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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?

A.

Cleanse the site with povidone-iodine

B.

Monitor the rectal temperature every 4 hours .

C.

Prepare for surgical closure after 72 hours

D.

Administer broad-spectrum antibiotics

Answer and Explanation

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 A

Explanation

Choice A rationale
The instillation of antibiotic ophthalmic ointment is delayed to facilitate bonding between the newborn and the parent. Immediate skin-to-skin contact between the newborn and the parent has been shown to have several benefits, including stabilizing the newborn’s heart rate, temperature, and breathing, stimulating digestion, helping the newborn to sleep, promoting weight gain, and aiding in maternal attachment.
Choice B rationale
The newborn’s weight does not affect the timing of the instillation of antibiotic ophthalmic ointment.
Choice C rationale
Manifestations of infection in the newborn’s eyes would not be immediately apparent following birth, so this would not be a reason to delay the instillation of antibiotic ophthalmic ointment.
Choice D rationale
The mode of delivery, whether vaginal or cesarean, does not affect the timing of the instillation of antibiotic ophthalmic ointment.

Correct Answer is C

Explanation

Choice A rationale
A thick, white vaginal discharge is more commonly associated with a yeast infection, not trichomoniasis.
Choice B rationale
Vulva lesions are not a typical symptom of trichomoniasis. They can be associated with other conditions such as herpes.
Choice C rationale
Trichomoniasis is a sexually transmitted infection caused by a parasite. One of the common symptoms in women is a foul-smelling vaginal discharge, which can be clear, white, yellowish, or greenish.
Choice D rationale
While urinary frequency can occur with trichomoniasis, it is not as specific or common as malodorous discharge.

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