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
Constipation is a common postpartum issue due to decreased bowel motility, dehydration, and fear of pain during defecation. Suppositories are a common treatment option to help relieve constipation in postpartum clients. However, there are certain contraindications to the use of suppositories.
Option A, abdominal distention, is not a contraindication to the use of a suppository, as it can help relieve the distention and promote bowel movement.
Option C, vaginal candidiasis, is also not a contraindication to the use of a suppository. In fact, antifungal suppositories may be prescribed to treat the candidiasis.
Option D, afterpain, is not a contraindication to the use of a suppository, as afterpains are normal
postpartum contractions that occur as the uterus returns to its pre-pregnancy size.
Option B, third-degree perineal laceration, is a contraindication to the use of a suppository. The suppository can cause further trauma to the already injured perineal area and delay the healing process. In this case, alternative treatment options, such as stool softeners or laxatives, should be considered.
Correct Answer is D
Explanation
New onset tachypnea in a newborn is a concerning symptom and requires immediate assessment by the nurse. Tachypnea is defined as a respiratory rate greater than 60 breaths per minute in a newborn. It can be a sign of respiratory distress or other serious conditions, such as sepsis or cardiac disease.
Option a. A newborn who has a short frenulum and is having difficulty breastfeeding is a common issue that can be addressed by the nurse or lactation consultant. It does not require immediate assessment.
Option b. A newborn who is 24 hr old and has not had a meconium stool may be concerning, but it is not an emergency situation. It may be a sign of a bowel obstruction, but it is not an urgent condition.
Option c. A newborn who is 10 hr old and has blood-tinged discharge in her diaper may be a concerning symptom, but it is not an emergency situation. It may be related to maternal hormones and is a common finding in newborns.
Therefore, the correct option is d. A newborn who is 10 hr old and has new onset tachypnea. The nurse should assess the newborn's respiratory status, heart rate, and oxygen saturation and notify the healthcare provider immediately if there are any concerns.
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