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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
In the event of shoulder dystocia during the second stage of labor, the provider may instruct the nurse to perform the McRoberts maneuver. This involves assisting the client in pulling their knees toward their abdomen. This position effectively flattens the sacrum, changes the angle of the pelvic inlet, and allows more room for the baby to pass through the birth canal.
Correct Answer is D
Explanation
Choice A rationale
While it’s true that there may not have been any indication of GBS in earlier prenatal testing, this does not explain why the test was not conducted earlier. GBS can come and go in the body, so a negative test earlier in pregnancy does not guarantee that the woman will still be GBS-negative later in pregnancy.
Choice B rationale
Even if previous deliveries were all negative for GBS, this does not mean that the woman will not have GBS in this pregnancy. GBS can come and go in the body, so each pregnancy is considered separately.
Choice C rationale
GBS is usually asymptomatic in adults, so the woman would not typically report any symptoms of GBS during her pregnancy. This does not explain why the test was not conducted earlier.
Choice D rationale
GBS testing is typically done between 35-37 weeks of gestation. This is because GBS can come and go in the body, so testing during this time frame gives the best prediction of whether or not the woman will have GBS at the time of delivery.
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