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
The correct answer is choice a. Check the client’s serum medication level.
Choice A rationale:
Checking the client’s serum medication level is the most direct and objective method to evaluate medication adherence. It provides a quantifiable measure of the digoxin level in the blood, indicating whether the client is taking the medication as prescribed.
Choice B rationale:
Determining the client’s apical pulse rate is important for monitoring the effects of digoxin, as it can affect heart rate. However, it does not directly measure medication adherence.
Choice C rationale:
Asking the client if they are taking the medication as prescribed relies on self-reporting, which can be inaccurate due to forgetfulness or intentional non-disclosure.
Choice D rationale:
Assessing the client’s kidney function is important for dosing and monitoring potential side effects of digoxin, but it does not directly evaluate medication adherence.
Correct Answer is B
Explanation
Choice A rationale
Taking a multivitamin daily is generally recommended during pregnancy to ensure the mother and baby receive necessary nutrients. It does not indicate a need for referral to a dietitian.
Choice B rationale
A weight gain of 4.5 kg (10 lb) since a positive pregnancy test could be a concern depending on the timeframe. If this weight gain occurred rapidly, it could indicate issues such as fluid retention or inadequate nutrition, which would warrant a referral to a dietitian.
Choice C rationale
Nausea, particularly in the morning, is a common symptom of early pregnancy often referred to as “morning sickness”. It does not typically require dietary intervention unless it is severe (hyperemesis gravidarum), leading to weight loss and dehydration.
Choice D rationale
Eating prunes is a natural method to manage constipation, a common issue during pregnancy due to hormonal changes that slow digestion. This choice does not indicate a need for a dietitian referral.
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