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?
Cleanse the site with povidone-iodine
Monitor the rectal temperature every 4 hours .
Prepare for surgical closure after 72 hours
Administer broad-spectrum antibiotics
The Correct Answer is D
The correct answer is choice d. Administering broad-spectrum antibiotics.
Choice A rationale:
Cleansing the site with povidone-iodine is not recommended because it can be irritating and potentially harmful to the exposed neural tissue.
Choice B rationale:
Monitoring the rectal temperature every 4 hours is not appropriate as it can increase the risk of infection and trauma to the site. Axillary temperature monitoring is preferred.
Choice C rationale:
Preparing for surgical closure after 72 hours is incorrect. Surgical closure is typically performed within the first 24 to 48 hours to prevent infection and further damage to the neural tissue.
Choice D rationale:
Administering broad-spectrum antibiotics is crucial to prevent infection, especially since the cerebrospinal fluid is leaking, which increases the risk of meningitis and other infections.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
While initiating an infusion of IV fluids for the patient is important, it is not the immediate next step after noticing a protruding umbilical cord.
Choice B rationale
Administering oxygen via a nonrebreather mask at 8L/min is a later step in the management of umbilical cord prolapse.
Choice C rationale
The immediate next step after noticing a protruding umbilical cord is to perform a vaginal examination and apply upward pressure on the presenting part to relieve cord compression.
Choice D rationale
Covering the umbilical cord with a sterile saline-saturated towel is a later step in the management of umbilical cord prolapse.
Correct Answer is C
Explanation
Choice A rationale
Administering an IV bolus of lactated Ringer’s is not the best action for a client with peripartum cardiomyopathy. This condition is a form of heart failure that occurs during the last month of pregnancy or up to five months postpartum. It can lead to fluid overload, so giving an IV bolus of lactated Ringer’s could exacerbate the client’s condition.
Choice B rationale
Assessing blood pressure twice daily is important for any postpartum client, but it is not the most critical action for a client with peripartum cardiomyopathy. This condition can lead to fluid overload and heart failure, so while monitoring blood pressure is important, it is not the primary intervention.
Choice C rationale
Restricting daily oral fluid intake is the correct action. Peripartum cardiomyopathy can lead to fluid overload and heart failure. Restricting fluid intake can help manage the client’s fluid status and prevent exacerbation of heart failure.
Choice D rationale
Obtaining a prescription for misoprostol is not relevant in this context. Misoprostol is a medication used to prevent stomach ulcers in patients taking NSAIDs and to induce labor or cause an abortion. It has no role in the management of peripartum cardiomyopathy.
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