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.

Answer and Explanation

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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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.

A. Blood pressure 80/50 mm Hg B. Cloudy urine C. Moderate lochia rubra D. Fundus firm to palpation E. Fundus at level of umbilicus

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"}}

Explanation

Blood pressure 80/50 mm Hg: Indication of Potential Worsening Condition - A decrease in blood pressure may indicate hypovolemic shock due to ongoing or worsening postpartum hemorrhage.

Cloudy urine: Indication of Potential Worsening Condition - Cloudy urine may indicate a urinary tract infection or another complication, which can worsen the client's condition.

Moderate lochia rubra: Indication of Potential Worsening Condition - Continued moderate lochia rubra suggests ongoing or worsening postpartum hemorrhage.

Fundus firm to palpation: Indication of Potential Improvement - A firm fundus suggests effective uterine contraction and control of bleeding, indicating potential improvement.

Fundus at level of umbilicus: Indication of Potential Worsening Condition - The fundus being at the level of the umbilicus suggests uterine atony or continued bleeding, which is a worsening condition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is 3 days postpartum. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"}}

Explanation

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