chapter 20 PREP U
48 mL
The infant is listless with sunken fontanels (fontanelles) and has been diagnosed with dehydration. The infant is still producing at least 1 mL/kg each hour of urine. The infant weighs 13.2 lb (6 kg). At the minimum, how many milliliters of urine will the infant produce during the next 8-hour shift? Record your answer using a whole number.
metabolic alkalosis
A child with severe vomiting for 3 days presents with hypopnea and hypokalemia. The nurse reports to the provider that this child is exhibiting signs of which condition?
"I can tape a quarter over the hernia to reduce it."
The nurse is caring for a 2-year-old boy with an umbilical hernia and is teaching the mother about this condition. Which response from the mother indicates a need for further teaching?
"Can you blow this cotton ball across the tray?"
The nurse is caring for a 4-year-old boy who has undergone an appendectomy. The child is unwilling to use the incentive spirometer. Which approach would be most appropriate to elicit the child's cooperation?
Take a stool culture
The nurse is caring for a 6-month-old infant who was admitted to the emergency department 24 hours ago with signs of severe diarrhea. The infant's rectal temperature is 104°F (40°C), with weak and rapid pulse and respirations. The skin is pale and cool. The child is on IV rehydration therapy, but the diarrhea is persisting. The infant has not voided since being admitted. Which is the priority nursing intervention?
mother age 42 with pregnancy
The nurse is reviewing the medical record of a child with a cleft lip and palate. When reviewing the child's history, what would the nurse identify as a risk factor for this condition?
"I should position him on his abdomen with knees bent."
The nurse is teaching the mother of a 5-year-old boy with a history of impaction how to administer enemas at home. Which response from the mother indicates a need for further teaching?
Ask the parents if they have any questions regarding the care of their child.
The nurse observes the interactions of parents with their infant who was born with a cleft lip. The mother is attempting to feed the baby, but does not make eye contact. The father is watching television with his back turned to the mother and baby. What psychosocial nursing intervention would be most helpful to this family?
Lower right
A 10-year-old male presents with low-grade fever, nausea, and abdominal pain. The nurse examining him suspects appendicitis and checks for rebound tenderness in what quadrant?
No intervention is needed, as the opening will most likely close spontaneously.
A 3-month-old girl is found to have an umbilical hernia at a well visit. On examination, the nurse discovers that the fascial ring through which the intestine protrudes is about 1 cm in diameter. Which statement by the nurse to the girl's father would indicate the likely intervention required to correct this condition?
severe dehydration
A 3-month-old is admitted with severe diarrhea. Yesterday, the infant weighed 11 pounds (5 kg). Today, this infant weighs 9 pounds, 8 ounces (4.3 kg). Based on this information the nurse documents that the infant has:
necessarily because it will be an adjustment
A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. The nurse should recognize that preparing this child psychologically is:
"Bring the child to the office today so we can evaluate her fluid balance and determine the best treatment."
A 4-month-old has had a fever, vomiting, and loose watery stools every few hours for 2 days. The mother calls the physician's office and asks the nurse what she should do. Which response by the nurse is most appropriate?
thicken formula with rice cereal
A 4-month-old infant has gastroesophageal reflux (GER) but is thriving without other complications. Which should the nurse suggest to minimize reflux?
Vomiting immediately after feeding
A 6-week-old infant is diagnosed with pyloric stenosis. When taking a health history from the parent, which symptom would the nurse expect to hear described?
"It is important to change the pouch and skin appliance every other day to decrease the risk of problems with the skin." "We will need to use an antimicrobial soap to cleanse the area around the stoma in order to prevent any skin infection."
A 9-year-old child has undergone a temporary colostomy in the ascending colon several days ago. The nurse has just completed discharge teaching to the child and the parents. Which statements by the child or parents warrants additional instruction from the nurse? Select all that apply.
lactated Ringer's normal saline
A child has been admitted to the acute care facility for the management of dehydration. The nurse is preparing to administer intravenous fluid replacement to the child. Which fluids are suitable for use? Select all that apply.
Do not rub or put pressure on the abdomen.
A child is admitted with a temperature, 101.2°F (38.4°C); pulse rate 100 beats/min; respirations 24 breaths/min. On admission the pain is localized in right lower quadrant. Legs are drawn up against the abdomen. Bowel sounds are sluggish. Rebound tenderness is present. White blood cell count of 17,000/mm3. Ultrasound confirms appendicitis. Which instruction would the nurse give to the child and the parent
IV fluid administration monitor of intake and output daily weight assessment
A child is hospitalized with dehydration as a result of rotavirus. When reviewing the plan of treatment, what can the nurse anticipate will be included? Select all that apply.
the infant's immature kidneys have a tendency to overconcentrate urine.
A group of students are reviewing information about fluid balance and losses in children in comparison to adults. The students demonstrate a need for additional review when they state that:
Only occurs with feeding
A mother calls the doctor's office and tells the nurse that she is concerned because her 4-month-old keeps "spitting up" with every feeding. What would indicate that the child is regurgitating as opposed to vomiting?
pyloric stenosis
A mother is alarmed because her 6-week-old boy has begun vomiting almost immediately after every feeding. In the past week, the vomiting has grown more forceful, with the vomit projecting several feet from his mouth. He is always hungry again just after vomiting. At the physician's office, the nurse holds the child and offers him a bottle. While he drinks, the nurse notes an olive-size lump in his right abdomen. Which condition should the nurse suspect in this child?
encouraging and helping mother to breastfeed
A mother who intended to breastfeed has given birth to an infant with a cleft palate. Nursing interventions should include:
Hirschsprung disease
A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease?
encouraging her to express her feelings
A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician explained the plan of therapy and its expected good results. However, the mother refuses to see or hold her baby. Initial therapeutic approach to the mother should be:
"I sense you could use more information on caring for a cleft palate. Would you be interested in meeting with other parents who have dealt with this?"
A nurse caring for an infant born with a cleft palate notices that the parents rarely interact with their child. The nurse overhears the mother telling her spouse that she "feels like crying" every time she looks at their infant. What would be the best response from the nurse?
hypertonic
A nurse is admitting an infant with dehydration caused from water loss in excess of electrolyte loss. Which type of dehydration is this infant experiencing?
"My daughter can eat any kind of fruit."
A nurse is caring for a 6-year-old girl recently diagnosed with celiac disease and is discussing dietary restrictions with the girl's mother. Which response indicates a need for further teaching?
upper GI tract
A nurse is conducting an in-service on gastrointestinal disorders. The nurse includes that melena, the passage of black, tarry stools, suggests bleeding from which area?
Feed the infant a formula thickened with rice cereal. Feed the infant while holding the infant in an upright position. Keep the infant upright in an infant chair/car seat for 30 minutes after feeding.
A parent brings the 2-week-old newborn to the office because the infant has been experiencing gastroesophageal reflux over the past week. Which intervention(s) should the nurse recommend to the parent at this point? Select all that apply.
Eggs and orange juice
A preschooler has celiac disease. The parent is preparing a gluten-free diet. The nurse knows that the parent understands the diet when the parent prepares which breakfast foods?
I should have my child eat a normal diet with easily digested foods for the next 48 hours.
A school-age child with diarrhea has been rehydrated. The nurse is discussing the childs diet with the family. Which statement by the parent would indicate a correct understanding of the teaching?
Normal to hyperactive bowel sounds early Hypoactive bowel sounds with perforation Irritation and pain in the right lower quadrant Low-grade fever, nausea, anorexia, and vomiting
A school-aged child is brought to the emergency room with severe abdominal pain. The nurse performs a physical assessment. Which assessment parameters indicate appendicitis? Select all that apply.
IV fluids.
A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. Therapeutic management of this child should begin with:
providing satisfaction of sucking needs
Caring for the newborn with a cleft lip and palate before surgical repair includes:
Remove restraints periodically to cuddle infant.
During the first few days after surgery for cleft lip, which intervention should the nurse do?
Prepare the infant for surgery.
In caring for an infant diagnosed with pyloric stenosis the nurse would anticipate which intervention?
antibiotic therapy
Parents call the clinic and report that their toddler has had acute diarrhea for 24 hours. The nurse should further ask the parents if the toddler has which associated factor that is causing the acute diarrhea?
hypertrophy of the pyloric muscle.
Pyloric stenosis can best be described as:
steatorrhea
The caregiver of a child diagnosed with celiac disease tells the nurse that the child has large amounts of bulky stools and what looks like fat in the stools. The clinical manifestation this caregiver is describing is:
"Offer 'magic mouthwash' followed by a popsicle."
The child is refusing fluids due to the pain and the mother is concerned about his hydration status. Which of the suggestions would be most appropriate?
"Infants this age commonly spit up."
The mother of a 3-week-old infant old brings her daughter in for an evaluation. During the visit, the mother tells the nurse that her baby is spitting up after feedings. Which response by the nurse would be most appropriate?
Encourage the mother to provide care for her infant.
The mother of a newborn with a cleft lip reports she is having a hard time looking her baby. What is the best action by the nurse?
Maintaining the intravenous (IV) fluid rate as ordered
The nurse has developed a plan of care for a 12-month-old hospitalized with dehydration as a result of rotavirus. Which intervention would the nurse include in the plan of care?
Tenting of skin
The nurse is assessing a 10-day-old infant for dehydration. Which finding indicates severe dehydration?
tenting of skin
The nurse is assessing a 10-day-old infant for dehydration. Which finding indicates severe dehydration?
"Breastfeeding is likely to be possible, but check with the surgeon."
The nurse is caring for a 2-month-old with a cleft palate. The child will undergo corrective surgery at age 3 months. The mother would like to continue breastfeeding the baby after surgery and wonders if it is possible. How should the nurse respond?
"I know my baby takes a lot longer to feed than most children this age." "It really worries me that my baby may have some other disorders that haven't been detected yet." "I wonder if my baby will develop speech problems when language development begins?" "Thankfully there are doctors that specialize in correcting this type of disorder."
The nurse is caring for a 6-month-old with a cleft lip and palate. The mother of the child demonstrates understanding of the disorder with which statements? (Select all that apply).
allow to assume position of comfort
The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis. Which is appropriate to relieve the abdominal discomfort?
Effortless vomiting just after the child has eaten
The nurse is caring for a child admitted with gastroesophageal reflux (GER). Which clinical manifestation would likely be seen in this child?
projectile vomiting
The nurse is caring for a child admitted with pyloric stenosis. Which clinical manifestation would likely have been noted in the child with this diagnosis?
79 The formula to determine maintenance fluid rate is: *100 ml/kg for first 10 kg *50 ml/kg for next 10 kg *20 ml/kg for remaining kg * Add together for total ml needed per 24-hour period. *Divide by 24 for ml/hour fluid requirement.
The nurse is caring for a child who was dehydrated following gastric surgery but has since been rehydrated. The health care provider prescribes intravenous maintenance fluids for the child. Calculate the intravenous maintenance fluid rate per hour for this child, who weighs 40 kg. Record your answer using a whole number.
Improving hydration
The nurse is caring for a child with a diagnosis of pyloric stenosis during the preoperative phase of the child's treatment. What is the highest priority at this time?
"I will add the nystatin to her bottle four times per day."
The nurse is caring for an infant recently diagnosed with oral candidiasis (thrush) who has been prescribed nystatin. Which statement by the infant's mother would suggest a need for further education?
cleansing the suture line, supine and side-lying positions, arm restraints.
The nurse is caring for an infant whose cleft lip was repaired. Important aspects of this infants postoperative care include:
Apply a barrier/healing cream or paste on the skin.
The nurse is caring for an infant with a temporary ileostomy. As part of the plan of care, the nurse monitors for skin breakdown around the stoma. If redness occurs, what would be most appropriate to promote healing and prevent further skin breakdown?
Visible peristalsis and weight loss
The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis
"Regurgitation is the backflow of stomach contents up into the esophagus or mouth."
The nurse is caring for an infant. The infant's mother asks the nurse, "What did the doctor mean when he said she may have regurgitation?" What response by the nurse is appropriate
1,600 mL (100 x 10) + (50 x 10) + (20 x 5)
The nurse is determining maintenance fluid requirements for a child who weighs 25 kg. How much fluid would the child need per day?
Persistent, right lower quadrant pain with rebound tenderness
The nurse is examining a 7-year-old with suspected appendicitis. Which physical findings would indicate the possibility of appendicitis?
brush teeth or rinse mouth after vomiting
The nurse is explaining to a parent how to care for a school-age child with vomiting associated with a viral illness. Which action should the nurse include?
right side-lying supine
The nurse is positioning an infant who has just had his left-sided cleft lip repaired. What positions are acceptable for this infant? Select all that apply.
"This means the hernia contents will be manipulated back into your peritoneal cavity during surgery."
The nurse is preparing a client for surgery and the client asks, "What does it mean when they say they are going to reduce my abdominal hernia?" Which response by the nurse is most appropriate?
545.45 -20mL/kg
The nurse is preparing to administer intravenous fluids to manage a child with dehydration. The medical record indicates the child weighs 60 pounds (27.2 kg). How many milliliters will initially be administered? Record your answer using two decimal places.
Obtain and set up equipment. Remove the old pouch. Assess the stoma and surrounding skin. Clean the stoma and skin as needed, allowing it to dry thoroughly. Measure the stoma. Mark the new pouch backing, and cut the new backing to size. Apply the new pouch.
The nurse is preparing to perform ostomy care on a pediatric client. The nurse has explained the procedure to the child and caregiver. Place the remaining steps of the procedure in the order the nurse will complete them. Use all options.
7 to 14 days (not perforated: 2-3 days)
The nurse is providing care to a child who has had an appendectomy for a perforated appendix. The nurse would anticipate intravenous antibiotic therapy for how long?
"She loves hot dogs, and we always cut hers up into small pieces."
The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac disease. The caregivers make the following statements. Which statement indicates a need for further teaching regarding the dietary restrictions for the child with celiac disease?
applesauce bananas skim milk
The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac syndrome. Which foods would be permitted in the diet of the child with celiac syndrome? Select all that apply.
Ultrasounds can be used to assess for these conditions. Most cleft lips and palates are found at delivery.
The nurse is talking with a pregnant client about cleft lips and palates. The client has asked if these can be tested for. What information should be included in the nurse's response? Select all that apply.
In this disorder the sphincter that leads into the stomach is relaxed.
The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of gastroesophageal reflux?
A thickened, elongated muscle causes an obstruction at the end of the stomach.
The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is most accurately related to the diagnosis of pyloric stenosis?
"Call the doctor immediately if the stoma is not pink/red and moist."
The nurse is teaching the mother of an infant with a temporary ileostomy about stoma care. What is the most important instruction to emphasize to the mother to avoid an emergency situation?
Apply a urine bag to the anal area.
The nurse is to obtain a stool specimen from a 4-year-old child who has very liquid stool. The child is ambulatory but weak. Which collection method would be most effective for the nurse to use?
occurs with feeding no appearance of distress
The nurse teaches a parent to differentiate between regurgitation and vomiting in the infant. The parent correctly states which characteristic of regurgitation? Select all that apply.
Hard, moveable, olive-shaped mass in the right upper quadrant
The parents of a 6-week-old boy come to the clinic for evaluation because the infant has been vomiting. The parents report that the vomiting has been increasing in frequency and forcefulness over the last week. The mother says, "Sometimes, it seems like it just bursts out of his mouth." A diagnosis of hypertrophic pyloric stenosis is suspected. When performing the physical examination, what would the nurse most likely find?
Having a wound, ostomy, and continence nurse meet with them
The parents of a boy diagnosed with Hirschsprung disease are anxious and fearful of the upcoming surgery. The mother states, "I'm worried about having to care for our son's ostomy." Which intervention would be most helpful for the parents?
fruit juice
The parents of a child diagnosed with celiac disease ask the nurse what types of food they can offer their child. What recommendation would the nurse include in the teaching plan?
"I will make sure there is plenty of orange juice available. It's her favorite juice."
The student nurse is caring for a child with the nursing diagnosis "Risk for fluid volume deficit related to inadequate oral intake." Which statement by the student would indicate a need for further education by the nursing instructor?
"Symptoms of celiac disease include diarrhea, steatorrhea, anemia, and dental disorders." "The only treatment for celiac disease is a strict gluten-free diet." "Gluten is found in most wheat products, rye, barley and possibly oats."
The student nurse is preparing a presentation on celiac disease. What information should be included? Select all apply.
There is a partial or complete mechanical obstruction in the intestine.
What occurs in the gastrointestinal system of the child with Hirschsprung disease?
sudden relief from pain
When caring for a child with probable appendicitis, the nurse should be alert to recognize that which condition or symptom is a sign of perforation?
palpation -inspection, auscultation, percussion, palpation
When examining the abdomen of a child, which technique would the nurse use last?
abdominal pain that is most intense at mcburney point
Which clinical manifestation would be the most suggestive of acute appendicitis?
fever
Which condition in a child should alert a nurse for increased fluid requirements?
sunken fontanels
Which finding would lead the nurse to suspect that a child is experiencing moderate dehydration?
Refer to a nutritionist for detailed dietary instructions and education.
Which is an important nursing consideration in the care of a child with celiac disease?
Palpable olive-like mass
Which observation made of the exposed abdomen is most indicative of pyloric stenosis?
rotavirus
Which pathogen is the viral pathogen that frequently causes acute diarrhea in young children?
Oral rehydration solution (ORS)
Which therapeutic management should the nurse prepare to initiate first for a child with acute diarrhea and moderate dehydration?
surgical removal of affected section of bowel
Which therapeutic management treatment is implemented for children with Hirschsprung disease?
isotonic dehydration
Which type of dehydration is defined as dehydration that occurs in conditions in which electrolyte and water deficits are present in approximately balanced proportion?
gastroesophageal reflux disease
An 18-month-old infant is brought to the emergency department with flu-like symptoms. The infant is diagnosed with pneumonia secondary to aspiration of stomach contents. The nurse explains to the parents that pneumonia is a condition that often occurs secondary to:
gastroesophageal reflux disease.
An 18-month-old infant is brought to the emergency department with flu-like symptoms. The infant is diagnosed with pneumonia secondary to aspiration of stomach contents. The nurse explains to the parents that pneumonia is a condition that often occurs secondary to:
"Are you having breast pain when you nurse the baby?"
An 8-month-old infant is brought to the clinic for evaluation. The mother tells the nurse that she has noticed some white patches on the infant's tongue that look like curdled milk after breastfeeding. The nurse suspects oral candidiasis (thrush). Which question would the nurse use to help confirm this suspicion?
poor skin turgor
An infant is brought to the emergency department with dehydration. Which physical assessment finding does the nurse expect?
metabolic alkalosis.
An infant with pyloric stenosis experiences excessive vomiting that can result in:
teaching family signs of central venous catheter infection.
An infant with short bowel syndrome will be discharged home on total parenteral nutrition (TPN) and gastrostomy feedings. Nursing care should include:
500 to 1,000 mL
After teaching the parents of a 6-year-old how to administer an enema, the nurse determines that the teaching was successful when they state that they will give how much solution to their child?
peanut butter carbonated drinks shellfish jelly
After teaching the parents of a child diagnosed with celiac disease about nutrition, the nurse determines that the teaching was effective when the parents identify which foods as appropriate for their child? Select all answers that apply.
normal saline
Enemas are ordered to empty the bowel preoperatively for a child with Hirschsprung disease. The enema solution should be:
