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?
Administer broad-spectrum antibiotics.
Cleanse the site with povidone-iodine.
Monitor the rectal temperature every 4 hr.
Prepare for surgical closure after 72 hr.
The Correct Answer is A
A. Administering broad-spectrum antibiotics is important because a leaking myelomeningocele increases the newborn’s risk for infection, including meningitis. Early prophylactic antibiotic therapy helps prevent serious complications.
B. Cleansing the site with povidone-iodine is not recommended because antiseptics can irritate neural tissue and worsen leakage. The sac should be kept sterile and moist using a saline-soaked sterile dressing instead.
C. Monitoring rectal temperature is contraindicated because rectal manipulation can risk trauma to the myelomeningocele sac. Noninvasive temperature monitoring, such as axillary measurement, is safer.
D. Surgical closure should be performed as soon as possible, ideally within 24–48 hours after birth, rather than waiting 72 hours, to reduce the risk of infection and further neurologic damage.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. When teaching parents about the Plastibell circumcision technique, it's important to explain that a yellow exudate (sometimes referred to as granulation tissue) will typically form at the surgical site within 24 hours after the procedure. This is a normal part of the healing process and should not be a cause for concern.
B. The end of the penis will likely get red, then develop a yellow discharge, and finally scab over, “like a skinned knee.” This is the normal healing process and will progress over the 7-14 days that the Plastibell Ring stays on. The correct size Plastibell Ring is secured with a string and the excess skin trimmed. The skin that overlaps the ring will turn dark “like the umbilical cord” before the ring falls off at 7-14 days.
C. The Plastibell is typically left in place for several days, not removed 4 hours after the procedure.
D. Ensuring the newborn's diaper is snug may help keep the Plastibell in place, but it is not the most crucial aspect of care related to the circumcision technique.
Correct Answer is D
Explanation
A. Subconjunctival hemorrhage is common in newborns due to birth trauma and usually resolves without intervention. It does not typically require reporting.
B. Rust-stained urine in the first few days of life is caused by uric acid crystals and is considered a normal finding during neonatal adaptation.
C. Transient circumoral cyanosis (bluish discoloration around the mouth) can occur immediately after birth due to immature peripheral circulation and generally resolves quickly with warming and oxygenation.
D. A single palmar crease, especially if present on one hand, can be associated with chromosomal abnormalities such as trisomy 21 (Down syndrome). This finding warrants further evaluation and should be reported to the provider for assessment and potential diagnostic follow-up.
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