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 C
Explanation
The nurse should provide the instruction to “verify the identity of anyone who wants to remove your baby from the room” in the teaching about security procedures. It is important for parents to be vigilant and ensure that only authorized personnel have access to their baby.
Correct Answer is ["8"]
Explanation
Step 1 is to determine the total amount of metronidazole needed, which is 2 g.
Step 2 is to convert grams to milligrams, as the available medication is in milligrams. So, 2 g is equal to 2000 mg.
Step 3 is to calculate the number of tablets needed. Each tablet contains 250 mg of metronidazole. Therefore, the calculation is 2000 mg ÷ 250 mg/tablet.
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