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?

Explanation

Choice A Reason:

Vaginal candidiasis is an infection that affects the vagina and does not directly contraindicate the use of a rectal suppository. However, if the suppository is intended for vaginal use, it may not be suitable in the presence of vaginal candidiasis due to the risk of exacerbating the infection.

Choice B Reason:

Afterpains refer to uterine contractions that occur after childbirth as the uterus returns to its normal size. Afterpains are not a contraindication to the use of a rectal suppository for constipation.

Choice C Reason:

Third-degree perineal laceration is correct. A suppository is a medication delivery system that is inserted into the rectum or vagina. In the case of constipation, rectal suppositories are often used to stimulate bowel movements. However, in the presence of a third-degree perineal laceration, the insertion of a rectal suppository could potentially worsen the injury or cause discomfort.

Choice D Reason:

Abdominal distention, or bloating, is a common symptom that may accompany constipation. It is not a contraindication to the use of a rectal suppository for constipation; in fact, relieving constipation may help alleviate abdominal distention.

Explanation

Choice A Reason:

"When was the last time you ate meat?" This question is not relevant for a client who adheres to a vegan diet, as they abstain from consuming meat or animal products.

Choice B Reason:

"How much protein do you eat in a day?" Assessing the client's protein intake is essential because protein is a critical component of a healthy diet, especially during pregnancy. Since the client adheres to a vegan diet, obtaining an understanding of their protein intake is particularly important, as plant-based protein sources may require more careful planning to ensure adequate intake. Adequate protein intake is vital for supporting maternal tissue growth, blood volume expansion, and fetal development.

Choice C Reason:

"Are you taking a Vitamin C supplement?" While vitamin C is important, especially for individuals following a vegan diet to aid in the absorption of non-heme iron from plant-based sources, it may not be the primary concern when assessing overall dietary intake. Additionally, vitamin C supplementation may not be necessary if the client consumes a varied diet rich in fruits and vegetables.

Choice D Reason:

"Have you considered eating shellfish?" This question is not appropriate for a client who adheres to a vegan diet, as shellfish are animal products and are not consumed in a vegan diet. Instead, the focus should be on assessing the client's intake of plant-based protein sources.