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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should insert an orogastric decompression tube with low wall suction. The newborn has Escherichia coli infection resulting in necrotizing enterocolitis, which can cause abdominal distention, decreased activity level, and bloody stools. The newborn also has a superficial rash on the abdominal wall, which may indicate a bacterial infection. The presence of a fist clenching, thrashing, and crying during light palpation of the
abdomen may indicate pain caused by bowel distention. An orogastric decompression tube with low wall suction can help decompress the bowel and relieve abdominal distention.
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.
. 
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today