Chapter 21: Nursing Care of the Child With an Alteration in Urinary Elimination/Genitourinary Disorder

A nurse is developing a teaching plan for the parents of an 8-year-old experiencing nocturnal enuresis. The nurse determines that additional teaching is needed when the parents identify what as an appropriate measure?

Encouraging fluid intake after dinner In many children, limiting fluids after dinner can be helpful for nocturnal enuresis. Bladder-stretching exercises also can be helpful. If these measures are ineffective, desmopressin may be prescribed. Stress factors may be contributing to the child's problem. Therefore, measures to address stress and promote coping would be appropriate

A child is administered oxybutynin (Ditropan) following surgical repair of a hypospadias. The purpose of this drug is to:

Relieve bladder spasms. The presence of a urethral catheter can cause painful bladder spasms. A drug such as ocybutynin reduces the possibility of this.

The nurse is reinforcing teaching with the caregiver of 5-year-old twins regarding urinary tract infections (UTIs). The caregiver is puzzled about why her daughter has had three urinary tract infections but her son has had none. She reports that their diets and fluid intake is similar. Which statement would be accurate for the nurse to tell this mother?

"A girl's urethra is much shorter and straighter than a boy's, so it can be contaminated fairly easily." Many different bacteria may infect the urinary tract, and intestinal bacteria, particularly Escherichia coli, account for about 80% of acute episodes. The female urethra is shorter and straighter than the male urethra, so it is more easily contaminated with feces.

The nurse is doing a presentation for a group of nursing students about the topic of menstrual disorders. After discussing the disorder secondary amenorrhea, the students make the following statements. Which statement made by the nursing students is the most accurate regarding the cause of secondary amenorrhea?

"Emotional stress can be a cause of this disorder." Secondary amenorrhea can be the result of discontinuing contraceptives, a sign of pregnancy, the result of physical or emotional stress, or a symptom of an underlying medical condition. A complete physical examination, including gynecologic screening, is necessary to help determine the cause. Primary amenorrhea occurs when a girl has had no previous menstruation. A spontaneous abortion does not cause secondary amenorrhea.

The nurse is conducting a follow-up visit for a 13-year-old girl who has been treated for pelvic inflammatory disease. Which remark indicates a need for further teaching?

"I cannot have unprotected sex again until my partner is treated." The girl's partner should be treated, but she must strongly encourage the girl to require her partner to wear a condom every time they have sex, even after he undergoes antibiotic therapy.

The nurse is caring for the parents of a newborn who has an undescended testicle. Which comment by the parents indicates understanding of the condition?

"Our son's condition may resolve on its own." Normally both testes will descend prior to birth. In the event this does not happen the child will be observed for the first 6 months of life. If the testicle descends without intervention further treatment will not be needed. Surgical intervention is not needed until after 6 months if the testicle has not descended

The caregiver of a 1-year-old son calls the nurse, upset that his wife has just told him that their son is being given a hormone. His wife says that the pediatrician called it human chorionic gonadotropic hormone but that is all she understood. The nurse most accurately clarifies the caregiver's question by making which statement regarding the son's treatment?

"The doctor is hoping that the hormone will cause your son's undropped testes to move into their proper place." Shortly before or soon after birth, the male gonads (testes) descend from the abdominal cavity into their normal position in the scrotum. Occasionally one or both of the testes do not descend, which is a condition called cryptorchidism. The testes are usually normal in size; the cause for failure to descend is not clearly understood. A surgical procedure called orchiopexy is used to bring the testes down into the scrotum and anchor them there. Some physicians prefer to try medical treatment such as injections of human chorionic gonadotropic hormone before doing surgery. If this is unsuccessful in bringing down the testes, orchiopexy is performed. If both testes remain undescended, the male will be sterile. If the processus does not close, fluid from the peritoneal cavity passes through, causing hydrocele. If the hydrocele remains by the end of the first year, corrective surgery is performed

A single male caregiver of a 14-year-old girl accompanies his daughter to her pre-high school physical. In the course of discussion about how his daughter is developing, he remarks, "She's terrific most of the time. Of course when she gets her period, she's miserable and mean, but I tell her that's just what it's like to be a woman." What would be the most appropriate response by the nurse?

"There are nutritional and medical things she can do to lessen the symptoms; I'll give both of you information about some strategies and we'll track her for a few months." Women of all ages are subject to the discomfort of premenstrual syndrome (PMS), but the symptoms may be alarming to the adolescent. Symptoms include edema (resulting in weight gain), headache, increased anxiety, mild depression, and mood swings. Generally the discomforts of PMS are minor and can be relieved by reducing salt intake during the week before menstruation, taking mild analgesics, and applying local heat. When symptoms are more severe, the physician may prescribe a mild diuretic to be taken the week before menstruation to relieve edema; occasionally oral contraceptive pills are prescribed to prevent ovulation.

A nurse is caring for a 10-year-old boy with nocturnal enuresis with no physiologic cause. He says he is embarrassed and wishes he could stop immediately. How should the nurse respond?

"There are several things we can do to help you achieve this goal." The child wants to stop this problem immediately, so the nurse's most therapeutic response is to assure the child that enuresis is indeed solvable. For some children, learning about the high prevalence of the problem may provide consolation. However, this may not alleviate the child's embarrassment and it does not address his desire for solutions. Telling the child that he will "grow out of this" downplays his embarrassment and does not address his desire to solve the problem. Pull-ups conceal the consequences of enuresis but do not provide a solution

A 12-year-old girl who has not yet reached menarche comes to the pediatrician's office for her annual well-child check. As the nurse is weighing and measuring her, the child says emphatically that she does not want to get her period. Which response would be most appropriate for the nurse to make to this child?

"What have you heard about it that makes you worried?" The beginning of menstruation, called menarche, normally occurs between the ages of 12 and 13 years. For many girls this is a joyous affirmation of their womanhood, but others may have negative feelings about the event depending on how they have been prepared for menarche and for their roles as women. The nurse would need to explore the child's understanding of the implications of menarch

A group of nursing students is discussing terminology related to the genitourinary system during a post-conference setting. One of the students asks what mittelschmerz is or what it means. A classmate of this student correctly answers that mittelschmerz is:

A dull, aching abdominal pain at ovulation Mittelschmerz is a dull, aching abdominal pain at the time of ovulation (hence the name, which means "midcycle"). The beginning of menstruation is called menarche. Symptoms include edema (resulting in weight gain), headache, increased anxiety, mild depression, and mood swings. Nonsteroidal, anti-inflammatory drugs (NSAIDs), such as ibuprofen (advil, motrin) inhibit prostaglandins and are the treatment of choice for primary dysmenorrhea, which is painful menstruation. (less)

An 8-year-old boy and his father visit the pediatrician's office with reports of a sudden onset of abdominal pain and reddish-brown urine. A urinalysis shows 4+ protein. On taking the boy's health history, the nurse learns that he had strep throat a little over a week ago. Which condition should the nurse suspect?

Acute glomerulonephritis Glomerulonephritis, inflammation of the glomeruli of the kidney, is most common in children between the ages of 5 and 10 years. The child typically has a history of a recent streptococcal respiratory infection (within 7 to 14 days). Symptoms are as described above. Kidney agenesis (absence of kidneys) and polycystic kidneys (formation of large, fluid-filled cysts in the place of normal kidney tissue) are serious congenital conditions that would likely be discovered either in utero or shortly after birth, not conditions that would appear acutely in an 8-year-old. Nephrosis is altered glomerular permeability apparently due to an autoimmune process or a T-lymphocyte dysfunction that results in fusion of the glomeruli membrane surfaces, which, in turn, leading to abnormal loss of protein in urine. The highest incidence is at 3 years of age, and it occurs more often in boys than in girls. In addition to proteinuria, a major symptom of nephrosis is edema, which is absent in this case.

The caregiver of a child with a history of ear infections calls the nurse and reports that her son has just told her his urine "looks funny." He also has a headache, and his mother reports that his eyes are puffy. Although he had a fever 2 days ago, his temperature is now down to 100 degrees Fahrenheit. The nurse encourages the mother to have the child seen by the care provider because the nurse suspects the child may have:

Acute glomerulonephritis. Acute glomerulonephritis is a condition that appears to be an allergic reaction to specific infections, most often group A beta-hemolytic streptococcal infections such as rheumatic fever. Presenting symptoms appear one to three weeks after the onset of a streptococcal infection such as strep throat, otitis media, tonsillitis, or impetigo. Usually the presenting symptom is grossly bloody urine. Periorbital edema may accompany or precede hematuria. Fever may be 103 to 104 degrees Fahrenheit at the onset but decreases in a few days to about 100 degrees Fahrenheit. Slight headache and malaise are usual, and vomiting may occur.

A parent is asking how she can help her son deal with the peer ridicule at school in regards to enuresis. What is the best response by the nurse?

Demonstrate love and acceptance at home. Demonstrating love and acceptance at home will help counteract the ridicule the child is getting at school.

A 16-year-old girl visits her gynecologist with a complaint of metrorrhagia, or bleeding between menstrual periods, since her last visit 3 months ago. On consulting the client's chart, the nurse learns that she was prescribed an oral contraceptive at her last visit. Which intervention should the nurse implement in this situation?

Explain that breakthrough bleeding is normal during the first 3 or 4 months of oral contraceptive use but that it should go away after that. Metrorrhagia is bleeding between menstrual periods. This may occur in teenagers taking oral contraceptives (breakthrough bleeding) during the first 3 or 4 months of use. If metrorrhagia occurs for more than one menstrual cycle in a teenager who is not taking oral contraceptives (which is not the case here), she be referred to her primary care provider for examination, because abnormal vaginal bleeding is an early sign of uterine or cervical carcinoma or an ovarian cyst. Endometrium ablation, used with premenopausal women to halt metrorrhagia, is not recommended for adolescents. There is no need at this point for the client to change prescriptions, as the bleeding will likely go away in the next month or so as the client's body adapts to the current contraceptive.

A 16-year-old tells you she has terrible dysmenorrhea. Which action prostaglandinwould be the best health teaching measure regarding this?

Take over-the-counter ibuprofen for its prostaglandin action. An anti-inflammatory medication is most helpful in reducing the discomfort of dysmenorrhea.

In caring for a child with nephrotic syndrome, which interrventions will be included in the child's plan of care?

Weighing on the same scale each day The child with nephrotic syndrome is weighed every day using the same scale to accurately monitor the child's fluid gain and loss.

A newborn is diagnosed with hypospadias and the parents want him to be circumcised. What would be the best response by the nurse?

The foreskin is needed for repair. A child's foreskin is not removed since it is needed to help repair a hypospadias. Once the hypospadias is repaired, a circumcision can be performed at the same time. Meatal stenosis has to do with the urethral opening diameter, not the placement

A 4-year-old girl with a urinary tract infection is scheduled to have a voiding cystourethrogram. When preparing her for this procedure, the nurse would want to prepare her to:

Void during the procedure. A voiding cystourethrogram requires the child to void during the procedure so that bladder emptying and urethra flow can be assessed.

A 10-year-old in renal failure is on continuous ambulatory peritoneal dialysis (CAPD). What would it be important to teach his parents?

Cramping should not occur with an infusion. Continuous ambulatory peritoneal dialysis should not cause discomfort. The return flow should be clear; cloudy return flow suggests infection.

A nurse is teaching the parents about the kidney transplant their child is going to receive. What would be included in the teaching?

Immunosuppression is common after a kidney transplant. A child is placed on medications for immunosuppression after the transplant to prevent the body from rejecting the allograft.

Which nursing diagnosis would be the priority when caring for a child in renal failure following a kidney transplant?

Risk for infection related to immunocompromised state Children are administered anti-immune therapies to lower immune system response and help prevent rejection following a transplant; this leaves them susceptible to infection.

The nurse is caring for a child who receives dialysis via an AV fistula. Which finding indicates an immediate need to notify the physician?

Absence of a thrill The nurse should always auscultate the site for presence of a bruit and palpate for presence of a thrill. The nurse should immediately notify the physician if there is an absence of a thrill. Dialysate without fibrin or cloudiness is normal and is used with peritoneal dialysis, not hemodialysis

The nurse is collecting data on a 6-year-old child admitted with acute glomerulonephritis. Which vital sign would the nurse anticipate with this child's diagnosis?

Blood pressure 136/84 Hypertension appears in 60% to 70% of clients during the first 4 or 5 days with a diagnosis of acute glomerulonephritis. The pulse of 112 would be a little high for this age child, but not a concern with this diagnosis. The other vital signs are within normal limits for this age child

A child is being evaluated for renal and urinary tract disease. What would the nurse expect to be ordered to evaluate the child's glomerular filtration rate?

Creatinine clearance rate The glomerular filtration rate is measured by creatinine clearance rate, or the amount of creatinine excreted in 24 hours as determined by a 24-hour urine sample along with a venous blood sample and compared with the urine findings. Urinalysis provides general information about kidney function. A kidneys, ureters, and bladder x-ray provides information about the size and contour of the kidneys. A computed tomography reveals the size and density of kidney structures and adequacy of urine flow.

The nurse is performing double diapering for a male infant with hypospadias who has undergone a surgical repair. The nurse performs the following steps. Place the steps in the order in which the nurse performs them.

Cuts a hole in the front of the smaller diaper Unfolds both diapers, placing smaller diaper inside larger diaper Places both diapers under the infant Brings the penis and catheter/stent through the hole in the smaller diaper Closes the smaller diaper Closes the larger diaper When performing double diapering, the nurse cuts a hole or a cross-shaped slit in the front of the smaller diaper and then unfolds both diapers, placing the smaller diaper (with the hole) inside the larger one. Next, the nurse places both diapers under the child and carefully brings the penis (if applicable) and catheter/stent through the hole in the smaller diaper, closing the diaper. Finally, the nurse closes the larger diaper, making sure the tip of the catheter/stent is inside the larger diaper.

The nurse is caring for a child diagnosed with hydronephrosis. Which manifestation is consistent with complications of the disorder?

Hypertension Complications of hydronephrosis include renal insufficiency, hypertension, and eventually renal failure. Hypotension, hypothermia, and tachycardia are not associated with hydronephrosis.

Most urinary tract infections seen in children are caused by:

Intestinal bacteria Although many different bacteria may infect the urinary tract, intestinal bacteria, particularly Escherichia coli, account for about 80% of acute episodes. Hereditary and dietary concerns are not causes of urinary tract infections

The first method of choice for obtaining a urine specimen from a 3-year-old child with a possible urinary tract infection is:

Obtaining a clean catch voided urine In the cooperative, toilet-trained child, a clean midstream urine may be used successfully to obtain a "clean catch" voided urine. If a culture is needed, the child may be catheterized, but this is usually avoided if possible. A suprapubic aspiration also may be done to obtain a sterile specimen. In the toilet-trained child, using a cotton ball to collect the urine would not be appropriate

The nurse is teaching a group of nursing students about acute glomerulonephritis genitourinary conditions. A student asks the about a condition that occurs when there is a decreased volume of urine output. The condition the student is referring to is:

Oliguria Oliguria is a subnormal volume of urine. Amenorrhea is the absence of menstruation. Pyelonephritis is an inflammation of the kidney and renal pelvis. Ascites is edema in the peritoneal cavity

A child diagnosed with acute glomerulonephritis will most likely have a history of:

Recent illness such as strep throat Symptoms of acute glomerulonephritis often appear one to three weeks after the onset of a streptococcal infection such as strep throat.

When providing care to a child with vesicoureteral reflux (VUR), which nursing diagnosis would be the priority?

Risk for infection When vesicoureteral reflux is present, the primary goal is to avoid urine infection so that infected urine cannot gain access to the kidneys. Fluid volume typically is not a problem associated with VUR. Nutritional problems are not associated with VUR. Activity intolerance is not associated with VUR

The nurse is caring for a 10-year-old boy with end-stage renal disease (ESRD) with metabolic acidosis. What would the nurse expect to administer if ordered?

Sodium bicarbonate tablets Bicitra or sodium bicarbonate tablets are used for the correction of acidosis. Ferrous sulfate is used for the treatment of anemia. Vitamin D and calcium are used for the correction of hypocalcemia and hyperphosphatemia. Erythropoietin stimulates red blood cell growth

A 3-year-old is scheduled for a surgery to correct undescended testes. An important postoperative consideration the nurse would want to prepare the parents for is:

Some discomfort at the surgery site. After they are returned to the scrotum, testes may be sutured there to prevent them from returning to the abdominal cavity. This produces a "tugging" or painful sensation.

An adolescent girl and her caregiver present at the pediatrician's office. The adolescent reports severe abdominal pain. A diagnosis of pelvic inflammatory disease (PID) is made. The nurse notes in the child's chart that this is the third time she has been treated for PID. The most appropriate action by the nurse would be to:

Take the child to a private room and interview her regarding her sexual history and partners. Pelvic inflammatory disease can cause sterility in the female primarily by causing scarring in the fallopian tubes that prohibits the passage of the fertilized ovum into the uterus. Adolescents must be made aware of the seriousness of PID, a common result of a chlamydial infection. Be certain to provide the adolescent with a private interview. The adolescent may be extremely reluctant to reveal either social or sexual history especially in the presence of a family member.

The caregiver of a child being treated at home for acute glomerulonephritis calls the nurse reporting that her daughter has just had a convulsion. The child is resting comfortably but the caregiver would like to know what to do. The nurse would instruct the caregiver to do which action?

Take the child's blood pressure and report the findings to the nurse while the nurse is still on the phone. Blood pressure should be monitored regularly using the same arm and a properly fitting cuff. If hypertension develops, a diuretic may help reduce the blood pressure to normal levels. An antihypertensive drug may be added if the diastolic pressure is 90 mm Hg or higher. The concern is immediate so reporting the findings in a few hours could delay needed treatment. The child should be weighed daily in the same clothes and using the same scale, but the blood pressure is the priority in this situation.

The nurse is caring for a 5-month-old boy with an undescended left testis. What would the nurse identify as indicative of true cryptorchidism?

Testis cannot be "milked" down inguinal canal With true cryptorchidism, the retractile testis cannot be "milked" down the inguinal canal. Fluid in the scrotal sac is a hydrocele. A venous varicosity along the spermatic cord is a varicocele. Testis that can be brought into the scrotum refers to a retractile testis.

The nurse knows this is a description of peritoneal dialysis when compared to hemodialysis:

The child can live a more normal lifestyle. The child can live a more normal lifestyle with peritoneal dialysis. This is a 7-day-a-week procedure, but there are less diet restrictions and more freedom with this type of procedure. Peritoneal dialysis can be performed at home

A caregiver brings her 7-year-old son to the pediatrician's office, concerned about the child's bedwetting after being completely toilet trained even at night for over 2 years. The caregiver further reports that the child has wet the bed every night since returning home from a one-week fishing trip. The child refuses to talk about the bedwetting. The nurse notes the child is shy, skittish, and will not make eye contact. Further evaluation needs to be done to rule out what possible explanation for the bedwetting?

The child has been sexually abused, maybe on the fishing trip Enuresis may have a physiologic or psychological cause and may indicate a need for further exploration and treatment. Enuresis in the older child may be an expression of resentment toward family caregivers or of a desire to regress to an earlier level of development to receive more care and attention. Emotional stress can be a precipitating factor. The health care team also needs to consider the possibility that enuresis can be a symptom of sexual abuse. Bruising, bleeding, or lacerations on the external genitalia, especially in the child who is extremely shy and frightened, may be a sign of child abuse and should be further explored.

Urine that stands at room temperature for any length of time changes composition.

True For best results, specimens collected should be fresh because urine that stands at room temperature for any length of time changes composition.

The nurse is caring for a child who is undergoing peritoneal dialysis. Immediately after draining the dialysate, which action should the nurse should take immediately?

Weigh the old dialysate The nurse should weigh the old dialysate to determine the amount of fluid removed from the child. The fluid must be weighed prior to emptying it. The nurse should weigh the new fluid prior to starting the next fill phase. Typically, the exchanges are 3 to 6 hours apart so the nurse would not immediately start the next fill phase.

The nurse is caring for a 2-year-old girl with suspected vulvovaginitis. The nurse suspects the cause as Candida albicans based on which finding?

White cottage cheese-like discharge White cottage cheese-like discharge indicates C. albicans. Thin gray discharge with a fishy odor points to Bordetella or Gardnerella. Foul yellow-gray discharge indicates Trichomonas vaginalis. Irritation of the labia and vaginal opening is commonly found with poor hygiene

The nurse is caring for a child diagnosed with acute post-streptococcal glomerulonephritis. When assessing the child, what findings does the nurse anticipate?

• Headache • Generalized edema • Weight gain Acute post-streptococcal glomerulonephritis often follows a respiratory infection caused by one of the strains of group A beta-hemolytic streptococcus. With kidney function being decreased the nurse expects to assess signs and symptoms such as weight gain from edema and headache. Urine will likely be concentrated causing it to be dark in color.