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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Related Questions
Correct Answer is A
Explanation
A. "The car seat should be positioned in the car at a 45-degree angle." This statement is correct and indicates an understanding of car seat safety. Positioning the car seat at a 45-degree angle helps prevent the newborn's head from flopping forward, which could obstruct the airway. Proper positioning ensures both safety and comfort during travel.
B. "My baby will need a car seat challenge test before discharge." This statement is incorrect for a newborn delivered at 38 weeks of gestation. A car seat challenge test is typically required for premature infants (less than 37 weeks gestation) or those with specific health conditions to ensure they can tolerate sitting in a car seat without respiratory or cardiac issues.
C. "When my baby is 1 year old, I can turn their car seat facing forward." Incorrect. It is recommended to keep infants in a rear-facing car seat until they reach the maximum height or weight limit recommended by the car seat manufacturer, typically well beyond the first year of life.
D. “I can use a sleep sack to keep my baby warm in the car seat." While using a sleep sack can keep a baby warm, it's important not to use any additional padding or blankets in the car seat as they can interfere with the proper harness fit and increase the risk of injury in the event of a crash.
Correct Answer is A
Explanation
A.
Rationale:
A. Massaging the client's fundus is the priority action to address excessive vaginal bleeding.
Massaging the fundus helps promote uterine contractions, which can help control bleeding by compressing blood vessels.
B. Emptying the client's bladder may be necessary to relieve pressure on the uterus, but it is not the first priority when addressing excessive bleeding.
C. Providing oxygen may be indicated if the client shows signs of hypoxia, but it is not the first action to address excessive vaginal bleeding.
D. Administering oxytocin may be necessary to help control bleeding, but massaging the fundus is the first step in managing postpartum hemorrhage.
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