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 B
Rationale:
A. Administering broad-spectrum antibiotics is not indicated as the first-line intervention for a myelomeningocele that is leaking cerebrospinal fluid. Antibiotics may be initiated later if signs of infection develop.
B. Cleansing the site with povidone-iodine is essential to reduce the risk of infection and prevent contamination of the exposed neural tissue.
C. Monitoring the rectal temperature every 4 hours is important for assessing the newborn's overall health but is not specific to managing a myelomeningocele.
D. Surgical closure of the myelomeningocele may be necessary, but immediate care focuses on protecting the exposed neural tissue and preventing infection before surgical intervention.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Polyuria is not a common adverse effect of opioid analgesics administered via epidural block.
B. Bilateral crackles are not typically associated with opioid analgesics administered via epidural block.
C. Hyperglycemia (high blood sugar levels) is not a common adverse effect of opioid analgesics administered via epidural block.
D. Hypotension is a common adverse effect of opioid analgesics administered via epidural block. Opioids can cause peripheral vasodilation and decreased systemic vascular resistance, leading to a drop in blood pressure.
Correct Answer is B
Explanation
Rationale:
A. Avoiding sterile vaginal examinations is not the appropriate action for managing uterine atony and postpartum hemorrhage. Vaginal examinations may be necessary to assess the degree of cervical dilation and to identify potential causes of bleeding.
B. Anticipating a prescription for misoprostol is appropriate for managing uterine atony and postpartum hemorrhage. Misoprostol is a prostaglandin analog that helps to promote uterine contractions and control bleeding.
C. Obtaining a specimen for a Kleihauer-Betke test is not the priority action in this situation. The Kleihauer-Betke test is used to estimate the amount of fetal-maternal hemorrhage in Rh-negative mothers.
D. Administering betamethasone IM is not indicated for the management of uterine atony and postpartum hemorrhage. Betamethasone is a corticosteroid used to promote fetal lung maturity when preterm birth is anticipated.
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