choice D rationale:
Urinary output of 120 mL in 2 hours is an acceptable finding during labor and does not require immediate reporting to the provider. Adequate urinary output varies, but generally, 30 mL/hour is considered acceptable during labor.
Correct Answer is A
Explanation
Answer is: a. Urine protein of 3+
Explanation:
- Urine protein of 3+ indicates severe proteinuria, which is a sign of preeclampsia and can lead to kidney damage. The nurse should report this finding to the provider as it may require medication or delivery intervention.
- Deep tendon reflexes of 2+ are normal and do not indicate preeclampsia. The nurse should monitor the client for hyperreflexia, which is a sign of increased neuromuscular irritability and can precede seizures.
- Hemoglobin 13 g/dL is within the normal range for a pregnant client and does not indicate preeclampsia. The nurse should monitor the client for anemia, which can cause maternal and fetal complications.
- Blood glucose 110 mg/dL is slightly elevated but not diagnostic of gestational diabetes, which is a different condition from preeclampsia. The nurse should advise the client to follow a balanced diet and exercise regimen and to undergo a glucose tolerance test at 24 to 28 weeks of gestation.
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