Chapter 43: Nursing Care of the Child With an Alteration in Urinary Elimination/Genitourinary Disorder

A nurse is conducting a discussion group with parents of children who have genitourinary disorders. As part of the discussion, the nurse reviews the major functions of the kidneys. The nurse determines that the teaching was successful based on which statement by the group? "Problems with the kidneys raise the risk for infection because there is a problem with producing white blood cells." "We should expect problems with too much fluid in the brain because the kidneys are not able to keep the fluid in balance." "The kidneys help get rid of carbon dioxide from the body, so kidney problems can affect our child's breathing." "The kidneys help control blood pressure, so our child's blood pressure needs to be checked often."

"The kidneys help control blood pressure, so our child's blood pressure needs to be checked often." RATIONALE: Functions of the kidney include regulating blood pressure by making the enzyme renin and also making erythropoietin, which helps stimulate the production of red blood cells. Therefore, monitoring blood pressure is important. The kidney also excretes excess water and waste products and maintains a balance of electrolytes and acids-bases. White blood cells are formed in the bone marrow. Carbon dioxide is removed by the alveoli in the lungs. Cerebrospinal fluid circulates through the brain and spinal cord.

The nurse is administering cyclophosphamide as ordered for a 12-year-old boy with nephrotic syndrome. Which instruction is most accurate regarding administration? Administer in the evening on an empty stomach. Administer in the morning; encourage fluids and voiding during and after administration. Encourage fluids, adequate food intake, and voiding before and after administration Provide adequate hydration and encourage voiding.

Administer in the morning; encourage fluids and voiding during and after administration. RATIONALE: It is very important to administer in the morning, encourage large amounts of water/fluids, and encourage frequent voiding during and after infusion to decrease the risk of hemorrhagic cystitis.

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? Respirations 24 per minute Blood pressure 136/84 Pulse rate 112 bpm Pulse oximetry 93% on room air

Blood pressure 136/84 RATIONALE: 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 a child this age, but not a concern with this diagnosis. The other vital signs are within normal limits for a child of this age.

A nurse is performing postoperative care on a child with a ureteral stent. Which intervention will help manage bladder spasms? Apply antibiotic ointment to tube site. Increase low-fat foods. Encourage high fluid intake. Allow tubes to dangle freely to encourage flow.

Encourage high fluid intake. RATIONALE: Prevent bladder stimulation secondary to a full rectum by completing a preoperative bowel evacuation, encouraging a high fluid intake, promoting early ambulation postoperatively, and administering a stool softener or glycerin suppository postoperatively.

A 3-month-old boy is found to have undescended testes. The parents are concerned. What should the nurse anticipate as the next step for this client? Perform karyotyping to establish the client's gender. Schedule emergency orchiopexy to correct the condition. Administer low-dose human chorionic gonadotropin hormone. Reassess the client's testes at 6 months of age.

Reassess the client's testes at 6 months of age. RATIONALE: Because the testes sometimes descend spontaneously during the first year of life, treatment is usually delayed until at least 6 months of age. If testes have not descended between 6 and 12 months of age, the client may be given a short course of chorionic gonadotropin hormone to see if testicular descent can be stimulated. If this is not successful, surgical intervention (orchiopexy) will be needed to correct the condition to prevent infertility. Karyotyping is not needed in this situation, because the client's gender is already established.

When providing care to a child with vesicoureteral reflux (VUR), which nursing diagnosis would be the priority? Excess fluid volume Imbalanced nutrition less than body requirements Activity intolerance Risk for infection

Risk for infection RATIONALE: 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 taking a health history of a 12-year-old boy presenting with scrotal pain. Which assessment finding would indicate testicular torsion? Enlarged inguinal glands and fever Fever, scrotal swelling, and urethral discharge Hardened and tender epididymitis with edema and erythema of scrotum Sudden onset of severe scrotal pain with significant hemorrhagic swelling

Sudden onset of severe scrotal pain with significant hemorrhagic swelling RATIONALE: Testicular torsion is characterized by a testicle that is abnormally attached to the scrotum and twisted. Signs and symptoms include sudden onset of severe scrotal pain with significant hemorrhagic swelling. Enlarged glands and fever point to infection. A hardened and tender epididymis points to epididymitis. Fever and urethral discharge suggest infection. Scrotal swelling is associated with testicular torsion, epididymitis, and hydrocele.

The nurse is collecting data for a child diagnosed with acute glomerulonephritis. What would the nurse likely find in this child's history? The child had a congenital heart defect. The child recently had an ear infection. The child is being treated for asthma. The child has a sibling with the same diagnosis.

The child recently had an ear infection. RATIONALE: In the child with acute glomerulonephritis, presenting symptoms appear 1 to 3 weeks after the onset of a streptococcal infection, such as strep throat, otitis media, tonsillitis, or impetigo. There is not a family history of the disorder, a history of congenital concerns or defects, nor asthma in children with acute glomerulonephritis.

A client has just been admitted to the unit with a history of recent streptococcal infection, hematuria, and proteinuria. Based on these findings, the nurse suspects which condition? acute glomerulonephritis urinary tract infection acute kidney injury prune belly syndrome

acute glomerulonephritis RATIONALE: Recent streptococcal infection, hematuria, and proteinuria are indicative of acute glomerulonephritis. These symptoms do not suggest acute kidney injury, prune belly syndrome, or urinary tract infection.

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. performing a suprapubic aspiration. placing a cotton ball in the underwear to catch urine. placing an indwelling urinary catheter.

obtaining a clean catch voided urine. RATIONALE: 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 caring for a client newly diagnosed with acute glomerulonephritis? When receiving the pediatric client's history, which is anticipated? fatigue from viral infection onset 3 days ago onset of a streptococcus infection last week increased thirst, sweating, and shakiness since yesterday a sports injury to the kidney two weeks ago

onset of a streptococcus infection last week RATIONALE: The nurse is correct to anticipate a streptococcus infection 1 to 3 weeks prior to the diagnosis of acute glomerulonephritis. The presenting symptom is typically gross bloody urine. Acute glomerulonephritis is not related to a kidney infection, does not exhibit symptoms similar to diabetes, or a recent viral infection.

A 3-year-old child is scheduled for a surgery to correct undescended testes. For what postoperative consideration would the nurse want to prepare the parents? a liquid diet for 3 days some discomfort at the surgery site the need for maintaining a semi-Fowler position the need for complete bed rest for 10 days

some discomfort at the surgery site RATIONALE: An orchiopexy is the surgical procedure to release the spermatic cord and pull the testes into the scrotum. After the testes are in the scrotum, they are sutured into place to prevent them from returning to the abdominal cavity. This produces a "tugging" or painful sensation. Complete bed rest, a liquid diet, and remaining in a semi-Fowler position are not required as part of the postsurgical care.

A client has been admitted to the emergency department with nausea, vomiting, and severe scrotal pain. These findings indicate what condition? testicular torsion hydrocele testicular infection varicocele

testicular torsion RATIONALE: A hydrocele is a collection of fluid that collects in the fold of the scrotum, requiring no treatment. A varicocele is an abnormal dilation (dilatation) of the veins of the spermatic cord. Testicular torsion is evidenced by severe scrotal pain, nausea, and vomiting and is a surgical emergency. Testicular infection is not indicated.

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 may need surgery on his testes before we are discharged to go home." "Our son's condition may resolve on its own." "Our son may have to go through life without two testes." "Our son will likely have a high risk of cancer in his teen years as a result of this condition."

"Our son's condition may resolve on its own." RATIONALE: 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 boy 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? "Without the treatment your child's gonads will not reach normal size." "Without the hormone your son will have fluid that will collect in his scrotum." "The doctor is hoping that the hormone will cause your son's undropped testes to move into their proper place." "Your child's testes have not dropped, so the hormone is being administered to avoid causing degeneration until they do."

"The doctor is hoping that the hormone will cause your son's undropped testes to move into their proper place." RATIONALE: 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 processes vaginalis 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.

The nurse is caring for a 7-month-old female infant diagnosed with a urinary tract infection (UTI). The parents are upset as this is the infant's second UTI with a fever. Which instruction is most helpful? Select all that apply. A fever is commonly noted with a UTI. Female urethras are shorter and straighter than males. Change diapers promptly, especially after bowel movements. UTI's are common in male infants at this age. After 3 days on antibiotics, the infection is clear.

A fever is commonly noted with a UTI. Female urethras are shorter and straighter than males. Change diapers promptly, especially after bowel movements. RATIONALE: Urinary tract infections are common in females in the "diaper age" because the female urethras are shorter and straighter than in the males. This poses a potential for infection. Males have a higher rate of UTI's in the first 4 months. A fever is common with this diagnosis. Changing the diapers promptly eliminates the time that the infant is exposed to E-coli. The infant may feel better after 3 days of antibiotic use but it takes a full course of antibiotics to clear an infection.

A symptom often seen in acute glomerulonephritis is edema. The most common site the edema is first noted is in which area of the body? Sacrum Ankles Hands Eyes

Eyes RATIONALE: Periorbital edema may accompany or precede hematuria in children with acute glomerulonephritis. Edema in the ankles, hands, and sacrum are not noted in acute glomerulonephritis.

A nurse is performing postoperative care on a child with a ureteral stent. Which intervention will help manage tube patency? Maintain fluid restriction. Allow tubes to dangle freely to encourage flow. Provide a low-sodium diet. Monitor output.

Monitor output. RATIONALE: A ureteral stent is placed in the ureter temporarily to aid in the drainage of urine. It is removed via cystoscopy when it is time for discontinuation. The nurse should monitor output carefully when a ureteral stent is in place. This is an indication that the stent is patent and functioning properly. The tubes are inserted into the ureter so they would not dangle on the outside of the body. There is no need to maintain fluid restriction or a low-sodium diet just because of the stent. This would only be necessary if there were other disease processes affecting the child.

The parent of 6-month-old girl is concerned about the child getting a urinary tract infection. What should the nurse mention to the parent regarding this concern? Wipe from back to front when changing the girl's diaper. Discontinue prescribed antibiotics once symptoms of UTI have disappeared. Bathe the child with bubble bath once a week. Report any abnormally colored urine to the child's primary care provider.

Report any abnormally colored urine to the child's primary care provider. RATIONALE: Several important interventions can help prevent urinary and renal disease in children. The first intervention is to educate parents and caregivers about wiping from front to back (not back to front) when changing diapers of female infants. Remind parents of simple ways to prevent UTI, such as not allowing children to bathe with bubble bath. Teach parents to recognize that abnormally colored urine (red, black, or cloudy) should not be dismissed as this could be the beginning of a UTI or kidney disease. Educating parents about the importance of giving the full course of antibiotics prescribed for UTIs can help prevent return reinfection; giving the full course of antibiotics after a streptococcal infection can help prevent acute glomerulonephritis.

The nurse is caring for a child admitted with acute glomerulonephritis. Which clinical manifestation would likely have been noted in the child with this diagnosis? Strawberry-red tongue Loose, dark stools Jaundiced skin Tea-colored urine

Tea-colored urine RATIONALE: The presenting symptom in acute glomerulonephritis is grossly bloody urine. The caregiver may describe the urine as tea- or cola-colored. Periorbital edema may accompany or precede hematuria. Loose stools are seen in diarrhea. A strawberry-colored tongue is a symptom seen in the child with Kawasaki disease. Jaundiced skin is noted in hepatitis.

To prevent further urinary tract infections in a preschooler, what measures would you teach her mother? Suggest she drink less fluid daily to concentrate urine. Teach her to wipe her perineum front to back after voiding. Teach her to take frequent tub baths to clean her perineal area. Encourage her to be more ambulatory to increase urine output.

Teach her to wipe her perineum front to back after voiding. RATIONALE: Escherichia coli can be easily spread from the rectum to the urinary meatus and cause infection if girls do not take precautions against this.

In caring for a child with nephrotic syndrome, which intervention will be included in the child's plan of care? Increasing fluid intake by 50 ml per hour Weighing on the same scale each day Ambulating 3 to 4 times a day Testing the urine for glucose levels regularly

Weighing on the same scale each day RATIONALE: The child with nephrotic syndrome is weighed every day using the same scale to accurately monitor the child's fluid gain and loss. The child with nephrotic syndrome is very edematous so increasing fluid intake would be counterproductive to care needed. In nephrotic syndrome the urine is tested for protein, not glucose. Ambulation is important for all but it is not specific to the child with nephrotic syndrome.

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℉ (37.8℃). The nurse encourages the mother to have the child seen by the care provider because the nurse suspects the child may have: a urinary tract infection. lipoid nephrosis (idiopathic nephrotic syndrome). rheumatic fever. acute glomerulonephritis.

acute glomerulonephritis. RATIONALE: 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 1 to 3 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℉ (39.4℃ to 40℃) at the onset, but decreases in a few days to about 100℉ (37.8℃). Slight headache and malaise are usual, and vomiting may occur.

An infant has undergone a hypospadias repair. What intervention will the nurse teach the parents to keep the site clean and to reduce swelling? "It is important to use double diapering to keep stool off the site." "You can use a gauze dressing to cover the urethral stent." "The compression dressing should be changed if it becomes soiled." "Keep the penis taped to the abdomen, so stool can not get to the surgical site."

"It is important to use double diapering to keep stool off the site." RATIONALE: Hypospadias occurs when the urethral opening is on the ventral side of the penis. It needs to be repaired because, when older, the client will not be able to aim a urinary stream while standing and it causes erectile dysfunction. The penile dressing following surgery is usually a compression type, which will decrease edema and bruising. The easiest way to accomplish this type of dressing is through double diapering. Double diapering also prevents the stool from getting to the penis and surgical site, causing an infection. The penis is generally taped to the abdomen to prevent the catheter or stent from causing stress on the urethral sutures, not to keep the site clean or prevent swelling. Gauze is not used over the surgical site. Double diapering provides a compression dressing, and the soiled diaper should be changed with every bowel movement.

The nurse is preparing a 7-year-old girl for discharge after treatment for nephrotic syndrome. Which instructions would the nurse include in the discharge teaching plan for the parents? "Here is some written information from the dietitian." "She should try to avoid protein." "She must severely restrict her sodium intake." "Let's meet with the dietitian and plan some meals."

"Let's meet with the dietitian and plan some meals." RATIONALE: Consultation with a dietitian would be most helpful for meal planning because so many of children's favorite foods are high in sodium. Restricting sodium may not be necessary if the child is not edematous; in addition, the statement does not teach. Protein-rich snacks should be encouraged. The nurse needs to provide the parents with specific instructions, assistance, and resources in addition to simple written instructions.

The nurse is caring for an infant boy with grade IV vesicoureteral reflux. Which finding would lead the nurse to suspect that hydronephrosis is present? Enlarged inguinal glands Swollen testes Purulent drainage from the penis Abdominal mass

Abdominal mass RATIONALE: An abdominal mass indicates hydronephrosis. Enlarged inguinal glands are not associated with hydronephrosis. Purulent drainage from the penis is not associated with hydronephrosis. Swollen testes are not associated with hydronephrosis.

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? Computed tomography scan Urinalysis Kidneys, ureter, and bladder x-ray Creatinine clearance rate

Creatinine clearance rate RATIONALE: 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.

A 7-year-old boy has experienced repeated urinary tract infections (UTIs). His older sister also experienced repeated UTIs and was diagnosed with vesicoureteral reflux, a condition that tends to appear in families. Therefore, the nurse suspects this same condition in this client. Which diagnostic tests would confirm this suspicion? Urine culture Urinalysis Blood urea nitrogen test Cystoscopy

Cystoscopy RATIONALE: Cystoscopy, or examination of the bladder and ureter openings by direct examination with a cystoscope introduced into the bladder through the urethra, is done to evaluate for possible vesicoureteral reflux or urethral stenosis. A urine culture is used to diagnose a urinary tract infection (UTI), or the presence of bacteria in urine. Urinalysis involves use of a chemical reagent strip to detect glucose, protein, and occult blood and to measure pH, as well as use of a refractometer to measure specific gravity. A blood urea nitrogen (BUN) test measures the level of urea in blood or how well the kidneys can clear this from the bloodstream.

A 15-year-old client presents to the emergency room reporting an abrupt onset of severe, sudden pain on the right side of the scrotum while playing football. The nurse notes a blue-black swelling of the affected scrotum. Which action will the nurse complete next? Complete a head-to-toe assessment. Notify the primary health care provider. Monitor the client's urine output. Have the client rate the pain.

Notify the primary health care provider. RATIONALE: The nurse would suspect testicular torsion, which is a surgical emergency that necessitates immediate surgical correction to prevent testicular necrosis and possible gangrene. Therefore, the nurse would notify the health care provider immediately. The nurse would then have the client rate the pain, complete a head-to-toe assessment, and monitor urine output.

The nurse is caring for a 6-year-old child with acute glomerulonephritis. When reviewing the client's laboratory results, which result is most important to review with the health care provider? Urine culture positive for contaminants Negative for respiratory syncytial virus (RSV) Positive culture for group A streptococcus White blood cells: 8,000/µL (8.0 ×109/L

Positive culture for group A streptococcus RATIONALE: Acute glomerulonephritis may result as an autoimmune response to the invasion of group A streptococcus. This group of streptococci affect the glomeruli of the kidneys. This would be addressed by the health care provider and is the most important of the laboratory results presented. If there is an active strep infection, it would need to be treated with an antibiotic. The white blood cell count is within normal limits. It is good to be negative for respiratory syncytial virus. The urine culture would have to be redone due to contamination. It does not provide an accurate status of the child's urine.

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 take which action? Take the child's blood pressure and report the findings to the nurse while the nurse is still on the phone. Give the child fluids and report back to the nurse in a few hours. Give the child a diuretic and report back to the nurse in a few hours. Weigh the child in the same clothes she had been weighed in the day before and report the two weights to the nurse while the nurse is on the phone.

Take the child's blood pressure and report the findings to the nurse while the nurse is still on the phone. RATIONALE: 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.

A 4-year-old child with a urinary tract infection is scheduled to have a voiding cystourethrogram. When preparing the child for this procedure, the nurse would want to prepare the child to: drink three glasses of water during the procedure. anticipate a headache afterward. have a local anesthetic injected prior to the procedure. void during the procedure.

void during the procedure. RATIONALE: At the start of the voiding cystourethrogram, a catheter is inserted into the bladder. The contrast medium is inserted through the catheter into the bladder. Fluoroscopy is performed to demonstrate the filling of the bladder and the collapsing of the bladder upon emptying. The assessment of emptying requires the child to void during the procedure so that bladder emptying and urethra flow can be assessed. No anesthetic is required for this procedure. The fluid filling the bladder is inserted via the catheter so no drinking of water is required. A headache following the procedure would not be expected.