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. Right upper quadrant: This is not the correct location for hearing the fetal heart rate in the LOA position, as it is on the opposite side and higher than expected.
B. Left upper quadrant: The fetal heart rate in the LOA position is heard below, not above, the maternal umbilicus.
C. Left lower quadrant: The PMI of the fetal heart rate is best heard in the left lower quadrant when the fetus is in the left occipitoanterior position, as the fetal back (closest to the heart) is located on the left side and positioned anteriorly.
D. Right lower quadrant: This site is appropriate for a right occipitoanterior (ROA) fetal position, not LOA.
Correct Answer is B
Explanation
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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