PEDS: Chapter 46: Nursing Care of a Family when a Child has a Renal or Urinary Tract Disorder Prep-U

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

The nurse is caring for a 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. Change diapers promptly, especially after bowel movements. Female urethras are shorter and straighter than males. Explanation: 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 10-year-old girl is experiencing acute renal failure due to dehydration. The nurse is preparing to administer IV fluid. Which of the following interventions should the nurse take in caring for this child?

Administer the IV fluid slowly Explanation: If the child is dehydrated (as with diarrhea or hemorrhage), IV fluid is needed to replace plasma volume. Administer such fluid slowly, however, to avoid heart failure as extra fluid cannot be removed by the nonfunctioning kidneys. Be certain the fluid prescribed does not contain potassium until it is established kidney function is adequate; otherwise, the buildup of potassium could cause heart block. The child's diet should be low in protein, potassium, and sodium and high in carbohydrate to supply enough calories for metabolism yet limit urea production and control serum potassium levels. Oral fluid intake may be limited to prevent heart failure due to accumulating fluid that cannot be excreted.

The mother of 6-month-old girl is concerned about her daughter getting a urinary tract infection. What should the nurse mention to the mother to help prevent this condition?

Report any abnormally colored urine to the child's primary care provider. Explanation: 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 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:

acute glomerulonephritis. Explanation: 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.

The nurse is caring for a child with nephrotic syndrome. The child is noted to have edema. The edema would most likely be seen where on this child?

Eyes Explanation: Edema is usually the presenting symptom in nephrotic syndrome, appearing first around the eyes and ankles.

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

Risk for infection Explanation: 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.

Which instruction should a nurse give to a client who has a history of urinary tract infection to prevent recurrence?

Wipe from front to back. Encourage fluids throughout the day. Finish all antibiotic prescribed. Explanation: Teaching caregivers to wipe from front to back, encouraging fluids, and finishing all prescribed medications are vital principles in the prevention of recurring UTIs. The use of bubble bath is contraindicated because it can be a source of infection.

A concerned mother brings her 3-year-old to the primary care office because of nighttime voiding. Which response made by the nurse is best?

"Children are not expected to stay dry through the night until the age of 5." Explanation: Nighttime urinary control is not expected until a child reaches the age of 5. No testing is needed before that age. Asking why it is a concern is not effective therapeutic communication.

The nurse is teaching an in-service program on children diagnosed with nephrotic syndrome. Which statement made by the nurse accurately reflects information on the disease process?

"The child may look chubby, but he is really malnourished."" Explanation: In children with nephrotic syndrome, malnutrition may become severe. The generalized edema masks the loss of body tissue, causing the child to present a chubby appearance and to double his or her weight. After diuresis, the malnutrition becomes quite apparent. Anorexia, irritability, and loss of appetite develop. Hematuria is not usually present, although a few red blood cells may appear in the urine. There is an increase in the level of cholesterol in the blood.

If the newborn is following a normal development process, the child will most likely void when which amount of urine is in the bladder?

15 mL Explanation: In the newborn, the bladder empties when about 15 mL of urine is present.

The nurse is monitoring the fluid balance of a 9-year-old child. When evaluating urine output for the day, which output would the nurse identify as being within normal limits?

1200 mL Explanation: The typical 24-hour urine output for a 9 year old would range from 1000 to 1500 mL. Therefore, a urine output of 1200 mL would be within normal limits.

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

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

A nurse is preparing a presentation for a local parent group about urinary tract infections (UTIs) in children. Which organism would the nurse incorporate into the presentation as the most common cause?

Escherichia coli Explanation: E. coli most commonly causes UTI. Other less common causative organisms include Klebsiella, S. aureus, and Pseudomonas.

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?

Eyes Explanation: 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.

An infant is diagnosed with a urinary tract infection. What corroborating finding would the nurse expect on assessment?

Failure to thrive Explanation: Infants and neonates have poor feeding when they have a urinary tract infection. You would not be able to tell necessarily if an infant were having pain or urgency.

The nurse is assessing a male neonate and notes that the urethral opening is on the ventral aspect of the penis. Which finding is documented?

Hypospadias Explanation: Hypospadias is a condition in which the urethral opening in on the ventral surface of the penis. Epispadias is present when the urethral opening is on the dorsal surface of the penis. Patent urachus refers to a fistula between the bladder and umbilicus. Bladder exstrophy involves the bladder lying open and exposed on the abdomen.

The nurse is caring for an 8-year-old child hospitalized with nephrotic syndrome. Which nursing intervention would be appropriate for this child?

Measure the abdominal girth daily. Explanation: Measure the child's abdomen daily at the level of the umbilicus, and make certain that all staff personnel measure at the same level. Weigh the child at the same time every day on the same scale in the same clothing. Test the urine regularly for albumin and specific gravity. Elevated temperature is not an issue with nephrotic syndrome.

The nurse determines that interventions for a voiding disorder have been effective when the family of a child with enuresis demonstrates evidence of which of the following?

Parents/family use positive coping mechanisms in response to the child and the voiding disorder. Explanation: The family caregiver may become extremely frustrated dealing with wet bedding every morning. Health care personnel must facilitate coping and take a supportive and understanding attitude towards the caregiver and child. Surgery is not needed—fluid restrictions, bladder training and alarms are the most common approaches. Medications are sometimes used with alarms and positive reinforcement, parents usually accept the voiding disorder and often have a family member with a history of enuresis.

The nurse is triaging clients as they come in to an express care facility. Which assessment finding is clinically significant for early nephrotic syndrome?

Periorbital edema Explanation: Periorbital edema and edema in the ankles are the initial presenting symptoms. As the swelling advances, the edema becomes generalized with a pendulous abdomen full of fluid. Edema in the scrotum also appears. Edema in the hands, sacrum and facial puffiness can be a progression of the disease.

A 16-year-old girl has had several cases of cystitis in the past year. Which of the following should the nurse suspect as the cause, based on this finding?

Sexual activity Explanation: When cystitis is seen in adolescent girls, it is an alert a girl may be sexually active. Wiping from front to back after voiding helps prevent urinary tract infections, not cause them. Frequent voiding does not cause cystitis, nor does regular participation in a strenuous sport.

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?

Tea-colored urine Explanation: 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.

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

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

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 recently had an ear infection. Explanation: 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.

The nurse is discussing urinary tract infections (UTI's) in children with a group of peers. Which fact is the most accurate regarding urinary tract infection seen in children?

The most common age for UTIs in children is 2 to 6 years of age. Explanation: Urinary tract infections (UTIs) are fairly common in the "diaper age," in infancy, and again between the ages of 2 and 6 years. Older school-aged and adolescent girls are not as prone to UTIs.

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

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

A client has just been admitted to the unit with a history of recent strep infection, hematuria, and proteinuria. Based on these findings, the nurse would suspect which condition?

acute glomerulonephritis Explanation: Recent strep infection, hematuria, and proteinuria are indicative of acute glomerulonephritis. These symptoms do not suggest any of the other options.

Most urinary tract infections seen in children are caused by:

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

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

recent illness such as strep throat. Explanation: Symptoms of acute glomerulonephritis often appear 1 to 3 weeks after the onset of a streptococcal infection such as strep throat.

The nurse is caring for a client newly diagnosed with acute glomerulonephritis? When receiving the pediatric client's history, which is anticipated?

Onset of a streptococcus infection last week Explanation: 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.

Which child has the highest risk of urinary tract infection?

An 18-year-old female who is sexually active Explanation: After the neonatal period, females are at a higher risk for developing a urinary tract infection than males. The incidence of urinary tract infections in sexually active females is high. Circumcised males have a lower risk of urinary tract infections than uncircumcised males.

The nurse is caring for a post-surgical child with a new suprapubic catheter. The child begins to moan in pain suddenly. Which nursing intervention is the priority?

Check the catheter for patency. Explanation: During the postoperative period after placement of a suprapubic catheter, the catheter has a risk of getting clogged with mucous. This results in pain experienced in the lower abdomen. If pain is reported, the first priority is to check for patency of the catheter. Assessing the child's pain and vital signs, along with repositioning are all good interventions, just not the priority action.

A 6-year-old child has undergone a renal transplant and is receiving cyclosporine. The nurse instructs the parents to be especially alert for which complication?

Signs of infection Explanation: The parents should be especially alert for signs of infection as cyclosporine is an immunosuppressant drug. Weight gain instead of weight loss, hypertension instead of hypotension, and increased facial hair instead of hair loss are some other potential side effects.

A voiding cystourethrogram (VCUG) is ordered on a child. What education should be provided to the parents?

The VCUG will rule out VUR. Explanation: A VCUG will rule out reflux in the urinary tract. This may cause frequent infections and scarring if not diagnosed and treated.

The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with acute glomerulonephritis. In which age range is the peak incidence of this disorder noted?

6 to 7 years of age Explanation: Acute glomerulonephritis has a peak incidence in children 6 to 7 years of age and occurs twice as often in boys.

A 3-year-old child is exhibiting irritability, fever, and decreased appetite. A recent history of which of the following would make the nurse suspicious of a urinary tract infection (UTI)?

Abdominal pain Explanation: Signs and symptoms of UTI in the young child often are not clear-cut. The most frequent complaints are of abdominal pain.

The nurse is reviewing lab work prior to shift handoff on a client with a subnormal urine output. Which is the nurse most correct to report?

Oliguria Explanation: A subnormal urine output is termed as oliguria. Polyuria is the excessive or abnormally large production of urine. Pyuria is the presence of pus in the urine. Glycosuria is the excretion of glucose in the urine.

The nurse is working with a child with impaired urinary elimination. What is the purpose of monitoring the electrolytes and arterial blood gases (ABGs)?

This will determine if there is an acid-base problem. Explanation: This will determine if there is an acid-base problem. The electrolytes and ABGs would not necessarily determine if the child has glomerulonephritis, a UTI, or stone formation.

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

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

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

Blood pressure 136/84 Explanation: 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 this age child.

A teacher sends a child to see the school nurse for irritability and bruising. Which symptom would be indicative of hemolytic uremic syndrome?

Oliguria and jaundice Explanation: Signs of hemolytic uremic syndrome include oliguria, irritability, jaundice, bloody diarrhea, purpura, ecchymosis, and pallor 5 to 10 days after a prodromal illness. The child also usually experiences anorexia, slight fevers, and can become lethargic. Symptoms of polyuria, weight gain, high fever, and dysuria are not typically seen with hemolytic uremic syndrome.

The nurse is assessing a child with acute poststreptococcal glomerulonephritis. Which client symptoms would the nurse anticipate during assessment? Select all that apply.

Abdominal pain Hypertension Crackles Explanation: Assessment findings associated with acute poststreptococcal glomerulonephritis include fatigue, lethargy, abdominal pain, hypertension, crackles, and anorexia.

The nurse is caring for a pediatric client who is scheduled for the surgical removal of a Wilms tumor. Which is contraindicated in the client's care?

Abdominal palpation Explanation: Abdominal palpation is contraindicated preoperatively in a client with a Wilms tumor. Cells may break loose and spread the tumor. Intravenous fluids and supine positioning are appropriate in the client's care. A Foley catheter is typically not placed.

A pediatric client is scheduled for an intravenous pyelogram (IVP) of the kidney this afternoon. Which of these actions by the nurse would require immediate attention?

The child does not have intravenous access. Explanation: An intravenous pyelogram is an X-ray study of the upper urinary tract in which a radio opaque dye is injected into a peripheral vein, requiring intravenous access. The other choices are not a priority for this client.

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?

"Let's meet with the dietitian and plan some meals." Explanation: 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 educating the mother of a child who will receive a kidney transplant. Which statement made by the mother indicates further teaching is needed?

"This surgery will cure my child's condition." Explanation: Most children waiting for a kidney transplant will need to undergo dialysis until they receive their new kidney. Once a kidney transplant has been completed, the child will remain on immunosuppression medication for life. Most children can lead a normal life after successful kidney transplantation. Kidney transplantation is not a cure, however. The child will need medical attention and medication for the remainder of his/her life.

The nurse is collecting data on a child recently diagnosed with acute glomerulonephritis. Which of the following clinical manifestations was likely noted in this child?

Bloody urine Explanation: The presenting symptom in the child with acute glomerulonephritis is grossly bloody urine. The caregiver may describe the urine as smoky or bloody.

A nurse is caring for a 7-year-old girl scheduled for an intravenous pyelogram (IVP). Which action would be the priority before the test?

Checking with the parents for any allergies Explanation: It is important to double-check whether the girl has any allergies. The test is contraindicated in children allergic to shellfish or iodine. Adequate hydration is also important, but the check for allergies is a priority. Only females of reproductive age must be screened for pregnancy. An enema is not necessary at all institutions.

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

Creatinine clearance rate Explanation: 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.

Peritoneal dialysis is so effective that 3 hours of peritoneal dialysis accomplishes as much as 12 hours of hemodialysis.

False Explanation: Hemodialysis can be done as a continuous process, but it is so effective 3 hours of hemodialysis accomplishes as much as 12 hours of peritoneal dialysis.

Which of these laboratory results would be most important for the nurse to assess in a child who has a diagnosis of urinary tract infection?

urinalysis Explanation: A urinalysis is one of the simplest tests to reveal kidney function and presence of a urinary tract infection. A chemical reagent strip, specific gravity, and blood urea nitrogen are not the primary tests evaluated for the presence of a urinary tract disease.

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. Explanation: 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.

Which goal of therapy would be appropriate for a nurse to establish with a client's family and a client who has a diagnosis of enuresis?

The client remains continent throughout the night. Explanation: The goal of therapy is for the client to be continent of urine throughout the night. The nurse should encourage the child to awaken and void and not have any fluids before bedtime. During an activity, the child should be encouraged to void before and after the activity to prevent incontinence.

When caring for a child who has a diagnosis of acute glomerulohephritis, which nursing interventions would most likely be included in the child's plan of care? Select all that apply.

The nurse administers diuretics. The nurse administers antihypertensives. The nurse weighs the child every day using the same scale. The nurse dipsticks the child's urine to test for protein. Explanation: Fluid intake and urinary output should be carefully monitored and recorded. Special attention is needed to keep the intake within prescribed limits. The amount of fluid the child is allowed may be based on output, as well as on evidence of continued hypertension and oliguria. 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. Weigh the child daily, at the same time, on the same scale, and in the same clothes. The urine must be tested regularly for protein and hematuria using dipstick tests. Bed rest should be maintained until acute symptoms and gross hematuria disappear.

The nurse is collecting data on a school-aged child with the following symptoms: Abrupt beginning to urinary symptoms Gross hematuria VS -99 (F), 39.2 (C), 92, 22, 142/92 Mild edema Which disease condition does the nurse anticipate?

Acute glomerulonephritis Explanation: The symptoms which are presented are abrupt beginning to symptoms, gross hematuria, hypertension and mild edema. This is consistent with acute glomerulonephritis. Urinary tract infection includes a fever, burning upon urination and irritability. Nephrotic Syndrome begins insidiously. Hematuria is rare but edema is extreme. Wilms Tumor is a neoplasm of childhood.

The nurse is caring for an infant with bladder exstrophy. As part of the infant's preoperative plan of care, the nurse monitors for abdominal skin excoriation. Which action would be most appropriate for promoting healing and preventing further skin breakdown?

Applying a barrier/healing cream or paste on skin Explanation: The nurse should use a barrier/healing cream or paste on surrounding skin to promote healing and prevent further skin breakdown. Diaper wipes that contain fragrance or alcohol can sting if used on nonintact skin and can worsen skin breakdown. It is important to protect the bladder, but this will not address the skin excoriation. Meticulous attention to cleanliness is important, but the nurse should sponge-bathe the infant rather than immerse him in water to prevent pathogens from the water possibly entering the bladder

The location of the kidneys in the child in relationship to the location of the kidneys in the adult makes which fact a greater likelihood in the child?

The child has a greater risk for trauma to the kidney. Explanation: The kidneys in children are located lower in relationship to the ribs than in adults. This placement and the fact that the child has less of a fat cushion around the kidneys cause the child to be at greater risk for trauma to the kidneys. The location of the kidneys does not affect the urges to empty the bladder nor the retaining of fluids.