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?
Monitor the rectal temperature every 4 hr
Administer broad-spectrum antibiotics
Cleanse the site with povidone-iodine
Prepare for surgical closure after 72 hr
The Correct Answer is B
Rationale for A: Monitoring the rectal temperature is important, but every 4 hours may not be frequent enough to assess for signs of infection or other complications in a newborn with myelomeningocele.
Rationale for B: Administering broad-spectrum antibiotics is crucial to prevent infection, especially in cases of myelomeningocele where the protective covering of the spinal cord is compromised.
Rationale for C: Cleansing the site with povidone-iodine is not recommended as it can be irritating and potentially harmful to the delicate tissue surrounding the defect.
Rationale for D: Surgical closure is typically performed as soon as possible after birth, often within 24 hours, rather than delaying it for 72 hours.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Counterpressure is a technique that involves applying pressure to specific areas of the body during labor to help alleviate pain and discomfort. This technique is particularly helpful during the active phase of labor when contractions are strong and painful. The most common area to apply counterpressure is the lower back, as this is where many women experience the most intense pain during labor.
Option A “Your partner will apply pressure to the top of your uterus during contractions” is incorrect as applying pressure to the top of the uterus is not a recommended technique and could be harmful to the mother and the baby.
Option C “Your partner will apply continuous, firm pressure between your thumb and index finger” is incorrect as this technique is used to alleviate pain and discomfort during contractions in the hand and wrist, not for counterpressure.
Option D “Your partner will apply upward pressure on your lower abdomen between contractions” is incorrect as this technique is used to help turn a baby who is in a posterior position, not for counterpressure.
Correct Answer is A
Explanation
Hypovolemic shock occurs when there is a significant decrease in the circulating blood volume, which can happen after severe bleeding during childbirth. The body tries to compensate for this decrease in blood volume by constricting blood vessels and increasing heart rate. However, these compensatory mechanisms can only last for a certain amount of time before the body starts to show signs of shock.
One of the hallmark signs of hypovolemic shock is cool, clammy skin, which is caused by the body diverting blood flow away from the skin to maintain perfusion to vital organs. Other common signs and symptoms include tachycardia (fast heart rate), hypotension (low blood pressure), tachypnea (fast breathing rate), decreased urine output, and altered mental status.
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