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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. A blood pressure of 120/70 mm Hg is within the normal range for a postpartum client and does not require immediate reporting to the provider.
B. Cool clammy skin may indicate hypoperfusion or inadequate blood flow, which could be a sign of hemorrhage or other circulatory issues. This finding should be reported promptly for further evaluation and intervention.
C. Moderate lochia serosa is a normal finding in the early postpartum period and does not typically require immediate reporting.
D. A heart rate of 89/min is within the normal range for a postpartum client and does not require immediate reporting to the provider.
Correct Answer is A
Explanation
A.
Rationale:
A. Maternal cytomegalovirus can be transmitted to the newborn through contact with infected bodily fluids, including saliva and urine.
B. Airborne precautions are not necessary for cytomegalovirus, as it is primarily transmitted through contact with infected bodily fluids, not through airborne droplets.
C. There is no prophylactic treatment with acyclovir for cytomegalovirus; treatment options are limited and typically reserved for severe cases.
D. Lesions are not typically visible on the mother's genitalia with cytomegalovirus; the virus is often asymptomatic or causes mild symptoms in healthy adults.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.