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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
Rationale:
A. Excessive crying:
Correct answer. Neonatal abstinence syndrome (NAS) often presents with irritability, inconsolable crying, and difficulty soothing.
B. Decreased muscle tone: NAS can cause hypertonia or increased muscle tone rather than decreased muscle tone.
C. Absent Moro reflex: NAS may cause hyperactive Moro reflex rather than absent.
D. Diminished deep tendon reflexes: NAS can cause hyperactive deep tendon reflexes rather than diminished.
Correct Answer is A
Explanation
A.
Rationale:
A. Breast tenderness:
Correct answer. Clomiphene citrate, a medication used to induce ovulation, can cause breast tenderness as a common adverse effect due to its estrogenic effects.
B. Chills: Chills are not a common adverse effect of clomiphene citrate.
C. Tinnitus: Tinnitus, or ringing in the ears, is not typically associated with clomiphene citrate use.
D. Urinary frequency: Urinary frequency is not a common adverse effect of clomiphene citrate.
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