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 B

Explanation

The correct answer is choice B: Hearing loss. Cytomegalovirus (CMV) is a common virus that can cause serious complications in infants who are infected with the virus during pregnancy. Infants with congenital CMV infection can have hearing loss, vision impairment, and developmental delays.

Choice A, macrosomia, choice C, urinary tract infection, and choice D, cataracts, are not typical findings in infants with congenital CMV infection.

A. Fortified soy milk B. Brown rice C. Fresh citrus fruits D. Raw carrots

Correct Answer is A

Explanation

The correct answer is choice A: Fortified soy milk. Vitamin B12 is found in animal products, so vegans are at risk of vitamin B12 deficiency. Fortified soy milk is a good source of vitamin B12 for vegans.

Choice B, brown rice, choice C, fresh citrus fruits, and choice D, raw carrots, are not good sources of vitamin B12.

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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 B

Explanation

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Correct Answer is A

Explanation

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