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?
Prepare for surgical closure after 72 hr.
Monitor the rectal temperature every 4 hr.
Cleanse the site with povidone-iodine.
Administer broad-spectrum antibiotics.
The Correct Answer is D
Myelomeningocele is the most severe type of spina bifida, a birth defect in which the spinal cord and its protective covering (meninges) protrude outside the body through an opening in the spine. This can cause nerve damage, muscle weakness, bladder and bowel dysfunction, and/or paralysis. Myelomeningocele requires surgical treatment after birth to repair the opening in the spine and prevent infections and further complications. According to the Mayo Clinic, the following actions should be included in the plan of care for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid:
Cover the sac with a sterile, moist dressing to prevent it from drying out and becoming infected.
Place the baby in a prone position (on the stomach) or on the side to avoid putting pressure on the sac.
Monitor the vital signs, especially the temperature, as the baby may have difficulty regulating body temperature.
Administer antibiotics as prescribed to prevent meningitis and other infections.
Prepare for surgical closure of the sac within the first 24 to 48 hours after birth.
Therefore, the correct answer to your question is d. Administer broad-spectrum antibiotics. The other options are not appropriate for the immediate postnatal care of a newborn with myelomeningocele. Preparing for surgical closure after 72 hours is too late, as the risk of infection and complications increases with time. Monitoring the rectal temperature every 4 hours is not enough, as the baby may need more frequent checks and interventions to maintain a normal body temperature. Cleansing the site with povidone-iodine is not recommended, as it may irritate the delicate tissues and cause more harm than good
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Changing the perineal pad once daily could lead to infection, which would delay wound healing.
Choice B rationale:
Witch hazel pads are often used for their soothing and anti-inflammatory properties, which can aid in healing.
Choice C rationale:
Cleaning the perineum with a squeeze bottle after urinating helps to keep the area clean and promote healing.
Choice D rationale:
A well-approximated suture line indicates that the wound edges are close together, which is conducive to healing.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
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Color: Consistent with genetic background
- Interpretation: B) Sign of potential improvement
- Rationale: The newborn’s color being consistent with their genetic background indicates a normal adjustment and is not a sign of deterioration. This suggests improvement from the initial condition of acrocyanosis.
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Axillary Temperature: 36.3°C (97.4°F)
- Interpretation: B) Sign of potential improvement
- Rationale: The axillary temperature is within the normal range (36.1°C to 37.2°C), which is a positive sign and suggests that the newborn is maintaining normal body temperature.
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Reflex Irritability: Cry
- Interpretation: B) Sign of potential improvement
- Rationale: A good cry indicates normal reflex irritability and is a positive sign of neurological and overall well-being.
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Muscle Tone: Flaccid
- Interpretation: C) Sign of potential worsening condition
- Rationale: Flaccid muscle tone is concerning as it might indicate a worsening condition or potential neurological issues. It is less typical for muscle tone to be flaccid after the initial adjustment period.
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Respiration Effort: Good cry
- Interpretation: B) Sign of potential improvement
- Rationale: A good cry indicates effective respiration and is a positive sign of the newborn’s respiratory status.
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Heart Rate: 140/min
- Interpretation: B) Sign of potential improvement
- Rationale: The heart rate is within the normal range for newborns (120-160/min), indicating that the cardiovascular system is functioning properly.
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