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 C
Explanation
This can be a sign of magnesium toxicity and should be reported to the provider.
Choice A is incorrect because magnesium sulfate is used to treat hypertension associated with preeclampsia.
Choice B is incorrect because a respiratory rate of 16/min is within normal range.
Choice D is incorrect because hyperglycemia is not a known adverse reaction to magnesium sulfate.
Correct Answer is A
Explanation
Rust-stained urine.
Rust-stained urine in a newborn can be a sign of a serious medical condition and should be reported to the provider.
Choice B is not the answer because subconjunctival hemorrhage in a newborn is usually normal and harmless.
It may be caused by pressure changes during vaginal delivery and will disappear on its own after two or three weeks.
Choice C is not the answer because single palmar creases develop while a baby
is growing in the womb and appear in about 1 out of 30 people.
While some single palmar creases may indicate problems with development and be linked with certain disorders, it is not necessarily a cause for concern.
Choice D is not the answer because transient circumoral cyanosis refers to blue discoloration around the mouth only and is usually seen in infants.
It’s often considered a type of acrocyanosis which happens when small blood vessels shrink in response to cold.
This is very normal in infants during the first few days after birth.
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