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.

Administer broad-spectrum antibiotics.

Prepare for surgical closure after 72 hours.

Monitor the rectal temperature every 4 hours.

Answer and Explanation

The Correct Answer is B

A. Using povidone-iodine on the site of a myelomeningocele is not recommended as it can be irritating to the tissue and might not be safe for use on open neural tissue. The focus should be on preventing infection through other means.

B. Administering broad-spectrum antibiotics is crucial as the cerebrospinal fluid (CSF) leak increases the risk of infection, such as meningitis. Antibiotics help protect the newborn from potentially serious infections until surgical repair can be performed.

C. Surgical closure of a myelomeningocele is typically done as soon as possible, often within 24-48 hours after birth, to minimize the risk of infection and further damage to the exposed spinal cord.

D. While monitoring temperature is important, rectal temperature measurement is not recommended for a newborn with a myelomeningocele due to the risk of causing further complications. Axillary temperature measurement would be safer and less invasive.

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Correct Answer is B

Explanation

Among the given options, the client who has hyperemesis gravidarum and a sodium level of 110 mEq/L should be assessed first. Hyperemesis gravidarum is a condition characterized by severe and persistent vomiting during pregnancy, leading to dehydration and electrolyte imbalances. A sodium level of 110 mEq/L indicates hyponatremia, which is an abnormally low level of sodium in the blood.

Hyponatremia can lead to serious complications, including neurological symptoms such as confusion, seizures, and coma. Prompt assessment and intervention are necessary to correct the electrolyte imbalance and prevent further complications.

Option a) A client with preeclampsia and a creatinine level of 1.1 mg/dL should be monitored closely, as elevated creatinine levels can indicate impaired kidney function. However, in this scenario, the client with hyperemesis gravidarum and severe hyponatremia requires more immediate attention due to the potential for neurological complications.

Option c) A client with diabetes mellitus and an HbA1C of 5.8% may require further management and monitoring, but it does not present an immediate risk or urgency compared to the client with hyperemesis gravidarum and severe hyponatremia.

Option d) A client with placenta previa and a hematocrit of 35% may need close monitoring for potential bleeding, but it does not pose an immediate threat compared to the client with hyperemesis gravidarum and severe hyponatremia.

Therefore, the nurse should assess the client who has hyperemesis gravidarum and a sodium level of 110 mEq/L as the first priority due to the risk of complications associated with severe hyponatremia.

A. Compress the bulb syringe. B. Place the bulb syringe in the newborn's mouth. C. Assess the newborn for reﬂex bradycardia. D. Use the bulb syringe to suction the newborns nose.

Correct Answer is A, B, D, C

Explanation

Compressing the bulb syringe before placing it in the newborn's mouth or nose creates a vacuum that allows the suctioning of the mucus¹².
Placing the bulb syringe in the newborn's mouth first helps clear the oral airway and prevent aspiration of mucus into the lungs¹². The nozzle of the bulb syringe should be gently inserted into the corner of the mouth, not the center, to avoid stimulating the gag reﬂex¹².
Using the bulb syringe to suction the newborns nose helps clear the nasal airway and improve breathing¹². The nozzle of the bulb syringe should be gently inserted into one nostril at a time, and not too far, to avoid injuring the nasal mucosa¹².
Assessing the newborn for reﬂex bradycardia helps monitor for any adverse eﬀects of suctioning, such as a decrease in heart rate due to vagal stimulation¹³. Reﬂex bradycardia can cause hypoxia and acidosis in newborns, and may require oxygen administration or resuscitation³. The normal heart rate for a newborn is 120 to 160 beats per minute³.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is A, B, D, C

Explanation

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