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
The correct answer is choice C, the newborn's pulse oximetry is 91%. A pulse oximetry reading below 95% indicates hypoxemia, which can occur when the newborn has excessive secretions or a partial airway obstruction. Suctioning the nasopharynx can help to remove the secretions or obstruction and improve the newborn's oxygen saturation. Assessment of the newborn's respiratory rate and pattern, as well as coughing, are important in determining if the newborn needs suctioning. However, the presence of these signs alone does not indicate that suctioning is required. Additionally, a respiratory rate of 32/min is within the normal range for a newborn, so it does not indicate a need for suctioning.
Correct Answer is A
Explanation
. The nurse should report cervical dilation to the provider as an indication of an imminent spontaneous abortion. Cervical dilation is a sign of cervical incompetence and can lead to spontaneous abortion. Scant, bright red spotting is a common finding in early pregnancy and may not indicate an imminent spontaneous abortion. Slight abdominal cramps can also be a normal finding in early pregnancy. Elevated hcG levels can indicate a viable pregnancy.
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