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

Answer and Explanation

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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Correct Answer is D

Explanation

A.Administering oxygen is unnecessary for early decelerations because they are not caused by fetal hypoxia or distress.

B.Discontinuing oxytocin is indicated for late decelerations or signs of fetal distress, not early decelerations.

C.Positioning the client on her side may help with certain decelerations, but it is not required for early decelerations caused by head compression, which is expected in active labor.

D.Early decelerations in the fetal heart rate are typically benign and often associated with fetal head compression during contractions. These decelerations usually mirror the contraction pattern and do not indicate fetal distress. Therefore, continuing to monitor the client is the appropriate action, as early decelerations are a normal finding during active labor.

A. Conduct a vaginal exam. B. Perform vibroacoustic stimulation. C. Collect a specimen for an indirect Coombs' test. D. Place the client in the Trendelenburg position.

Correct Answer is B

Explanation

Perform vibroacoustic stimulation. A nonstress test is a prenatal test that is used to evaluate fetal well-being. It involves monitoring the fetal heart rate in response to fetal movement. The absence of accelerations for 20 minutes may indicate fetal distress. Vibroacoustic stimulation is a technique used to elicit fetal movement and accelerate the fetal heart rate. It involves applying a vibrating device to the mother's abdomen.

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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 D

Explanation

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Correct Answer is B

Explanation

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