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 ["A","E"]
Explanation
The nurse should plan to immunize the client with the inactivated influenza vaccine (A) and the diphtheria-acellular pertussis vaccine (E).
The Centers for Disease Control and Prevention (CDC) recommends that pregnant women get two vaccines during every pregnancy: the inactivated flu vaccine and the Tdap vaccine.
The other vaccines listed are not recommended during pregnancy:
- The human papillomavirus vaccine is not recommended during pregnancy.
- The varicella vaccine is not recommended during pregnancy.
- The measles, mumps, and rubella vaccine is not recommended during pregnancy.
Correct Answer is C
Explanation
A nurse caring for a newborn who has exstrophy of the bladder should cover the newborn’s bladder with a sterile, non-adherent dressing prior to the beginning of surgical correction.
Choice A is incorrect because it is not necessary to restrict the newborn’s fluid intake.
Choice B is incorrect because it is not necessary to keep the newborn in a side- lying position.
Choice D is incorrect because it is not appropriate to exert gentle pressure on
the newborn’s bladder with sterile gauze.
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