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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?
- A. Administer broad-spectrum antibiotics.
- B. Monitor the rectal temperature every 4 hr.
- C. Cleanse the site with povidone-iodine.
- D. Prepare for surgical closure after 72 hr.
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. This is crucial in preventing infection, as the leaking cerebrospinal fluid puts the newborn at risk for meningitis. Antibiotics help reduce the risk of infection until surgical closure can be performed. Monitoring rectal temperature (B) is important but not the priority. Cleansing the site with povidone-iodine (C) may further irritate the area. Planning for surgical closure after 72 hr (D) is important, but immediate infection prevention is the priority.
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Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.
- A. Educate the parents to begin range of motion exercises on the affected arm after 1 week.
- B. Assess for grasp reflex in the affected extremity.
- C. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt.
- D. Instruct parents to limit physical handling for 2 weeks.
Correct Answer:
Rationale: Educate the parents to begin range of motion exercises on the affected arm after 1 week is indicated. Passive ROM exercises of the arm are indicated to restore function of the extremity. The initiation of these exercises is delayed for approximately 1 week to prevent additional injury to the brachial plexus. Assess for grasp reflex in the affected extremity is indicated. With Erb-Duchenne paralysis, only the upper arm is affected. The function of the wrists and fingers should be unaffected; the nurse should assess for a palmar grasp reflex.Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt is indicated. Intermittent immobilization of the affected arm across the newborn's abdomen can be achieved by pinning the sleeve to the shirt.Instruct parents to limit physical handling for 2 weeks is contraindicated. Parents and guardians should participate in the physical care of their newborn to increase parental-infant attachment. Providing education and practice opportunities for the parents will decrease their fears of injuring the newborn and increase confidence and bonding.
The nurse is reviewing the provider's prescriptions in the adolescent's medical chart.Complete the following sentence by using the list of options. The nurse should first implement ---------------------- and
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- A. Providing education on medications
- B. Administering ceftriaxone
- C. Administering metronidazole and educating on condom use
Correct Answer: A,B
Rationale: Providing education on medications is correct. The nurse should first educate the adolescent regarding medications because clients have the right to know the purpose and potential adverse reactions of all prescribed medications before receiving them. An understanding of the prescribed medications will increase the likelihood that the adolescent will adhere to the prescribed therapy. Scheduling follow-up appointments and administering doxycycline is incorrect. The nurse should schedule the adolescent for a follow-up appointment; however, there is another action that the nurse should take first. The nurse should not administer
doxycycline because it is a prescription for the adolescent to begin once discharged, and the prescription will be provided to the adolescent upon discharge; therefore, there is another action that the nurse should take.Administering ceftriaxone is correct. Ceftriaxone is designated as a NOW prescription, which means it should be given within 90 min of the provider writing the prescription. The nurse should administer ceftriaxone after educating the adolescent about the purpose and potential adverse reactions of the medication. Administering metronidazole and educating on condom use is incorrect. The nurse should not administer metronidazole because it is a prescription for the adolescent to begin once discharged, and the prescription will be provided to the adolescent upon discharge; therefore, there is another action that the nurse should take. The nurse should educate the adolescent regarding condom use; however, there is another action that the nurse should take first.
A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?
- A. Temperature 37.4°C (99.3°F)
- B. WBC count 9,000/mm3
- C. Uterine tenderness
- D. Scant lochia
Correct Answer: C
Rationale: The correct answer is C: Uterine tenderness. Endometritis is an infection of the uterine lining, causing inflammation and tenderness. This finding is expected in a client with endometritis. A: A slightly elevated temperature may be present, but it is not specific to endometritis. B: A normal WBC count does not rule out endometritis. D: Scant lochia is not a characteristic finding in endometritis. Other answer choices are not provided, but uterine tenderness is the most relevant symptom in this scenario.
A nurse is caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?
- A. Thick, white vaginal discharge
- B. Urinary frequency
- C. Vulva lesions
- D. Malodorous discharge
Correct Answer: D
Rationale: The correct answer is D: Malodorous discharge. Trichomoniasis is a sexually transmitted infection caused by a parasite, resulting in a foul-smelling, greenish-yellow vaginal discharge. This characteristic discharge is due to the infection and inflammation of the vaginal mucosa. Option A (Thick, white vaginal discharge) is more indicative of a yeast infection, while option B (Urinary frequency) is not specific to trichomoniasis. Option C (Vulva lesions) is not a common symptom of trichomoniasis. Overall, the malodorous discharge is the key finding in diagnosing trichomoniasis at 20 weeks of gestation.
A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identity as a manifestation of Increased risk for child abuse?
- A. I want to meet other parents to see if they are going through the same things.
- B. I try to respond to the baby quickly so she doesn't cry very long.
- C. I think the baby should be sleeping through the night by now.
- D. I have several friends who come by to help out with the baby.
Correct Answer: C
Rationale: Expecting a newborn to sleep through the night is unrealistic and may indicate frustration or lack of understanding, which are risk factors for child abuse. Other statements reflect normal parental concerns or support systems.