Health Promotion and Maintenance
24. An RN is completing a home visit with a client who delivered a full-term infant 4 days ago. The client states that she is exclusively bottle feeding her infant. Upon assessment, the RN notes white, curdlike patches on the newborn's oral mucous membranes. Which action should the RN take?
. Explain that the newborn will need to receive some medication.
. Suggest that the newborn's formula be changed.
. Remind the caregiver not to let the infant sleep with the bottle.
. Determine the baby's blood glucose level.
Test-Taking Tip
Consider the outcome for each option; will the intervention solve the issue? If not, eliminate the answer.
Content Area: Child Health, Newborn; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Health Promotion and Maintenance
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Answer 1 is correct because the newborn most likely has thrush (oral candidiasis): white plaque on the oral mucous membranes, gums, or tongue. Treatment usually includes good hand washing and nystatin (Mycostatin). Answer 2 is incorrect because thrush in newborns is caused by poor hand washing or exposure to Candida during vaginal birth. Changing formula is unnecessary and will not cure the thrush. Answer 3 is incorrect because thrush in newborns is not caused by bottle propping. Tooth decay is related to sleeping with a bottle. Answer 4 is incorrect because thrush in newborns is caused by poor hand washing or exposure to Candida during vaginal birth, not glucose.