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

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale
An oxygen saturation of 89% in a newborn who was born 2 hours ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet indicates a decline in the newborn’s status. This level of oxygen saturation is below the normal range for a newborn, which is typically above 95%10111213. This could indicate that the newborn is not getting enough oxygen, which could be due to a variety of conditions, including respiratory distress syndrome.
Choice B rationale
Nasal flaring is a sign of respiratory distress in a newborn. However, it is a nonspecific sign and does not necessarily indicate a decline in the newborn’s status. It could be a normal response to the newborn’s efforts to breathe more effectively.
Choice C rationale
Fine crackles can be a sign of a lung condition in a newborn. However, they are a nonspecific sign and do not necessarily indicate a decline in the newborn’s status. They could be a normal finding in a newborn who was born 2 hours ago.
Choice D rationale
An apneic episode less than 15 seconds in a newborn who was born 2 hours ago is not necessarily indicative of a decline in the newborn’s status. Brief periods of apnea (pauses in breathing) are common in newborns and are usually not a cause for concern unless they last longer than 20 seconds or are associated with other signs of distress.

A. Hematuria B. BUN 40 mg/dL C. Leukorrhea D. Platelet count 90,000/mm .

Correct Answer is B

Explanation

Choice A rationale
Hematuria, or blood in the urine, is not a normal finding in pregnancy. It could indicate a urinary tract infection, kidney stones, or other kidney problems. However, without more information, it’s not possible to determine the significance of this finding in a client who is at 33 weeks of gestation.
Choice B rationale
A BUN (Blood Urea Nitrogen) level of 40 mg/dL is higher than the normal range, which is between 7 and 20 mg/dL17181920. This could indicate that the kidneys are not working properly. However, it could also be due to a high-protein diet, dehydration, or other factors.
Choice C rationale
Leukorrhea, or vaginal discharge, is a common symptom of pregnancy. It is usually thin, white or clear, and mild smelling. If the discharge is yellow, green, or gray, has a strong smell, or is accompanied by itching or burning, it could indicate an infection.
Choice D rationale
A platelet count of 90,000/mm is lower than the normal range, which is between 150,000 and 450,000/mm25. This could indicate a condition called thrombocytopenia, which can be caused by various conditions, including pregnancy25. However, without more information, it’s not possible to determine the significance of this finding in a client who is at 33 weeks of gestation25.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating a newborn who was born 2 hours ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet. Which finding indicates a decline in the newborn’s status?

Correct Answer is A

Explanation

A nurse is caring for a client who is at 33 weeks of gestation. The nurse is assessing the client 24 hours later. How should the nurse interpret the findings?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is at 30 weeks of gestation. Which finding should the nurse identify as a manifestation of pyelonephritis?

A nurse is caring for a client who is one day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?

A nurse is teaching about car seat safety to the parents of a newborn who was delivered at 38 weeks of gestation. Which statement by a parent indicates an understanding of the teaching?

A nurse is performing a nutritional assessment for a client during their first prenatal visit at 12 weeks of gestation. Which of the following findings indicates that the client should be referred to a registered dietician?

A nurse is providing teaching to the guardians of a preterm newborn about temperature instability. Which of the following statements should the nurse make?

A nurse is providing information about newborn security to the parents of a newborn. Which of the following instructions should the nurse provide?

A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet. Which of the following Questions should the nurse ask to assess the client’s dietary intake?

A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus (MRSA). Which type of isolation precautions should the nurse initiate?

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?