The nurse is examining a 12-month-old who was brought to the clinic for persistent, painful diaper rash after being treated for otitis media with antibiotics. The nurse finds red perianal inflammation with satellite lesions. This is most likely caused by:

Choice A reason: This is not a correct statement, as coarse breath sounds, abnormal ECG, and joint pain are not typical signs and symptoms of Kawasaki disease. Coarse breath sounds may indicate respiratory infection or congestion, abnormal ECG may indicate cardiac arrhythmia or damage, and joint pain may indicate arthritis or inflammation¹.

Choice B reason: This is not a correct statement, as murmur, tachycardia, and low erythrocyte sedimentation rate are not typical signs and symptoms of Kawasaki disease. Murmur may indicate a heart valve problem, tachycardia may indicate fever or dehydration, and low erythrocyte sedimentation rate may indicate anemia or inflammation¹.

Choice C reason: This is the correct statement, as fever, "strawberry tongue", and peeling palms and soles are typical signs and symptoms of Kawasaki disease. Fever is the most common symptom, lasting for more than five days and not responding to antibiotics or antipyretics. "Strawberry tongue" is a term used to describe the red, swollen, and cracked appearance of the tongue. Peeling palms and soles are a late sign, occurring in the second or third week of the illness¹².

Choice D reason: This is not a correct statement, as abdominal pain, vomiting, and restlessness are not typical signs and symptoms of Kawasaki disease. Abdominal pain and vomiting may indicate gastrointestinal infection or irritation, and restlessness may indicate discomfort or anxiety¹.

Choice A reason: Encouraging and helping mother to breastfeed is a supportive and beneficial nursing intervention for a mother who has given birth to an infant with a cleft palate. Breastfeeding provides optimal nutrition, immunity, and bonding for the infant, and may also help prevent infections and promote healing of the cleft. Breastfeeding may be possible for some infants with cleft palate, especially if the cleft is mild or only affects the soft palate. The nurse should assist the mother with positioning, latching, and using devices such as a nipple shield, a breast pump, or a supplemental nursing system. The nurse should also monitor the infant's weight gain, hydration, and output, and provide emotional support and education to the mother.

Choice B reason: Teaching mother to feed breast milk by gavage is not a necessary or desirable nursing intervention for a mother who has given birth to an infant with a cleft palate. Gavage feeding is a method of providing nutrition through a tube that is inserted through the nose or mouth into the stomach. It is usually used for infants who have severe feeding difficulties or other medical conditions that require tube feeding. However, most infants with cleft palate can be fed orally with proper techniques and equipment, and do not need gavage feeding. Gavage feeding may have complications such as infection, irritation, displacement, or obstruction of the tube. It may also interfere with the infant's oral development and bonding with the mother.

Choice C reason: Giving medication to suppress lactation is not a helpful or respectful nursing intervention for a mother who has given birth to an infant with a cleft palate. Medication to suppress lactation is a drug that inhibits the production of breast milk. It is usually used for mothers who choose not to breastfeed or who have medical contraindications to breastfeeding. However, a cleft palate is not a contraindication to breastfeeding, and the mother may still want to breastfeed or express breast milk for her infant. Giving medication to suppress lactation may cause side effects such as nausea, headache, or depression. It may also deprive the infant of the benefits of breast milk, and the mother of the choice and satisfaction of breastfeeding.

Choice D reason: Providing mother with the appropriate formula for the patient is not a sufficient or comprehensive nursing intervention for a mother who has given birth to an infant with a cleft palate. Formula is an artificial substitute for breast milk that provides nutrition for infants who cannot or do not breastfeed. Formula may be used for infants with cleft palate, especially if breastfeeding is not possible or adequate. However, formula does not provide the same immunity, protection, and bonding as breast milk. Providing formula alone does not address the mother's needs, preferences, or feelings about feeding her infant. The nurse should also offer other options, such as expressing breast milk, using a special bottle or cup, or combining breastfeeding and formula feeding. The nurse should also teach the mother how to prepare, store, and administer the formula safely and hygienically.