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?
Prepare for surgical closure after 72 hr.
Administer broad-spectrum antibiotics.
Cleanse the site with povidone-iodine.
Monitor the rectal temperature every 4 hr.
The Correct Answer is B
The correct answer is. Administering broad-spectrum antibiotics.
Cleansing the site with povidone-iodine is not recommended because it can be irritating and potentially harmful to the exposed neural tissue.
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.
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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
“Use an automatic puncture device on the heel.” This is the most common and minimally invasive method to draw capillary blood from an infant for medical testing.
Choice A is incorrect because the heel should be punctured on the outer aspect of the foot to avoid damaging the calcaneus bone.
Choice C is incorrect because the heel should be cleansed with an alcohol swab
before, not after, the procedure.
Choice D is incorrect because there is no need to place an ice pack on the newborn’s heel before the procedure.
Correct Answer is D
Explanation
A nurse caring for a client who is receiving prenatal care and is at her 24-week appointment should plan to conduct a one-hour glucose tolerance test.
This test is done to screen for gestational diabetes that can develop during pregnancy.
Choice A, Group B strep culture, is not an answer because it is a test usually done between 35-37 weeks of pregnancy to check for the presence of Group B streptococcus bacteria.
Choice B, Rubella titer, is not an answer because it is a blood test usually done early in pregnancy to check for immunity to rubella.
Choice C, Blood type and Rh, is not an answer because it is a blood test usually done early in pregnancy to determine the mother’s blood type and Rh factor.
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