Chapter 23: The Child with Gastrointestinal Dysfunction

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? a) History of hypoxia at birth b) Preterm birth c) Maternal use of acetaminophen in third trimester d) Mother age 42 with pregnancy

d) Mother age 42 with pregnancy

A 6-month-old infant with Hirschsprung disease is scheduled for a temporary colostomy. What should postoperative teaching to the parents include? a. Dilating the stoma b. Assessing bowel function c. Limitation of physical activities d. Measures to prevent prolapse of the rectum

ANS: B In the postoperative period, the nurse involves the parents in the care of the child with a temporary colostomy, allowing them to help with feedings and observe for signs of wound infection or irregular passage of stool (constipation or true incontinence). Some children will require daily anal dilatations in the postoperative period to avoid anastomotic strictures but not stoma dilatations. Physical activities should be encouraged. There is not a risk of prolapse of the rectum in Hirschsprung disease, just strictures.

Therapeutic management of most children with Hirschsprung disease is primarily a. Daily enemas b. Low-fiber diet c. Permanent colostomy d. Surgical removal of the affected section of the bowel

ANS: D Feedback A Preoperative management may include enemas and a low-fiber, high-calorie, high-protein diet, until the child is physically ready for surgery. B Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet, until the child is physically ready for surgery. C The colostomy that is created in Hirschsprung disease is usually temporary. D Most children with Hirschsprung disease require surgical rather than medical management. Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter.

The nurse is caring for a neonate with a suspected tracheoesophageal fistula (TEF). Nursing care should include a. Elevating the head but give nothing by mouth b. Elevating the head for feedings c. Feeding glucose water only d. Avoiding suction unless infant is cyanotic

ANS: A Feedback A When a newborn is suspected of having TEF, the most desirable position is supine with the head elevated on an incline plane of at least 30 degrees. It is imperative that any source of aspiration be removed at once; oral feedings are withheld. Feedings should not be given to infants suspected of having TEF.

DELETEWhat immunization is recommended for all newborns? a. Hepatitis A vaccine b. Hepatitis B vaccine c. Hepatitis C vaccine d. Hepatitis A, B, and C vaccines

ANS: B Universal vaccination for hepatitis B is recommended for all newborns. Hepatitis A vaccine is recommended for infants starting at 12 months. No vaccine is currently available for hepatitis C.

What does the nurse expect the appearance of the stools of a child with celiac disease to be? A) Ribbon like B) Hard,constipated C) Bulky,frothy D) Loose,foul-smelling

C) Bulky,frothy Celiac disease causes malabsorption. Stools that are large, bulky, and frothy may indicate malabsorption.

The nurse is caring for an infant whose cleft lip was repaired. Important aspects of this infant's postoperative care include: a. arm restraints, postural drainage, mouth irrigations. b. cleansing the suture line, supine and side-lying positions, arm restraints. c. mouth irrigations, prone position, cleansing suture line. d. supine and side-lying positions, postural drainage, arm restraints.

b. cleansing the suture line, supine and side-lying positions, arm restraints. The suture line should be cleansed gently after feeding. The child should be positioned on the back, on the side, or in an infant seat. Elbows are restrained to prevent the child from accessing the operative site.

DELETEMatch the following structural defects with the correct assessment data. Each item is used only once. 1. Failure to pass meconium in newborns 2. Stool of red currant jelly consistency 3. Olive-shaped mass in the right upper quadrant 4. Excess spitting up or forceful vomiting 5. Painless swelling extending toward the scrotum A. Intussusception B. Hypertrophic pyloric stenosis C. Hirschsprung's disease D. GERD E. Inguinal hernia

1 - C 2 - A 3 - B 4 - D 5 - E

The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet? 1.Rice 2.Oatmeal 3.Rye toast 4.Wheat bread

1. rice

When assessing a newborn with cleft lip, the nurse should be alert that which of the following will most likely be compromised? A. Sucking ability B. Respiratory status C. Locomotion D. GI function

A

A child is diagnosed with intussusception. The nurse anticipates that what action would be attempted first to reduce this condition? A.Barium enema B. Surgery C. Upper endoscopy D. Endoscopic retrograde cholangiopancreatography

A. Barium enema A barium enema is successful in reducing a large percentage of intussusception cases. Other cases are reduced surgically. Upper endoscopy is used to visualize the upper gastrointestinal tract from the mouth to the upper jejunum. Endoscopic retrograde cholangiopancreatography is used to view the hepatobiliary system.

A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. How should the nurse prepare this child? a. It is unnecessary because of child's age. b. It is essential because it will be an adjustment. c. Preparation is not needed because the colostomy is temporary. d. Preparation is important because the child needs to deal with negative body image.

ANS: B The child's age dictates the type and extent of psychologic preparation. When a colostomy is performed, it is necessary to prepare the child who is at least preschool age by telling him or her about the procedure and what to expect in concrete terms, with the use of visual aids. The preschooler is not yet concerned with body image.

Which assessment finding should the nurse expect in an infant with Hirschsprung disease? a. "Currant jelly" stools b. Constipation with passage of foul-smelling, ribbon-like stools c. Foul-smelling, fatty stools d. Diarrhea

ANS: B Feedback Constipation results from absence of ganglion cells in the rectum and colon, and is present since the neonatal period with passage of frequent foul-smelling, ribbon-like, or pellet-like stools.

The nurse is preparing to admit a 3-year-old child with intussusception. What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Absent bowel sounds b. Passage of red, currant jelly-like stools c. Anorexia d. Tender, distended abdomen e. Hematemesis f. Sudden acute abdominal pain

ANS: B, D, F Intussusception occurs when a proximal segment of the bowel telescopes into a more distal segment, pulling the mesentery with it and leading to obstruction. Clinical manifestations of intussusception include the passage of red, currant jelly-like stools; a tender, distended abdomen; and sudden acute abdominal pain. Absent bowel sounds, anorexia, and hematemesis are clinical manifestations observed in other types of gastrointestinal dysfunction.

The nurse observes that a newborn is having problems after birth. What should indicate a tracheoesophageal fistula? a. Jitteriness b. Meconium ileus c. Excessive frothy saliva d. Increased need for sleep

ANS: C Excessive frothy saliva is indicative of a tracheoesophageal fistula. The child is unable to swallow the secretions, so there are excessive amounts of saliva in the mouth. Jitteriness is associated with several disorders, including electrolyte imbalances. Meconium ileus is associated with cystic fibrosis. Increased need for sleep is not associated with a tracheoesophageal fistula.

What maternal assessment is related to an infant's diagnosis of TEF? a. Maternal age more than 40 years b. First term pregnancy for the mother c. Maternal history of polyhydramnios d. Complicated pregnancy

ANS: C Feedback A maternal history of polyhydramnios is associated with TEF. Complicated pregnancy is not a risk factor for TEF.

A newborn infant is diagnosed with tracheoesophageal fistula (TEF). The nurse assesses the infant, knowing that a typical finding in this disorder is: A. Slowed reflexes B. Cyanosis, coughing, and choking C. Diaphragmatic breathing D. Passage of large amounts of frothy stool

B

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. A. Corn flakes B. Bananas C. Skim milk D. Rye bread E. Wheat bread F. Applesauce

B. Bananas C. Skim milk F. Applesauce

Which intervention should the nurse include in care of an infant following surgical repair of a cleft lip? A. Position the infant in the prone position for feedings, to avoid aspiration. B. Use a special feeding device with shorter nipples. C. Administer pain medications as ordered. D. Let the infant touch the suture lines as a means of self-comfort.

C

Which question would be most helpful in obtaining a nursing history from the mother of an infant with suspected intussusception? A. Is your child eating normally? B. How often has your child been vomiting? C. What do your child's stools look like? D. When did your child last urinate?

C

A newborn's failure to pass meconium within the first 24 to 48 hours after birth may indicate all of the following conditions EXCEPT: A. Cystic fibrosis B. Hirschspring's disease C. Imperforate anus D. Intussusception

D

A nurse is preparing a child for a barium enema. For which of the following conditions would this plan of care be appropriate? A. Gastroschisis B. Pyloric stenosis C. Appendicitis D. Intussusception

D

Which assessment finding would be most likely found on an infant diagnosed with Hirschsprung's disease? A. Scaphoid abdomen (sunken, concave abdomen) B. Cyanosis of distal extremities C. Hyperactive reflexes D. Weight less than normal for height and age

D

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. a) Right side lying b) Left side lying c) Supine d) Prone e) High fowlers

a) Right side lying c) Supine

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? a) Explain to the parents that surgical intervention will fix the defect in the baby's lip. b) Ask the parents if they have any questions regarding the care of their child. c) Teach the mother the appropriate technique for breast-feeding an infant with cleft lip. d) Refer the family to a social worker or mental health practitioner.

b) Ask the parents if they have any questions regarding the care of their child.

The nurse is conducting a physical examination of an 18-month-old with suspected intussusception. Which finding would the nurse identify as the hallmark of this condition? a) Skin tenting b) Perianal skin tags c) Abdominal pain and guarding d) A sausage-shaped mass in the upper midabdomen

d) A sausage-shaped mass in the upper midabdomen

What statement best describes Hirschsprung disease? a. The colon has an aganglionic segment. b. It results in frequent evacuation of solids, liquid, and gas. c. The neonate passes excessive amounts of meconium. d. It results in excessive peristaltic movements within the gastrointestinal tract.

ANS: A Mechanical obstruction in the colon results from a lack of innervation. In most cases, the aganglionic segment includes the rectum and some portion of the distal colon. There is decreased evacuation of the large intestine secondary to the aganglionic segment. Liquid stool may ooze around the blockage. The obstruction does not affect meconium production. The infant may not be able to pass the meconium stool. There is decreased movement in the colon.

The nurse is caring for an infant who had surgical repair of a tracheoesophageal fistula 24 hours ago. Gastrostomy feedings have not been started. What do nursing actions related to the gastrostomy tube include? a. Keep the tube clamped. b. Suction the tube as needed. c. Leave the tube open to gravity drainage. d. Lower the tube to a point below the level of the stomach.

ANS: C In the immediate postoperative period, the gastrostomy tube is open to gravity drainage. This usually is continued until the infant is able to tolerate feedings. The tube is unclamped in the postoperative period to allow for the drainage of secretions and air. Gastrostomy tubes are not suctioned on an as-needed basis. They may be connected to low suction to facilitate drainage of secretions. Lowering the tube to a point below the level of the stomach would create too much pressure.

A child has a nasogastric (NG) tube after surgery for Hirschsprung disease. What is the purpose of the NG tube? a. Prevent spread of infection. b. Monitor electrolyte balance. c. Prevent abdominal distention. d. Maintain accurate record of output.

ANS: C The NG tube is placed to suction out gastrointestinal secretions and prevent abdominal distention. The NG tube would not affect infection. Electrolyte content of the NG drainage can be monitored. Without the NG tube, there would be no drainage. After the NG tube is placed, it is important to maintain an accurate record of intake and output. This is not the reason for placement of the tube.

A 3-day-old infant presents with abdominal distention, is vomiting, and has not passed any meconium stools. What disease should the nurse suspect? a. Pyloric stenosis b. Intussusception c. Hirschsprung disease d. Celiac disease

ANS: C The clinical manifestations of Hirschsprung disease in a 3-day-old infant include abdominal distention, vomiting, and failure to pass meconium stools. Pyloric stenosis would present with vomiting but not distention or failure to pass meconium stools. Intussusception presents with abdominal cramping and celiac disease presents with malabsorption.

What term describes invagination of one segment of bowel within another? a. Atresia b. Stenosis c. Herniation d. Intussusception

ANS: D Intussusception occurs when a proximal section of the bowel telescopes into a more distal segment, pulling the mesentery with it. The mesentery is compressed and angled, resulting in lymphatic and venous obstruction. Atresia is the absence or closure of a natural opening in the body. Stenosis is a narrowing or constriction of the diameter of a bodily passage or orifice. Herniation is the protrusion of an organ or part through connective tissue or through a wall of the cavity in which it is normally enclosed.

The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac syndrome. The caregivers make the following statements. Which statement indicates a need for further teaching regarding the dietary restrictions for the child with celiac syndrome? A."The soup we eat at our house is all made from scratch." B."She loves hot dogs, and we always cut hers up into small pieces." C."I have learned to make my own bread with no gluten." D. "Even though milk and pudding are good for her, we don't give her those foods."

B "She loves hot dogs, and we always cut hers up into small pieces." Commercially canned creamed soups, cold cuts, frankfurters, and pudding mixes generally contain wheat products and should not be included in the diet of the child with celiac syndrome. This caregiver needs further teaching regarding giving her child hot dogs, even if they are cut into small pieces. The other choices show an understanding of the dietary restrictions.

The nurse is caring for a neonate with a suspected tracheoesophageal fistula. What should nursing care include? a. Feed glucose water only. b. Elevate the patient's head for feedings. c. Raise the patient's head and give nothing by mouth. d. Avoid suctioning unless the infant is cyanotic.

ANS: C When a newborn is suspected of having a tracheoesophageal fistula, the most desirable position is supine with the head elevated on an inclined plane of at least 30 degrees. It is imperative that any source of aspiration be removed at once; oral feedings are withheld. The oral pharynx should be kept clear of secretions by oral suctioning. This is to prevent the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx.

Which description of a stool is characteristic of intussusception? a. Ribbon-like stools b. Hard stools positive for guaiac c. "Currant jelly" stools d. Loose, foul-smelling stools

ANS: C Feedback A Ribbon-like stools are characteristic of Hirschsprung disease. B With intussusception, passage of bloody mucus stools occurs. Stools will not be hard. C Pressure on the bowel from obstruction leads to passage of "currant jelly" stools. D Loose, foul-smelling stools may indicate infectious gastroenteritis

What is an appropriate statement for the nurse to make to parents of a child who has had a barium enema to correct an intussusception? a. "I will call the physician when the baby passes his first stool." b. "I am going to dilate the anal sphincter with a gloved finger to help the baby pass the barium." c. "I would like you to save all the soiled diapers so I can inspect them." d. "Add cereal to the baby's formula to help him pass the barium."

ANS: C Feedback A The physician does not need to be notified when the infant passes the first stool. B Dilating the anal sphincter is not appropriate for the child after a barium enema. C The nurse needs to inspect diapers after a barium enema because it is important to document the passage of barium and note the characteristics of the stool. D After reduction, the infant is given clear liquids and the diet is gradually increased.

A nurse caring for Paulo, an infant born with a cleft palate, notices that the parents rarely interact with their child. The nurse overhears the mother telling her husband that she "feels like crying" every time she looks at their son. What would be the best response from the nurse? a) "Many infants are born with this condition. Your son's palate is not nearly as bad as some cases." b) "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?" c) "Your son needs you right now. You should put your negative feelings about his condition aside for his sake." d) "Keep in mind that your son's condition is not life-threatening and can be corrected eventually."

B

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? A. Explain that surgery will make this better in the future. B. Encourage the mother to provide care for her infant. C. Encourage the child's mother to hold her infant against her shoulder to provide closeness while avoiding visualizing the defect. D. Tell the mother that while this is difficult it will get easier.

B. Encourage the mother to provide care for her infant. Providing care to the infant is the best means for the mother to begin bonding with her baby. Activities such as feeding, diapering and bathing will be helpful. Encouraging the mother to avoid looking at the cleft lip will not assist her in the process of accepting it. While surgery will be performed it will not take place for a few months making it vital that she begin bonding with her infant. Telling the parent she will get used to it minimizes her concerns and is not the most therapeutic response by the nurse.

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? a) "There is gluten hidden in unexpected foods." b) "My daughter is eating more vegetables." c) "There are many types of flour besides wheat." d) "My daughter can eat any kind of fruit."

d) "My daughter can eat any kind of fruit." While most fruits and fruit juices are allowed, the nurse needs to make sure the mother knows that some fruit pie fillings and dried fruit may contain gluten.

A preschooler with a history of cleft palate repair comes to the clinic for a routine well-child checkup. To determine if this child is experiencing a long-term effect of cleft palate, which question should the nurse ask? 1."Was the child recently treated for pneumonia?" 2."Does the child play with an imaginary friend?" 3."Is the child unresponsive when given directions?" 4."Has the child had any difficulty swallowing food?"

3."Is the child unresponsive when given directions?" Unresponsiveness may be an indication of hearing loss. A child who has a history of cleft palate should be routinely checked for hearing loss.

A 9-month-old girl is brought to the emergency room with what appears to be bouts of intense abdominal pain 15 minutes apart in which she draws up her legs and cries, often accompanied by vomiting. In between the bouts, the child recovers and appears to be without symptoms. Blood is found in the stool. What condition should the nurse suspect in this case? A.Intussusception B.Celiac disease C.Enterocolitis D. Gastroentercolitis

A. Intussusception Intussusception, the invagination of one portion of the intestine into another, usually occurs in the second half of the first year of life. Children with this disorder suddenly draw up their legs and cry as if they are in severe pain; they may vomit. After the peristaltic wave that caused the discomfort passes, they are symptom-free and play happily. In approximately 15 minutes, however, the same phenomenon of intense abdominal pain strikes again. After approximately 12 hours, blood appears in the stool and possibly in vomitus, described as a "currant jelly" appearance. Volvulus with malrotation and necrotizing enterocolitis typically occur in the first 6 months of life and do not match the symptoms described above. Short-bowel/short-gut syndrome typically occurs when a large portion of the intestine has been removed due to a previous disease or trauma.

DELETEA child with acute gastrointestinal bleeding is admitted to the hospital. The nurse observes which sign or symptom as an early manifestation of shock? a. Restlessness b. Rapid capillary refill c. Increased temperature d. Increased blood pressure

ANS: A Restlessness is an indication of impending shock in a child. Capillary refill is slowed in shock. The child will feel cool. The blood pressure initially remains within the normal range and then declines.

Which order should the nurse question when caring for a 5-year-old child after surgery for Hirschsprung disease? a. Monitor rectal temperature every 4 hours and report an elevation greater than 38.5° C. b. Assess stools after surgery. c. Keep the child NPO until bowel sounds return. d. Maintain IV fluids at ordered rate.

ANS: A Feedback A Rectal temperatures should not be taken after this surgery. Rectal temperatures are generally not the route of choice for children because of the route's traumatic nature.

A nurse is teaching a group of parents about TEF. Which statement made by the nurse is accurate about TEF? a. This defect results from an embryonal failure of the foregut to differentiate into the trachea and esophagus. b. It is a fistula between the esophagus and stomach that results in the oral intake being refluxed and aspirated. c. An extra connection between the esophagus and trachea develops because of genetic abnormalities. d. The defect occurs in the second trimester of pregnancy.

ANS: A Feedback When the foregut does not differentiate into the trachea and esophagus during the fourth to fifth week of gestation, a TEF occurs. TEF is an abnormal connection between the esophagus and trachea. There is no connection between the trachea and esophagus in normal fetal development. This defect occurs early in pregnancy during the fourth to fifth week of gestation.

A mother who intended to breastfeed has given birth to an infant with a cleft palate. Nursing interventions should include: a. giving medication to suppress lactation. b. encouraging and helping mother to breastfeed. c. teaching mother to feed breast milk by gavage. d. recommending use of a breast pump to maintain lactation until infant can suck.

b. encouraging and helping mother to breastfeed. The mother who wishes to breastfeed may need encouragement and support because the defect does present some logistical issues. The nipple must be positioned and stabilized well back in the infant's oral cavity so that the tongue action facilitates milk expression. Because breastfeeding is an option, if the mother wishes to breastfeed, medications should not be given to suppress lactation. Because breastfeeding can usually be accomplished, gavage feedings are not indicated. The suction required to stimulate milk, absent initially, may be useful before nursing to stimulate the let-down reflex.