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
Explanation
Choice A rationale:
The client is experiencing postpartum hemorrhage, and the nurse should first collect hemoglobin and hematocrit levels to assess the extent of blood loss.
Choice B rationale:
Inserting an indwelling urinary catheter is not the immediate priority. It may be done later to monitor fluid balance.
Choice C rationale:
Administering oxygen is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.
Choice D rationale:
Preparing the client to receive a plasma expander is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.
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