with Answers Graded A
The nurse is caring for an infant who has been prescribed nystatin (Mycostatin). The nurse
teaches the mother how to prevent aggravation of oral thrush. Which statements by the
mother indicate the need for further teaching? Select all that apply. - Ans -"I should
boil the pacifier for at least 20 minutes on alternate days."
"I should apply the medication at least 20 minutes before feeding."
"I should boil the reusable nipples for at least 5 minutes after washing."
Rationale: Nystatin (Mycostatin) is used to treat oral thrush in infants. Boiling the pacifier
for 20 minutes on alternate days can increase the risk of infection because daily boiling of
the pacifier is the best way to ensure efficient sterilization and killing of pathogens.
Therefore, pacifiers should be boiled daily for at least 20 minutes. Nystatin (Mycostatin)
should be administered to the child after feeding, not before feeding. Reusable nipples
should be boiled at least 20 minutes after washing to remove spores, which are heat-
resistant. Rinsing the infant's mouth after feeding with plain water reduces the risk of
infection in the infant. Nystatin (Mycostatin) should be applied four times a day to the
infant's oral cavity to ensure effective drug action.
Which assessment findings of a child would indicate a need for genetic consultation?
Select all that apply. - Ans -Visual or hearing problems , Family history of mental
illness, Development and speech delays, Excessive bleeding or excessive clotting
Rationale: Visual or hearing problems may indicate a genetic disorder and should be
assessed thoroughly. Mental illness is a hereditary disorder that can be transmitted
through genes to the child. Therefore, a family history of any mental illness indicates a need
for genetic consultation so that preventive measures and treatment can be initiated.
Development and speech delays may indicate a genetic disorder, like autism or another
behavioral disorder. Bleeding disorders like sickle cell anemia are also inherited and need
genetic consultation. Fetal alcohol syndrome is not inherited, but caused by maternal
consumption of alcohol during pregnancy.
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, While caring for a breastfeeding patient, the nurse instructs the patient to begin feeding the
infant when the child is quiet and alert. The nurse observes that the infant begins fussing
and crying. What behavior does the infant display? - Ans -Prefeeding behavior
Rationale: The infant is crying and fussing, which indicates high arousal and hunger. This
behavior is termed prefeeding behavior. To enable the infant to gain a proper grasp of the
mother's breast, the nurse instructs the mother to begin feeding before the onset of
prefeeding behavior. The infant who is satisfied with the feeding exhibits satiety and usually
becomes calm and falls asleep. Sucking movements and rooting reflex indicate approach
behavior. Consummatory behavior is demonstrated by coordinated sucking and
swallowing.
What are the different patterns of physical development and maturation of neuromuscular
functions in a child? Select all that apply. - Ans -Proximodistal, Cephalocaudal ,
Differentiation
Rationale: Proximodistal development refers to near-to-far development in the infant. The
infant first gains motor control of the shoulder and then the hands. Additionally, the infant's
central nervous system (CNS) develops more rapidly than the peripheral nervous system
(PNS). Cephalocaudal is the head-to-tail growth seen in a child. The infant achieves control
of the head first, followed by the trunks and extremities. Infants gain control of their hands
before they are able to control their feet. Differentiation refers to the development from
simple operations to more complex activities and functions. For instance, early embryonal
cells develop into an immensely complex organism made up of highly specialized and
diversified cells, tissues, and organs. Sensorimotor development is not a pattern of
development, but a part of the theory of cognitive development as proposed by Piaget.
Fowler proposed the undifferentiated stage of spiritual development, in which the child has
no concept of right and wrong to guide the child's behavior.
While assessing a stool sample from an infant, the nurse finds that the infant has passed
golden-colored stool. What does the nurse interpret from this finding? - Ans -The
infant is breastfeeding.
Rationale: An infant who is being breastfed will pass golden-colored stool. An infant with
jaundice will pass greenish-yellow stools due to excess bilirubin. An infant who is on
formula milk will pass pale-yellow to light-brown stools. The first stool passed by an infant
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after birth is called meconium and is black and tarry.