Gastrointestinal/Nutrition - NCLEX-Style Questions

The nurse is caring for a child diagnosed with Hirschsprung disease with significant abdominal distention. The client is scheduled for a colon resection in the afternoon. Which intervention should the nurse include in the plan of care? A) Administer oral antibiotics, as prescribed. C) Check the client's gag reflex D) Digitally disimpact the client C) Maintain the nasogastric tube (NG) at a low intermittent suctioning

C) Maintain the nasogastric tube (NG) at a low intermittent suctioning Rationale: For clients diagnosed with Hirschsprung disease, an NG tube may be ordered preoperatively to decrease abdominal distention. The NG tube should be set at a low intermittent suction to reduce the risk of aspirating gastric contents, allow the bowel to rest, and treat abdominal distention. When caring for a client with an NG tube, the nurse should maintain the tube at the settings for which it is ordered.

The nurse provides home care instructions to the parents of a child w/ celiac disease. The nurse would teach the parents to include which food item in the child's diet? A) Rice B) Oatmeal C) Rye toast D) Wheat Bread

A) Rice Rationale: Celiac disease refers to the intolerance to gluten, the protein component of wheat, barely, rye, and oats.

The nurse educator is teaching students about clinical findings associated with hypertrophic pyloric stenosis in an infant. Which student statement indicates that further teaching is required? A) "A baby with pyloric stenosis may have an elevated serum sodium level." B) "An infant with pyloric stenosis will have clay colored stools." C) "A mass in the upper left abdominal quadrant is associated with pyloric stenosis." D) "An infant with pyloric stenosis will have a flat anterior fontanelle."

D) "An infant with pyloric stenosis will have a flat anterior fontanelle." Rationale: In pyloric stenosis, persistent vomiting can lead to a severe loss of stomach acid, causing dehydration, electrolyte imbalances, and hypochloremic hypokalemic metabolic alkalosis. Elevated serum sodium occurs as a result of fluid loss and dehydration.

The nurse is caring for a 3-month-old being evaluated for possible Hirschsprung disease. His parents call the nurse and show her his diaper containing a large amount of mucus and bloody diarrhea. The nurse notes that the infant is irritable and his abdomen appears very distended. Which should be the nurse's next action? A) Reassure the parents that this is an expected finding and not uncommon. B) Call a code for a potential cardiac arrest and stay with the infant. C) Immediately obtain all vital signs with a quick head-to-toe assessment. D) Obtain a stool sample for occult blood.

C) Immediately obtain all vital signs with a quick head-to-toe assessment. Rationale: All vital signs need to be evaluated because the child with enterocolitis can quickly progress to a state of shock. A quick head-to-toe assessment will allow the nurse to evaluate the child's circulatory system.

A child is hospitalized because of persistent vomiting. The nurse would monitor the child closely for which problem? A) Diarrhea B) Metabolic acidosis C) Metabolic alkalosis D) Hyperactive bowel sounds

C) Metabolic alkalosis Rationale: Vomiting cause loss of HCL and leads to metabolic alkalosis.

The nurse is administering omeprazole (Prilosec) to a 3-month-old with gastroesophageal reflux (GER). The child's parents ask the nurse how the medication works. Which is the nurse's best response? A) "Prilosec is a proton pump inhibitor that is commonly used for reflux in infants." B) "Prilosec decreases stomach acid, so it will not be as irritating when your child spits up." C) "Prilosec helps food move through the stomach quicker, so there will be less chance for reflux." D) "Prilosec relaxes the pressure of the lower esophageal sphincter."

B) "Prilosec decreases stomach acid, so it will not be as irritating when your child spits up." Rationale: Option "B" is an accurate description that gives the parents information that is clear and concise. Although option "A" is an accurate description of the mechanism of action, it does not tell the parents how the medication functions.

The nurse is providing education to the parents of an infant who is diagnosed with Hirschsprung disease. Which information should the nurse include in the teaching? A) Segments of the colon are missing B) The nerves in segments of the colon are overactive C) Clusters of nerves from segments of the colon are missing D) Segments of the colon have decreased blood flow

C) Clusters of nerves from segments of the colon are missing Rationale: Hirschsprung disease is a congenital condition in which neural ganglia, or clusters of nerves from segments of the colon, are missing.

The nurse is caring for a pediatric client with Hirschsprung disease who underwent the placement of a temporary colostomy one day ago. Which finding should the nurse immediately report to the healthcare provider? A) A stoma located well above the level of the skin B) Rosy-colored stoma C) Excoriated skin around the stoma D) Hypoactive bowel sounds

C) Excoriated skin around the stoma Rationale: The skin around the stoma should be intact; therefore, the nurse should report the findings to the healthcare provider.

An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which *best* position at this time? A) Prone position B) On the stomach C) Left lateral position D) Right lateral position

C) Left lateral position Rationale: After cleft lip repair, the nurse avoids positioning an infant on the side of the repair or in the prone position, because these positions can cause rubbing of the surgical site on the mattress.

The nurse has provided postoperative teaching to the parents of an infant post-pyloromyotomy for hypertrophic pyloric stenosis. Which statement made by a parent indicates an understanding of the teaching? A) "I will lay my baby down while I am feeding him." B) "I understand my baby will not experience any more vomiting." C) "I will plan on feeding my baby less frequently." D) "I will make sure that I burp my baby after he eats."

D) "I will make sure that I burp my baby after he eats." Rationale: The infant should be burped frequently during feedings to prevent gastric distention, which can cause vomiting and pain.

The nurse is preparing to care for a child w/ a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented? A) Watery diarrhea B) Ribbon-like stools C) Profuse projectile vomiting D) Bright red blood and mucus in the stools

D) Bright red blood and mucus in the stools Rationale: Intussusception is a serious condition in which part of the intestine slides into an adjacent part of the intestine. This telescoping action often blocks food or fluid from passing through. Intussusception also cuts off the blood supply to the part of the intestine that's affected. A child w/ this condition often has sever abd. pain that is crampy and intermittent, causing the child to draw in the knees to the chest. Vomiting may be present, but is not projectile. Bright red blood and mucus are passed through the rectum and commonly are described as currant jelly-like stools.

The nurse is caring for an 8-week-old male who has just been diagnosed with Hirschsprung disease. The parents ask what they should expect. Which is the nurse's best response? A) "It is really an easy disease to manage. Most children are placed on stool softeners to help with constipation until it resolves." B) "A permanent stool diversion, called a colostomy, will be placed by the surgeon to bypass the narrowed area." C) "Daily bowel irrigations will help your child maintain regular bowel habits." D) "Although your child will require surgery, there are different ways to manage the disease, depending on how much bowel is involved."

D) "Although your child will require surgery, there are different ways to manage the disease, depending on how much bowel is involved." Rationale: The aganglionic portion needs to be removed. Although most children have a temporary colostomy placed, many infants are able to bypass the colostomy and have the bowel immediately reattached.

The nurse receives a call from the mother of a 6-month-old who describes her child as alternately sleepy and fussy. She states that her infant vomited once this morning and had two episodes of diarrhea. The last episode contained mucus and a small amount of blood. She asks the nurse what she should do. Which is the nurse's best response? 1. "Your infant will need to have some tests in the emergency department to determine whether anything serious is going on." 2. "Try feeding your infant in about 30 minutes; in the event of repeat vomiting, bring the infant to the emergency department for some tests and intravenous rehydration." 3. "Many infants display these symptoms when they develop an allergy to the formula they are receiving; try switching to a soy-based formula." 4. "Do not worry about the blood and mucus in the stool; it is not unusual for infants to have blood in their stools because their intestines are more sensitive."

1. "Your infant will need to have some tests in the emergency department to determine whether anything serious is going on." The infant is displaying signs of intussusception. This is an emergency that needs to be evaluated to prevent ischemia and perforation.

The nurse is caring for a newborn with a cleft lip and palate. The mother states, "I will not be able to breastfeed my baby." Which is the nurse ' s best response? 1. "It sounds like you are feeling discouraged. Would you like to talk about it?" 2. "Sometimes breastfeeding is still an option for babies with a cleft lip and palate. Would you like more information?" 3. "Although breastfeeding is not an option, you can pump your milk and then feed it to your baby with a special nipple." 4. "We usually discourage breastfeeding babies with cleft lip and palate as it puts them at an increased risk for aspiration."

2. "Sometimes breastfeeding is still an option for babies with a cleft lip and palate. Would you like more information?" Some mothers are able to breastfeed their infants who have a cleft lip and palate. The breast can help fill in the cleft and help the infant create suction.

The nurse educator is teaching students about clinical findings associated with hypertrophic pyloric stenosis in an infant. Which student statement indicates that further teaching is required? A) "An infant with pyloric stenosis will have a flat anterior fontanelle." B) "A mass in the upper left abdominal quadrant is associated with pyloric stenosis." C) "An infant with pyloric stenosis will have clay colored stools." D) "A baby with pyloric stenosis may have an elevated serum sodium level."

A) "An infant with pyloric stenosis will have a flat anterior fontanelle." Rationale: A flat fontanelle is a clinical finding associated with adequate hydration. Infants with pyloric stenosis experience excessive vomiting, which causes dehydration. A sunken anterior fontanelle is an anticipated finding for a dehydrated infant with pyloric stenosis. In pyloric stenosis, persistent vomiting can lead to a severe loss of stomach acid, causing dehydration, electrolyte imbalances, and hypochloremic hypokalemic metabolic alkalosis. Elevated serum sodium occurs as a result of fluid loss and dehydration.

Which clinical finding(s) should the nurse anticipate for an infant with pyloric stenosis? *Select all that apply.* A) Lethargy B) Loss of appetite C) Blood-tinged emesis D) Projectile vomiting E) Scaphoid abdomen

A) Lethargy C) Blood-tinged emesis D) Projectile vomiting Rationale: In pyloric stenosis, as the passageway between the stomach and small intestine narrows, it results in vomiting that may get more intense over time until it leads to projectile vomiting where the vomit literally launches out of the infant's mouth. The vomit is non-bilious, meaning it doesn't contain bile, and in babies, it consists primarily of milk and stomach acid. The non-bilious projectile vomiting is a classic sign of hypertrophic pyloric stenosis. Babies often demonstrate excessive hunger after vomiting and appear irritable and fussy. Continual vomiting irritates the esophagus, leading to blood-tinged vomit. The persistent vomiting can also lead to a severe loss of stomach acid, causing dehydration, electrolyte imbalances, and hypochloremic hypokalemic metabolic alkalosis. This can lead to long-term complications and also impairs peristalsis, the normal process where the smooth muscle of the digestive tract moves in a series of waves to push food through the digestive system. This can cause weight loss and failure to thrive.

The nurse is caring for an infant newly diagnosed with Hirschsprung disease. What does the nurse understand about this infant's condition? *Select all that apply.* A) There is a lack of peristalsis in the large intestine and an accumulation of bowel contents, leading to abdominal distention. B) There is excessive peristalsis throughout the intestine, resulting in abdominal distention. C) There is a small-bowel obstruction, leading to ribbon-like stools. D) There is inflammation throughout the large intestine, leading to accumulation of intestinal contents and abdominal distention. E) There is an accumulation of bowel contents, leading to non-passage of stools.

A) There is a lack of peristalsis in the large intestine and an accumulation of bowel contents, leading to abdominal distention. E) There is an accumulation of bowel contents, leading to non-passage of stools. Rationale: In Hirschsprung disease, a portion of the large intestine has an area lacking in ganglion cells. This results in a lack of peristalsis as well as an accumulation of bowel contents and abdominal distention. There is accumulation of stool above the aganglionic bowel, which does not allow stool to pass through.

The nurse is caring for a 4-year-old client with acetaminophen poisoning that occurred 6 hours ago. Which is an expected gastrointestinal symptom the nurse can anticipate documenting? A) Vomiting B) Diarrhea C) Constipation D) Acid reflux

A) Vomiting Rationale: There are four stages of acetaminophen poisoning the nurse should be familiar with and each stage presents with a specific set of symptoms. The first stage may last up to 24 hours after the ingestion and during this period clients can have no or mild symptoms, such as nausea and vomiting. The second stage starts about 18 to 72 hours after the ingestion. During the second stage, the client typically presents with right upper quadrant pain due to liver involvement and hypotension. The third stage occurs 72 to 96 hours post-ingestion and is characterized by liver dysfunction. Clinical manifestations of liver involvement include jaundice, coagulopathy, and hepatic encephalopathy. Clients can also develop renal failure which may lead to metabolic acidosis. The fourth stage usually occurs after five days post-ingestion, where the client can either completely recover or progress to multi-organ failure or even death.

The nurse is gathering data from the parent of an 8-year-old child suspected of having Hirschsprung disease. Which question is most appropriate for the nurse to include in the focused assessment? A) "Does your child have frequent hiccups?" B) "How often does your child have a bowel movement?" C) "Has your child's appetite increased?" D) "Has your child recently had diarrhea?"

B) "How often does your child have a bowel movement?" Rationale: Many clients with Hirschsprung disease are diagnosed by six months; however, diagnosis can occur later in childhood. Clients who are born with Hirschsprung fail to pass meconium, their first stool, a process that usually happens within the first two days after birth. The rectum and the distal sigmoid colon, which are the areas closest to the anus, are usually affected, so feces builds up before the obstruction, which causes severe constipation. A digital rectal examination of the newborn often leads to explosive passage of gas and watery stools known as squirt or blast sign. Excessive constipation can also lead to massive colon dilation, or megacolon, which causes abdominal distention and increases the risk of bowel rupture. Older infants may also present with bilious vomiting, poor feeding, refusal to feed, and failure to gain weight, while older children may present chronic constipation. These symptoms might persist into childhood without intervention.

The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parent about the child's symptoms? A) Watery diarrhea B) Projectile vomiting C) Increased urine output D) Vomiting large amounts of bile

B) Projectile vomiting Rationale: In pyloric stenosis, the passageway between the stomach and small intestine is narrowed due to hypertrophy and hyperplasia. This causes a narrowing between the opening of the stomach and small intestine. Clinical manifestations include projectile vomiting, irritability, hunger and crying, constipation, and signs of dehydration.

A parent of an infant newly diagnosed with Hirschsprung disease asks the nurse, "What caused my baby to get this condition?" Which topic should the nurse discuss with the parent? A) Male gender B) Maternal cigarette smoking during pregnancy C) Fetal genetic mutation D) Maternal alcohol use while pregnant

C) Fetal genetic mutation Rationale: Hirschsprung disease can be caused by mutations in the RET or EDNRB genes.

The nurse has provided teaching to the parents of an infant diagnosed with Hirschsprung disease who recently underwent bowel resection. Which statement the client's parent made indicates an understanding of the information? A) "I will give my baby a sponge bath until the steri-strips fall off." B) "My baby will no longer have problems with constipation." C) "The opening of the anus will constrict over the next few weeks to allow for less passage of stool." D) "I can expect my baby to have quite a bit of diarrhea initially."

D) "I can expect my baby to have quite a bit of diarrhea initially." Rationale: The nurse should teach clients how Hirschsprung's disease impairs the movement of feces through the bowel and that the goal of the surgery is to remove the part of the bowel that was not working correctly. Parents should be informed that the child will initially have a lot of diarrhea. The nurse should also teach them how to protect the skin around the anus using the prescribed barrier cream. Also, the nurse must stress the importance of monitoring for skin breakdown with each diaper change and prompt the parent to let their healthcare provider know if excessive irritation occurs or if a rash does not improve with cleaning and applying the prescribed creams. In addition, the nurse can remind them of the importance of ensuring their child is well hydrated until the diarrhea resolves. The nurse should also teach the parents to administer the prescribed pediatric acetaminophen as needed for pain and instruct them to call their healthcare provider if their child continues to be uncomfortable. Also, the nurse should teach them how to care for the incisional site, showing them the steri-strips covering the incisions, and let them know that it is okay to bathe their child with them in place and that they usually fall off on their own in a couple of weeks. The nurse can explain that some redness and swelling may occur while the incisions heal. Then, the nurse should stress the importance of contacting their healthcare provider immediately if they notice worsening redness or swelling or if their child develops a fever. The nurse will further instruct the parents that, at first, the opening in their child's anus may not be large enough for stool to pass quickly and that the anus may need to be gently dilated or stretched for several weeks after surgery. Reassure them that the home healthcare nurse will assist them in learning how to perform the procedure independently as needed.

A student nurse caring for an infant with Hirschsprung disease asks the nurse, "What is the pathophysiology of this disease?" Which is the best response by the nurse? A) "Part of the colon becomes flaccid due to developmental delays." B) "The sympathetic nervous system does not properly innervate the colon." C) "The parasympathetic ganglion cells in the nerve plexus are weakened." D) "There is no development of the parasympathetic ganglion cells in the nerve plexuses in the rectum and parts of the colon."

D) "There is no development of the parasympathetic ganglion cells in the nerve plexuses in the rectum and parts of the colon." Rationale: Hirschsprung disease can be caused by mutations in the RET or EDNRB genes. The genetic mutations in these genes can disrupt the neuroblast journey toward the anus. As a result, parasympathetic ganglion cells are not developed in the nerve plexuses in the rectum or parts of the colon. The absence of parasympathetic ganglion cells results in unopposed sympathetic stimulation of the intestines resulting in the inability to relax; therefore, they remain in a state of sustained contraction. Ultimately, this results in a lack of peristalsis, which blocks the movement of feces.

The parents of a 4-year-old ask the nurse how to manage their child's constipation. Select the nurse's best response. A) "Add 2 ounces of apple or pear juice to the child's diet." B) "Be sure your child eats a lot of fresh fruit such as apples and bananas." C) "Encourage your child to drink more fluids." D) "Decrease bulky foods such as whole-grain breads and brown rice."

C) "Encourage your child to drink more fluids." Rationale: Increasing fluid consumption helps to decrease the hardness of the stool.

A child is diagnosed with chronic constipation that has been unresponsive to dietary and activity changes. Which pharmacological measure is most appropriate? A) Natural supplements and herbs. B) Stimulant laxative. C) Osmotic agent. D) Pharmacological measures are not used in pediatric constipation.

C) Osmotic agent. Rationale: A stool softener (osmotic agent) is the drug of choice because it will lead to easier evacuation.

The nurse in the pediatric clinic is caring for a client suspected of having Hirschsprung disease. Which diagnostic test does the nurse understand as being diagnostic for the condition? A) Barium enema B) Anorectal manometry C) Rectal suction biopsy D) Abdominal x-ray

C) Rectal suction biopsy Rationale: A diagnosis of Hirschsprung disease can be confirmed by performing a rectal suction biopsy of the narrowed area in the colon. If the client has this condition, it will show the absence of the ganglion cells.

Which should be the nurse's immediate action when a newborn begins to cough and choke and becomes cyanotic while feeding? 1. Inform the health-care provider of the situation. 2. Have the mother stop feeding the infant, and observe to see if the choking episode resolves on its own. 3. Immediately determine the infant's oxygen saturation and have the mother stop feeding the infant. 4. Take the infant from the mother and administer oxygen while obtaining the infant's oxygen saturation.

4. Take the infant from the mother and administer oxygen while obtaining the infant's oxygen saturation.

The parent of a child being evaluated for celiac disease asks the nurse why it is important to make dietary changes. Which is the nurse's best response? 1. "The body's response to gluten causes damage to the mucosal cells in the intestine, leading to absorption problems." 2. "The body's response to consumption of anything containing gluten is to create special cells called villi, which leads to more diarrhea." 3. "The body's response to gluten causes the intestine to become more porous and hang on to more of the fat-soluble vitamins, leading to vitamin toxicity." 4. "The body's response to gluten causes damage to the mucosal cells, leading to malabsorption of water and hard, constipated stools."

1. "The body's response to gluten causes damage to the mucosal cells in the intestine, leading to absorption problems."

Which child may need extra fluids to prevent dehydration? Select all that apply. 1. A 7-day-old receiving phototherapy. 2. A 6-month-old with newly diagnosed pyloric stenosis. 3. A 2-year-old with pneumonia. 4. A 2-year-old with full-thickness burns to the chest, back, and abdomen. 5. A 13-year-old who has just started her menses.

1. A 7-day-old receiving phototherapy. 2. A 6-month-old with newly diagnosed pyloric stenosis. 3. A 2-year-old with pneumonia. 4. A 2-year-old with full-thickness burns to the chest, back, and abdomen.

The nurse is caring for a 4-month-old who has just had an isolated cleft lip repaired. Select the best position for the child in the immediate post-operative period. 1. Right side-lying. 2. Left side-lying. 3. Supine. 4. Prone.

3. Supine. The supine position is preferred because there is decreased risk of the infant rubbing the suture line.

The nurse is caring for a newborn who has just been diagnosed with tracheoesophageal fistula and is scheduled for surgery. Which should the nurse expect to do in the preoperative period? 1. Keep the child in a monitored crib, obtain frequent vital signs, and allow the parents to visit but not hold their infant. 2. Administer intravenous fluids and antibiotics. 3. Place the infant on 100% oxygen via a non-rebreather mask. 4. Have the mother feed the infant slowly in a monitored area, stopping all feedings 4 to 6 hours before surgery.

2. Administer intravenous fluids and antibiotics. The infant should be monitored, and vital signs should be obtained frequently, but the parents should be encouraged to hold their baby. Intravenous fluids are administered to prevent dehydration because the infant is NPO. Intravenous antibiotics are administered to prevent pneumonia because aspiration of secretions is likely. The infant should receive only the amount of oxygen needed to keep saturations above 94%. As soon as the diagnosis is made, the infant is made NPO because the risk for aspiration is extremely high.

The nurse is caring for a 5-month-old infant with a diagnosis of intussusception. The infant has periods of irritability during which the knees are brought to the chest and the infant cries, alternating with periods of lethargy. Vital signs are stable and within age-appropriate limits. The health-care provider elects to give an enema. The parents ask the purpose of the enema. Which is the nurse ' s most appropriate response? 1. "The enema will confirm the diagnosis. If the test result is positive, your child will need to have surgery to correct the intussusception." 2. "The enema will confirm the diagnosis. Although very unlikely, the enema may also help fix the intussusception so that your child will not immediately need surgery." 3. "The enema will help confirm the diagnosis and has a good chance of fixing the intussusception." 4. "The enema will help confirm the diagnosis and may temporarily fix the intussusception. If the bowel returns to normal, there is a strong likelihood that the intussusception will recur."

3. "The enema will help confirm the diagnosis and has a good chance of fixing the intussusception."

Which is the best position for an 8-year-old who has just returned to the pediatric unit after an appendectomy for a ruptured appendix? 1. Semi-Fowler. 2. Prone. 3. Right side-lying. 4. Left side-lying.

3. Right side-lying. The right side-lying position promotes comfort and allows the peritoneal cavity to drain.

The parents of a newborn diagnosed with a cleft lip and palate ask the nurse when their child's lip and palate will most likely be repaired. Which is the nurse's best response? 1. "The palate and the lip are usually repaired in the first few weeks of life so that the baby can grow and gain weight." 2. "The palate and the lip are usually not repaired until the baby is approximately 6 months old so that the mouth has had enough time to grow." 3. "The lip is repaired in the first few months of life, but the palate is not usually repaired until the child is 3 years old." 4. "The lip is repaired in the first few weeks of life, but the palate is not usually repaired until the child is 18 months old."

4. "The lip is repaired in the first few weeks of life, but the palate is not usually repaired until the child is 18 months old."

The clinic nurse reviews the record of an infant and notes that the PCP has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign *most likely* led the parent to seek health care for the infant. A) Diarrhea B) Projectile vomiting C) Regurgitation of feedings D) Foul-smelling ribbon-like stools

D) Foul-smelling ribbon-like stools Rationale: Chronic constipation beginning in the first month of life resulting in pellet-like or ribbon-like stools that are foul-smelling is a clinical manifestation of this disorder.

Which should be included in the plan of care for a 14-month-old whose cleft palate was repaired 12 hours ago? Select all that apply. 1. Allow the infant to have familiar items of comfort such as a favorite stuffed animal and a "sippy" cup. 2. Once liquids have been tolerated, encourage a bland diet such as soup, Jell-O, and saltine crackers. 3. Administer pain medication on a regular schedule, as opposed to an as-needed schedule. 4. Use a Yankauer suction catheter on the infant's mouth to decrease the risk of aspiration of oral secretions. 5. When discharged, remove elbow restraints.

1. Allow the infant to have familiar items of comfort such as a favorite stuffed animal and a "sippy" cup. 3. Administer pain medication on a regular schedule, as opposed to an as-needed schedule. The child should not be allowed to use anything that creates suction in the mouth, such as pacifiers or straws. "Sippy" cups are acceptable. The child should not have anything hard in the mouth, such as crackers, cookies, or a spoon. Pain medication should be administered regularly to avoid crying, which places stress on the suture line. A Yankauer suction should not be used in the mouth because it creates suction and is a hard instrument that could irritate the suture line. The child should be positioned to allow secretions to drain out of the child's mouth. Suction should be used only in the event of an emergency. Elbow restraints are used until the repaired palate has healed. When at home, the parents need to monitor the child closely if restraints are removed to move the arms or for bathing.

The nurse is caring for an 8-week-old infant being evaluated for pyloric stenosis. Which statement by the parent would be typical for a child with this diagnosis? 1. "The baby is a very fussy eater and just does not want to eat." 2. "The baby tends to have a very forceful vomiting episode about 30 minutes after most feedings." 3. "The baby is always hungry after vomiting, so I feed her again." 4. "The baby is happy in spite of getting really upset after spitting up."

3. "The baby is always hungry after vomiting, so I feed her again." Infants with pyloric stenosis vomit *immediately* after a feeding, especially as the pylorus becomes more hypertrophied. Infants with pyloric stenosis are always hungry and often appear malnourished. Most infants with pyloric stenosis are irritable because they are hungry. Parents do not usually describe the vomiting episodes as "spitting up" because infants tend to have projectile vomiting.

The nurse will soon receive a 4-month-old who has been diagnosed with intussusception. The infant is described as very lethargic with the following vital signs: T 101.8°F (38.7°C), HR 181, BP 68/38. The reporting nurse states the infant's abdomen is very rigid. Which is the most appropriate action for the receiving nurse? 1. Prepare to accompany the infant to a computed tomography scan to confirm the diagnosis. 2. Prepare to accompany the infant to the radiology department for a reducing enema. 3. Prepare to start a second intravenous line to administer fluids and antibiotics. 4. Prepare to get the infant ready for immediate surgical correction.

4. Prepare to get the infant ready for immediate surgical correction. Intussusception with peritonitis is a surgical emergency, so preparing the infant for surgery is the nurse's top priority.

The nurse is assessing an infant with pyloric stenosis. The assessment findings include a sunken anterior fontanelle, dry mucous membranes, and no tears when crying. Based on these findings, which is the nurse's priority action? A) Continue to monitor the infant B) Obtain a weight C) Increase number of feedings D) Initiate IV fluids

D) Initiate IV fluids Rationale: An isotonic intravenous fluid should be initiated to correct the fluid volume deficit. Isotonic solutions remain in the vascular system and help to increase the vascular volume.

The nurse is teaching a newly graduated nurse about the physiology of the large bowel. *Complete the following sentences using the list of options.* The intestines move the waste through the bowels in one direction only via coordinated wave-like smooth muscle contractions called ____________ *(peristalsis, impulses, constriction)*. The __________ *(central, peripheral, autonomic)* nervous system controls this.

The intestines move the waste through the bowels in one direction only via coordinated wave-like smooth muscle contractions called *peristalsis.* The *autonomic* nervous system controls this.

The nurse is reviewing the nursing diagnoses for an infant with pyloric stenosis. Which diagnosis is a priority for the nurse to address? A) Deficient fluid volume related to excessive vomiting B) Deficient parental knowledge and anxiety related to the illness and hospitalization of their child C) Imbalanced nutrition, less than body requirements related to excessive vomiting D) Acute pain related to abdominal distension, forceful vomiting, or abdominal cramping

A) Deficient fluid volume related to excessive vomiting Rationale: Deficient fluid volume is the most life-threatening concern. The deficient fluid volume places the infant at risk for electrolyte imbalances and metabolic alkalosis, both of which are life-threatening conditions.

Which child can be discharged without further evaluation? A) A 2-year-old who has had 24 hours of watery diarrhea that has changed to bloody diarrhea in the past 12 hours. B) A 3-year-old who had a relapse of one diarrhea episode after restarting a normal diet. C) A 6-year-old who has been having vomiting and diarrhea for 2 days and has decreased urine output. C) A 10-year-old who has just returned from a Scout camping trip and has had several episodes of diarrhea.

B) A 3-year-old who had a relapse of one diarrhea episode after restarting a normal diet. Rationale: It is common for children to have a relapse of diarrhea after resuming a regular diet. Diarrhea containing blood needs further evaluation to determine the source of the blood, and the child's blood counts and electrolyte balance need to be tested. Children who have had vomiting and diarrhea for more than 2 days require evaluation to determine whether IV rehydration and hospital admission are necessary. Diarrhea following a camping trip needs further evaluation because it may be caused by bacteria or parasites.

The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia w/ tracheoesophageal fistula is suspected. The nurse expects to note which *most likely* sign of this condition documented in the record? A) Incessant crying B) Coughing at nighttime C) Choking w/ feedings D) Sever projectile vomiting

C) Choking w/ feedings Rationale: In this condition, the esophagus terminates before it reaches the stomach, ending in a blind pouch, and a fistula is present that forms an unnatural connection w/ the trachea. Any child who exhibits the "3 C's" - coughing and choking w/ feedings and unexplained cyanosis - would be suspected to have tracheoesophageal fistula.

Which should the nurse include in the plan of care to decrease symptoms of gastroesophageal reflux (GER) in a 2-month-old? *Select all that apply.* A) Place the infant in an infant seat immediately after feedings. B) Place the infant in the prone position immediately after feeding to decrease the risk of aspiration. C) Encourage the parents not to worry because most infants outgrow GER within the first year of life. D) Encourage the parents to hold the infant in an upright position for 30 minutes following a feeding. E) Suggest that the parents burp the infant after every 1-2 ounces consumed.

D) Encourage the parents to hold the infant in an upright position for 30 minutes following a feeding. E) Suggest that the parents burp the infant after every 1-2 ounces consumed. Rationale: Keeping the infant in an upright position is the best way to decrease the symptoms of GER. The infant can also be placed in the supine position with the head of the crib elevated. A harness can be used to keep the child from sliding down. Burping the infant frequently may help decrease spitting up by expelling air from the stomach more often.

A 10-year-old is being evaluated for possible appendicitis and complains of nausea and sharp abdominal pain in the right lower quadrant. An abdominal ultrasound is scheduled, and a blood count has been obtained. The child vomits, finds the pain relieved, and calls the nurse. Which should be the nurse's next action? A) Cancel the ultrasound and obtain an order for oral ondansetron (Zofran). B) Cancel the ultrasound and prepare to administer an intravenous bolus. C) Prepare for the probable discharge of the patient. D) Immediately notify the health-care provider of the child's status.

D) Immediately notify the health-care provider of the child's status. Rationale: The health-care provider should be notified immediately, because a sudden change or loss of pain often indicates a perforated appendix.

The nurse provides feeding instructions to the parent of an infant diagnosed w/ gastroesophageal reflux disease. Which instruction would the nurse give to the parent to assist in reducing the episodes of emesis? A) Provide less frequent, larger feedings B) Burp the infant less frequently during feedings C) Thin the feedings by adding water to the formula D) Thicken the feedings by adding rice cereal to the formula

D) Thicken the feedings by adding rice cereal to the formula Rationale: Small, more frequent feedings w/ frequent burping are often prescribed in the tx of gastroesophageal reflux disease. Feedings thickened w/ rice cereal may reduce episodes of emesis.

The nurse is caring for a 7-week-old scheduled for a pyloromyotomy in 24 hours. Which would the nurse expect to find in the plan of care? 1. Keep infant NPO; begin intravenous fluids at maintenance. 2. Keep infant NPO; begin intravenous fluids at maintenance; place nasogastric tube (NGT) to low wall suction. 3. Obtain serum electrolytes; keep infant NPO; do not attempt to pass NGT tube 4. Offer infant small frequent feedings; keep NPO 6 to 8 hours before surgery.

2. Keep infant NPO; begin intravenous fluids at maintenance; place nasogastric tube (NGT) to low wall suction. In addition to giving fluids intravenously and keeping the infant NPO, an NGT is placed to decompress the stomach. The pylorus is distal to the stomach, so an NGT is placed above the obstruction. The infant is made NPO as soon as diagnosis is confi rmed. Allowing the infant to feed perpetuates the vomiting and

The nurse is preparing to review the pathophysiology of hypertrophic pyloric stenosis with the parents of an infant newly diagnosed with the condition. Which information should the nurse include in the education? A) A mass has formed between the esophagus and the fundal portion of the stomach. B) The opening between the stomach and small intestine is narrowed. C) The constriction of the esophageal sphincter prevents it from closing. D) The muscle layers of the stomach are constricted.

B) The opening between the stomach and small intestine is narrowed. Rationale: In pyloric stenosis, the passageway between the stomach and small intestine is narrowed due to hypertrophy and hyperplasia. This causes a narrowing between the opening of the stomach and small intestine.

The nurse is caring for an infant diagnosed with Hirschsprung disease. The mother states she is pregnant with a boy and wants to know if her new baby will likely have the disorder. Which is the nurse's best response? A) "Genetics play a small role in Hirschsprung disease, so there is a chance the baby will develop it as well." B) "There is no evidence to support a genetic link, so it is very unlikely the baby will also have it." C) "It is rarely seen in boys, so it is not likely your new baby will have Hirschsprung disease." D) "Hirschsprung disease is seen only in girls, so your new baby will not be at risk."

A) "Genetics play a small role in Hirschsprung disease, so there is a chance the baby will develop it as well." Rationale: There is a genetic component to Hirschsprung disease, so any future siblings are also at risk. Hirschsprung disease is seen in both males and females, but is more common in males.

The nurse is caring for an infant who has experienced symptoms of pyloric stenosis for six months and is scheduled for a pyloromyotomy. Which clinical finding related to a long-term complication of pyloric stenosis should the nurse anticipate? A) Failure to thrive B) Gastroesophageal reflux disease C) Developmental delay D) Inflammatory bowel disease

A) Failure to thrive Rationale: Failure to thrive is a long-term complication of pyloric stenosis. Failure to thrive results from inadequate nutrition due to vomiting and weight loss associated with the condition.

The parent of a healthy three-year-old with no medical history asks the nurse at the pediatrician's office how to prevent diarrhea. Which is the best response by the nurse? A) "Do not allow your child to consume milk." B) "Teach your child to wash their hands." C) "Have your child wear a mask when around other children." D) "Eat a vegetarian diet in your home."

B) "Teach your child to wash their hands." Rationale: Healthy children without any underlying illness or food intolerances are most likely affected by infectious diarrhea. The best way to prevent infectious diarrhea is through proper handwashing, preventing the spread of infectious organisms. The nurse should instruct the child's parents to ensure they understand how to perform appropriate hand hygiene.

The nurse is creating a treatment plan for an older infant diagnosed with Hirschsprung disease who has not had a bowel movement for three days. Which non-surgical intervention is most appropriate for this client? A) Decrease dietary fiber in the client's meals B) Perform rectal irrigation with normal saline C) Administer loperamide as prescribed D) Insert a nasogastric tube

B) Perform rectal irrigation with normal saline Rationale: Rectal irrigation with normal saline will help relieve the client's constipation and is an appropriate non-surgical intervention to implement into the care plan.

A parent of an infant with hypertrophic pyloric stenosis says to the nurse, "I don't understand how my baby got this condition." Which response should the nurse provide the parent? A) "This condition is a congenital disorder." B) "Excessive vomiting injures the pyloric muscles." C) "The baby's pylorus did not develop properly." D) "The cause of this condition is unknown."

D) "The cause of this condition is unknown." Rationale: The cause of hypertrophic pyloric stenosis is unknown, but it is most likely due to a combination of genetic and environmental factors and is about four to five times more common in males than females—especially first-born males.