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
Explanation
Magnesium sulfate is used to prevent seizures in women with preeclampsia.
However, taking too much magnesium can be life-threatening to both mother and child.
In women, one of the most common symptoms of magnesium toxicity is muscle weakness12.
Choice B is not an answer because increased fetal movement is not a symptom of magnesium toxicity.
Choice C is not an answer because increased respiratory rate is not a symptom of magnesium toxicity.
Choice D is not an answer because increased urinary output is not a symptom of magnesium toxicity.
Correct Answer is D
Explanation
A nurse caring for a client following a vaginal delivery of a term fetal demise should offer the client the option to bathe and dress their baby if they would like to.
Choice A is incorrect because it is not appropriate for the nurse to suggest that the client should name the baby.
Choice B is incorrect because it is not appropriate for the nurse to suggest that not holding the baby will make letting go much harder.
Choice C is incorrect because it is not appropriate for the nurse to make assumptions about future pregnancies.
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