Peds Exam 2

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

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

The nurse is preparing to administer an enema to a toddler. How should she position the child?

On their abdomen with knees bent The best position for administering an enema to an infant or child is on their abdomen with knees bent. For a child or adolescent, place the child on the left side with right leg flexed toward the chest.

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

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

The nurse is conducting a physical examination of an 18-month-old with suspected intussusception. Which finding would the nurse identify as the hallmark of this condition?

A sausage-shaped mass in the upper midabdomen A sausage-shaped mass in the upper midabdomen is the hallmark of intussusception. Perianal skin tags are highly suspicious of Crohn disease. Abdominal pain and guarding are also common with intussusception but are seen with many other conditions. Tenting would indicate dehydration.

A child is experiencing an acute exacerbation of Crohn disease for which she is prescribed prednisone. The nurse teaches the parents and child about this medication. Which statement by the parents indicates that the teaching was successful?

"We should not stop this medication abruptly." Prednisone is a corticosteroid. Stopping the medication abruptly could lead to adrenal insufficiency. Weight gain would be associated with corticosteroid use. Weight loss is associated with the disease. Corticosteroids help to reduce inflammation and suppress the normal immune response. Typically, anti-inflammatory agents such as mesalamine may appear in the stool. This indicates poor absorption.

The nurse is caring for a 13-year-old girl with suspected autoimmune hepatitis. The girl inquires about the testing required to evaluate the condition. How should the nurse respond?

"You will most likely have a blood test to check for certain antibodies." Anti-nuclear antibodies are one of the diagnostic tests performed to diagnose autoimmune hepatitis. Ultrasound is to assess for liver or spleen abnormalities. Viral studies are performed to screen for viral causes of hepatitis. Ammonia levels may be ordered if hepatic encephalopathy is suspected.

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

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

The nurse is talking with a woman who is in her 2nd trimester of pregnancy who has been diagnosed with polyhdyramnios. The physician has ordered an ultrasound be performed to check for the presence of esophageal atresia. Which statement by the woman indicates an understanding of the relationship between these conditions?

"Babies with esophageal atresia have an inability to swallow amniotic fluid causing the excess buildup." Review the maternal history for polyhydramnios. Often this is the first sign of esophageal atresia because the fetus cannot swallow and absorb amniotic fluid in utero, leading to accumulation. Esophageal atresia is an underlying cause of polyhydramnios.

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

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

The nurse is discussing the treatment of congenital aganglionic megacolon with the caregivers of a child diagnosed with this disorder. Which statement is the best explanation of the treatment for this diagnosis?

"The treatment for the disorder will be a surgical procedure." Treatment of congenital aganglionic megacolon involves surgery with the ultimate resection of the aganglionic portion of the bowel. Chronic anemia may be present, but iron will not correct the disorder. Enemas may be given to initially achieve bowel elimination, but they will not treat the disorder. Differentiation must be made between this condition and psychogenic megacolon because of coercive toileting or other emotional problems. The child with aganglionic megacolon does not withhold stools or defecate in inappropriate places, and no soiling occurs.

The nurse is caring for a 2-year-old boy with an umbilical hernia and is teaching the mother about this condition. Which response from the mother indicates a need for further teaching?

"I can tape a quarter over the hernia to reduce it." The use of home remedies to reduce an umbilical hernia should be discouraged because of the risk of bowel strangulation. The mother needs to be aware that strangulation can occur, but it is rare with an umbilical hernia. Pain, tenderness, or redness indicates incarceration, which although rare with umbilical hernias, can occur. She needs to understand the signs of strangulation and understand that some children have self-esteem issues related to the large protrusion of the unrepaired umbilical hernia. Physical needs of the child have priority over any types of potential psychosocial issues. Self-esteem issues may arise due to a large protrusion of an unrepaired umbilical hernia.

The nurse is caring for a child who was involved in an automobile accident in which extensive damage to the small intestine occurred. A surgical resection of the small intestine resulted in massive small intestine loss, causing short bowel syndrome. The parents voice concern to the nurse that their child will "never be the same." What is the best response by the nurse?

"I can't imagine what you're going through. We will be here to support and educate you on your child's condition and treatments throughout their care." Being empathetic and reassuring the parents that the staff will be there to support them and educate them will provide some relief of anxiety since this is a chronic condition. Telling them their is nothing they could have done to prevent this from happening does not help the current situation. Giving hope is good, but giving possible false hope sets the family up for disappointment. Telling the family to be strong does not provide support.

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

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

The nurse has performed client teaching to a 15-year-old boy with Crohn disease, and his parents, regarding the cobblestone lesions in his small intestine. Which comment by the family indicates learning occurred?

"I have to be careful because I am prone to not absorbing nutrients." Crohn disease typically effects the small intestine more than the large intestine and it's onset is between the ages of 10 to 20 years. The cobblestone lesions in the small intestine prevents absorption of nutrients that normally occurs. The diarrhea is not directly related to the cobblestone lesions, and ulcerative colitis is characterized by the disease effecting the intestine(s) in a continuous pattern.

A nurse caring for Paulo, an infant born with a cleft palate, notices that the parents rarely interact with their child. The nurse overhears the mother telling her husband that she "feels like crying" every time she looks at their son. What would be the best response from the nurse?

"I sense you could use more information on caring for a cleft palate. Would you be interested in meeting with other parents who have dealt with this?" The nurse should support the family's adjustment to a child's condition by demonstrating an accepting, caring attitude toward the child and family and providing the parents with opportunities and support for normal infant-parent interactions.

The mother of an infant tells the nurse during a routine visit to the clinic that she often notices a bulging mass in the lower abdominal and groin area when her baby cries. She asks the nurse if this is normal. How should the nurse respond?

"I understand your concern. I will be sure to document this in your child's medical record and report this information to your child's physician immediately." The mother is describing common symptoms of an inguinal hernia. It may be possible to visualize the mass, but often the mass is seen only during crying or straining, making it difficult to actually identify in the clinic setting. It is important to notify the physician so treatment can be initiated.

The nurse is caring for an infant recently diagnoses with thrush and was prescribed nystatin. Which statement by the infant's mother would suggest a need for further education?

"I will add the nystatin to her bottle four times per day." Administer nystatin suspension four times per day following feeding, not mixed in the bottle, to allow the medication to remain in contact with the lesions. In the younger infant, apply nystatin to the lesions with a cotton-tipped applicator. Infants and young children often mouth their toys, so it is important to clean them appropriately. Explain to parents of infants with thrush the importance of reporting diaper rash because fungal infections in the diaper area often occur concomitantly with thrush and also need to be treated.

The student nurse is caring for a child with the nursing diagnosis "Risk for fluid volume deficit related to inadequate oral intake". Which statement by the student would indicate a need for further education by the nursing instructor?

"I will make sure there is plenty of orange juice available. It's her favorite juice." Proper interventions for children at risk for fluid volume deficit include maintaining IV line and administer IV fluid as ordered to maintain fluid volume. Offer small amounts of oral rehydration solution frequently to maintain fluid volume. Small amounts are usually well tolerated by children with diarrhea and vomiting. Avoid high-carbohydrate fluids such as Kool-Aid and fruit juice, as they are low in electrolytes, and increased simple carbohydrate consumption can decrease stool transit time. Daily weights are one of the best indicators of fluid volume status in children.

The nurse is performing discharge teaching for a 16-year-old diagnosed with peptic ulcer disease. Which statements by the parents and client demonstrate learning has occurred?

"I will need to make sure to take all of the antibiotic prescribed." "It's important to take my histamine agonist medication at the appropriate time." "The prednisone that I take for my rheumatoid arthritis may be a cause of my peptic ulcer disease." If Helicobacter pylori (H. pylori was detected as a cause of the peptic ulcer disease (PUD), the client will be prescribed an antibiotic and should take all of the medication. Histamine agonists and/or proton pump inhibitors should be taken routinely as prescribed. Risk factors include a family history of PUD or other GI diseases, or chronic salicylate or prednisone use.

A 9-year-old child has undergone a temporary colostomy in the ascending colon several days ago. The nurse has just completed discharge teaching to the child and the parents. Which statements by the child or parents warrants additional instruction from the nurse?

"It is important to change the pouch and skin appliance every other day to decrease the risk of problems with the skin." "We will need to use an antimicrobial soap to cleanse the area around the stoma in order to prevent any skin infection." Appliances and pouches can be left in place for 4 days as long as the appliance is intact; changing more frequently can lead to skin impairment. Regular soap, not antimicrobial soap, and water is all that is needed to clean around the stoma site. Antimicrobial and perfumed soaps may be irritating to the skin. An ascending colostomy will produce unformed, thick liquid stool so emptying the pouch more frequently will be necessary; this will likely be a challenge for the child at school initially. A pale stoma indicates poor perfusion; this should be reported to the physician immediately.

A nurse is caring for a 6-year-old girl recently diagnosed with celiac disease and is discussing dietary restrictions with the girl's mother. Which response indicates a need for further teaching?

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

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

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

The nurse is caring for an infant. The infant's mother asks the mother, "what did the doctor mean when he said she may have regurgitation?" What response by the nurse is appropriate?

"Regurgitation is the backflow of stomach contents up into the esophagus or mouth." Regurgitation is the backflow of stomach contents up into the esophagus and/or oral cavity. The muscle tone of the lower esophageal sphincter is not fully developed until age 1 month, so infants younger than 1 month of age frequently regurgitate after feedings. Many children younger than 1 year of age continue to regurgitate for several months, but this usually disappears with age

The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac syndrome. The caregivers make the following statements. Which statement indicates a need for further teaching regarding the dietary restrictions for the child with celiac syndrome?

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

The nurse is collecting data on a 2 ½-year-old child admitted with a diagnosis of gastroenteritis. When interviewing the caregivers, which question is most important for the nurse to ask?

"Tell me about the types of stools you child has been having." For the child with gastroenteritis, the interview with the family caregiver must include specific information about the history of bowel patterns and the onset of diarrheal stools, with details on number and type of stools per day. Recent eating patterns, if the child is toilet trained, and how many times a day the child urinates are important questions, but the highest priority is gathering data regarding the stools and stool pattern.

The student nurse is preparing a presentation on celiac disease. What information should be included? Select all apply.

"The only treatment for celiac disease is a strict gluten-free diet." "Symptoms of celiac disease include diarrhea, steatorrhea, anemia, and dental disorders." "Gluten is found in most wheat products, rye, barley and possibly oats." Celiac disease is an immunologic disorder in which gluten causes damage to the small intestine. The only treatment currently is a gluten-free diet. While the child needs to have a gluten-free diet, the rest of the family does not. Most children present by the age of 2 for evaluation. Symptoms of celiac disease include diarrhea, constipation, steatorrhea, weight loss, poor muscle tone, anemia and dental disorders. Gluten is found in most grains, like wheat, rye, barley and possibly oats.

A physician recommends a gastrostomy for a 4-year-old client with an obstruction. The parents ask the certified wound, ostomy, and continence nurse (CWOCN) what the surgery entails. What is the nurse's best response?

"The surgery creates an opening between the stomach and abdominal wall." Ostomies can be created at various sites in the GI tract, depending on the child's clinical condition. A gastrostomy provides an opening between the stomach and the abdominal wall, and an esophagostomy communicates between the esophagus and an external site on the neck. Ostomies may be created at various sites in the small intestine (e.g., jejunostomy, ileostomy) or in the large intestine (e.g., colostomy).

Which client most likely has ulcerative colitis rather than Crohn disease?

16-year-old female with continuous distribution of disease in the colon, distal to proximal Ulcerative colitis is usually continuous through the colon while the distribution of Crohn disease is segmental. Crohn disease affects the full thickness of the intestine while ulcerative colitis is more superficial. Both conditions share age at onset of 10 to 20 years, with abdominal pain and fever in 40% to 50% of cases.

The infant is listless with sunken fontanels and has been diagnosed with dehydration. The infant is still producing at least 1 mL/kg each hour of urine. The infant weighs 13.2 lb (6 kg). At the minimum, how many milliliters of urine will the infant produce during the next 8-hour shift? Record your answer using a whole number

48 Urine output should be calculated using weight in kilograms. 6 kg x 1 mL/kg = 6 mL/hour 6 mL x 8 hours = 48 mL/8-hour shift

The nurse is providing care to a child who has had an appendectomy for a perforated appendix. The nurse would anticipate intravenous antibiotic therapy for how long?

7 to 14 days The child with a perforated appendix requires 7 to 14 days of intravenous antibiotic therapy. If the child has a suppurative or gangrenous appendix that was not perforated, 2 to 3 days of antibiotics would be most likely ordered.

The nurse is caring for a child that was dehydrated following gastric surgery but has since been re-hydrated. The physician orders intravenous maintenance fluid rate for the child. How will the nurse determine the intravenous maintenance fluid rate per hour for this child who weighs 40 kg?

79 The formula to determine maintenance fluid rate is: *100 mL/kg for first 10 kg *50 mL/kg for next 10 kg *20 mL/kg for remaining kg *Add together for total mL needed per 24-hour period. *Divide by 24 for mL/hour fluid requirement. Therefore, for a child weighing 40kg the equation is: *100 X 10= 1000 *50 X 10= 500 *20 X 20= 400 *1000 + 500 + 400= 1900 *1900/24= 79.17= 79 mL/hr

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

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

The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of pyloric stenosis?

A thickened, elongated muscle causes an obstruction at the end of the stomach. Pyloric stenosis is characterized by hypertrophy of the circular muscle fibers of the pylorus, with a severe narrowing of its lumen. The pylorus is thickened to as much as twice its size, is elongated, and has a consistency resembling cartilage. As a result of this obstruction at the distal end of the stomach, the stomach becomes dilated. Congenital aganglionic megacolon is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Colic consists of recurrent paroxysmal bouts of abdominal pain. Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus is relaxed and allows gastric contents to be regurgitated back into the esophagus

A doctor orders an abdominal radiograph for a newborn to check for Hirschsprung disease. The nurse examines the infant and finds which symptoms that are indicative of this disease? Select all that apply.

Abdominal distention Absence of stool in the rectum Enterocolitis Bilious vomiting The nurse should suspect Hirschsprung disease when the newborn does not pass meconium in the first 24 hours after birth and has bilious vomiting or has abdominal distention, feeding intolerance, with bilious aspirates and vomiting. In anorectal malformations the anus is absent or displaced and the presence of a fistula may be noted when gas or stool is expelled from the urethra or vagina.

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

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

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

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

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

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

A mother brings her 3-year-old son to the ER and tells the triage nurse that he has been vomiting blood. A medical history determines that the 3-year-old has no history of GI disturbances and his only symptoms are a slightly elevated fever and vomiting bright red blood. Based on these symptoms, what condition might the nurse suspect?

Acute upper GI bleeding Vomiting bright red blood indicates acute upper GI bleeding. Emesis containing brown, foul-smelling stool indicates GI obstruction. Stool with red blood and mucus is associated with intussusception. Bleeding is not generally indicative of gastroesophageal reflux.

A child is diagnosed with short bowel syndrome. What would the nurse expect to be included in the child's plan of care? Select all that apply.

Antibiotics Vitamin supplements Total parenteral nutrition For the child with short bowel syndrome, typically, antibiotics, vitamin and mineral supplements, antidiarrheal agents, and total parenteral nutrition are prescribed. Laxatives and immunosuppressants are not used.

The nurse is doing dietary teaching with the caregivers of a child diagnosed with idiopathic celiac disease. Of the following foods, which would most likely be appropriate in the child's diet?

Bananas The young child should be started on a starch-free, low-fat diet. Bananas contain invert sugar and are usually well tolerated. Products that contain wheat, rye, or oats should be excluded.

The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac syndrome. Which foods would be permitted in the diet of the child with celiac syndrome? Select all that apply.

Bananas Skim milk Applesauce The child is usually started on a gluten-free, low-fat diet. Skim milk and bananas are usually well tolerated. Lean meats, puréed vegetables, and fruits are gradually added to the diet. Wheat, rye, oat products, corn flour, and cornmeal are not included in the diet.

A child is diagnosed with intussusception. The nurse anticipates that what action would be attempted first to reduce this condition?

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

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

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

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

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

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

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

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

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

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

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

A child is scheduled for a urea breath test. The nurse understands that this test is being performed for which reason?

Detect Helicobacter pylori Urea breath test is used to detect the presence of H. pylori in the exhaled breath. This test does not evaluate gastric pH. Serum amylase and lipase levels are used to confirm pancreatitis. Esophageal manometry is used to evaluate esophageal contractile activity and effectiveness.

The mother of a newborn with a cleft lip reports she is having a hard time looking her baby. What is the best action by the nurse?

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

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

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

The labor and delivery nurse is caring for a mother who has demonstrated polyhydramnios upon delivery. The newborn displays copious, frothy bubbles of mucus in the mouth and nose, as well as drooling. The nurse is concerned that the infant has what disorder?

Esophageal atresia Esophageal atresia refers to a congenitally interrupted esophagus where the proximal and distal ends do not communicate; the upper esophageal segment ends in a blind pouch and the lower segment ends a variable distance above the diaphragm. Polyhydramnios is often the first sign of esophageal atresia because the fetus cannot swallow and absorb amniotic fluid in utero, leading to accumulation. Omphalocele and gastroschisis are congenital anomalies of the anterior abdominal wall. Hiatal hernia involves a weakened diaphragm.

A nurse taking a health history of a newborn notes that there is a maternal history of polyhydramnios. What GI condition might this history precipitate?

Esophageal atresia (EA) A maternal history of polyhydramnios is usually present in one-third of cases of EA and in some cases of tracheoesophageal fistula (TEF).

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

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

Inguinal hernia usually occurs in girls.

False Inguinal hernia is a protrusion of a section of the bowel into the inguinal ring. It occurs usually in boys (9:1) because, as the testes descend from the abdominal cavity into the scrotum late in fetal life, a fold of parietal peritoneum also descends, forming a tube from the abdomen to the scrotum.

A father brings Jacob, age 2, to the health clinic with complaints of diarrhea, vomiting, and abdominal pain. The father tells the nurse that he is a single parent and Jacob is enrolled in a local daycare center. Based on this information, what gastrointestinal condition might the nurse suspect?

Gastroenteritis Outbreaks of gastroenteritis routinely occur in day care centers, schools, institutions for the handicapped, and other places where overcrowding is prevalent and hygiene is inadequate. Typical signs and symptoms include diarrhea, nausea, vomiting, and abdominal pain.

The nurse is conducting a physical examination of an infant with suspected pyloric stenosis. Which finding indicates pyloric stenosis?

Hard, moveable "olive-like mass" in the upper right quadrant A hard, moveable "olive-like mass" in the right upper quadrant is the hypertrophied pylorus. A sausage-shaped mass in the upper mid abdomen is the hallmark of intussusception. Perianal fissures and skin tags are typical with Crohn disease. Abdominal pain and irritability is common with pyloric stenosis but are seen with many other conditions.

An adolescent boy is diagnosed with hepatitis A. Which problem should be considered when planning care?

He will become fatigued easily. Most children with hepatitis are exhausted. Urine is not infectious.

Testing is being performed to confirm the presence of Meckel diverticulum. Which findings are consistent with this condition? Select all that apply.

Hemoglobin 9.4 g/dL Stool test reveals occult blood. Meckel diverticulum is a disorder where there are weaknesses on the intestine resulting in pouchlike areas. Test findings that are consistent with this disorder are anemia and the presence of occult blood. The values listed for white blood cell count, platelet levels, and hematocrit levels are within normal limits.

A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease?

Hirschsprung disease The nurse should suspect Hirschsprung disease when the newborn does not pass meconium in the first 24 hours after birth, and has bilious vomiting or abdominal distention and feeding intolerance with bilious aspirates and vomiting. Typical signs and symptoms of gastroenteritis include diarrhea, nausea, vomiting, and abdominal pain. The characteristic GI manifestation of UC is bloody diarrhea accompanied by crampy, typically left-sided lower abdominal pain. Clinical manifestations of untreated SBS include profuse watery diarrhea, malabsorption, and failure to thrive.

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

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

The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of gastroesophageal reflux?

In this disorder the sphincter that leads into the stomach is relaxed. Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus, which leads into the stomach, is relaxed and allows gastric contents to be regurgitated back into the esophagus. Congenital aganglionic megacolon is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Colic consists of recurrent paroxysmal bouts of abdominal pain. Pyloric stenosis is characterized by hypertrophy of the circular muscle fibers of the pylorus which leads to an obstruction at the distal end of the stomach.

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

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

The nurse is caring for a child with a diagnosis of pyloric stenosis during the preoperative phase of the child's treatment. What is the highest priority at this time?

Improving hydration Preoperatively the highest priority for the child with pyloric stenosis is to improve nutrition and hydration. Maintaining mouth and skin integrity, and relieving family anxiety are important, but these are not the priority. The child will not likely have intense pain. Preparing the family for home care would be a postoperative goal.

Most urinary tract infections seen in children are caused by:

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

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

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

A 10-year-old male presents with low-grade fever, nausea, and abdominal pain. The nurse examining him suspects appendicitis and checks for rebound tenderness in what quadrant?

Lower right With appendicitis, percussion reveals irritation and pain in the right lower quadrant. Rebound tenderness present with palpation in the right lower quadrant, is referred to as the McBurney point, an area of tenderness 1.5 to 2 in. (3.8 to 5 cm) in from the right anterior superior iliac spine along a line extending to the umbilicus.

The nurse is assessing a child who was admitted with a fever, chills, nausea and vomiting, and reports of abdominal pain. The physician suspects appendicitis. During the nursing assessment the nurse notes maximal tenderness upon palpation over the McBurney point. Place an X on McBurney's point.

McBurney's point is the area in the right lower quadrant of the abdomen where the most pressure tends to be felt upon palpation when the client has appendicitis. It lies between the naval and the right anterior superior iliac spine. p730

The parents of a 6-month-old have brought their child to the emergency department with vomiting and diarrhea for the past 3 days. The report the child as being very lethargic today. During the assessment the nurse notes decreased skin turgor, delayed capillary refill, and pale, slightly dry skin. Based on the objective and subjective data, what does the nurse determine the child to be?

Moderately dehydrated In addition to these signs and symptoms, signs and symptoms of moderate dehydration also include sunken fontanels, mildly sunken orbits, and urine output <1 mL/kg/hour.

The nurse is reviewing the medical record of a child with a cleft lip and palate. When reviewing the child's history, what would the nurse identify as a risk factor for this condition?

Mother age 42 with pregnancy Advanced maternal age is a risk factor for cleft lip and palate. Drugs such as anticonvulsants, steroids, and other medications during early pregnancy are considered risk factors. Acetaminophen is not associated with an increased risk for cleft lip and palate. Preterm birth is not a risk factor for the development of cleft lip and palate. Hypoxia or anoxia is a risk factor for the development of necrotizing enterocolitis.

The digestive process begins in which organ of the gastrointestinal system?

Mouth Food enters the mouth, and the digestive process begins. Digestion takes place by mechanical and chemical mechanisms. As the food continues through the stomach and intestines, digestion continues.

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

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

A mother calls the doctor's office and tells the nurse that she is concerned because her 4-month-old keeps "spitting up" with every feeding. What would indicate that the child is regurgitating as opposed to vomiting?

Only occurs with feeding Regurgitation typically occurs only with feeding, runs out of the mouth with little force, smells barely sour and is only slightly curdled, appears to cause no pain or distress, occurs only once per feeding, and amounts to only about 1 to 2 tsp. Vomiting may occur at times other than feeding, is forceful and is typically projected 1 ft or more away from infant, is extremely sour smelling and curdled, is typically accompanied by crying, continues until the stomach is empty, and amounts to the full stomach contents.

The nurse caring for an 18-month-old infant with Meckel diverticulum knows that the most common clinical manifestation of this condition is:

Painless rectal bleeding With Meckel diverticulum, most symptomatic children present younger than age 2 years. Intermittent, painless rectal bleeding is the most common clinical manifestation of Meckel diverticulum. The blood is most often bright red or maroon and may be passed independent of stool due to ulceration at the junction of the ectopic tissue and the normal ileal mucosa.

A mother brings her 10-year-old son to the ER with complaints of abdominal pain. The nurse performing a physical assessment notes the following symptoms: upper right quadrant pain that radiates to the back; fever; nausea; and abdominal distention. Which disease would the nurse consider as a diagnosis?

Pancreatitis The child admitted with the suspicion of pancreatitis typically has a complaint of abdominal pain, either epigastric, upper left, or upper right quadrant pain that may radiate to the back. Nausea and vomiting, fever, tachycardia, hypotension, and jaundice may be present. Abdominal signs such as abdominal distention, decreased bowel sounds, rebound tenderness, and guarding also may be noted.

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

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

The emergency department nurse is assessing a child who has presented with a 2-day history of nausea and vomiting with pain that is isolated to the right upper quadrant of the abdomen. Which action is most appropriate?

Prepare the child for admission to the hospital The child's presentation is consistent with cholecystitis, which necessitates surgery in most cases. The child should be kept NPO and antacids are of no benefit. Genitourinary involvement is atypical.

A 12-year-old boy has just undergone a liver transplantation and is recovering. After performing a finger stick puncture and assessing the results, the nurse administers a 10% solution of dextrose IV. What is the correct rationale for this intervention?

Prevention of hypoglycemia Hypoglycemia is a major danger following liver transplantation because glucose levels are regulated by the liver, and the transplanted organ may not function efficiently at first. Assess serum glucose levels hourly by finger stick puncture. A 10% solution of dextrose IV may be necessary to prevent hypoglycemia. Careful tissue matching before the transplantation is needed to reduce the possibility of stimulating T-cell rejection. Sodium, potassium, chloride, and calcium levels are evaluated approximately every 6 to 8 hours to be certain electrolyte balance is maintained, but potassium is rarely added to IV solutions because of the risk that renal failure has occurred. IV therapy with hypotensive agents such as hydralazine (Apresoline) and nitroprusside may be needed to reduce hypertension

The nurse is caring for a child admitted with pyloric stenosis. Which clinical manifestation would likely have been noted in the child with this diagnosis?

Projectile vomiting During the first weeks of life, the infant with pyloric stenosis often eats well and gains weight and then starts vomiting occasionally after meals. Within a few days the vomiting increases in frequency and force, becoming projectile. The child may have constipation, and peristaltic waves may be seen in the abdomen, but the child does not appear in severe pain. Urine output is decrease and urination is infrequent.

A group of nursing students are reviewing information about celiac disease. The students demonstrate understanding of this disorder when they identify which classic symptoms? Select all that apply.

Steatorrhea Constipation Diarrhea Failure to thrive Classic symptoms of celiac disease include steatorrhea, constipation, diarrhea, failure to thrive, weight loss, abdominal distention or bloating (not a sunken abdomen), and anemia (not polycythemia).

A nurse manages the interdisciplinary care for a client with pancreatitis. What are recommended interventions for this condition? Select all that apply.

Providing glycemia control Positioning the client in a fetal position Administering analgesics for pain Keeping the child NPO to rest the pancreas The main interventions for pancreatitis are supportive, including administration of antibiotics; stress ulcer prophylaxis; pain relief by analgesic administration; managing fluids; glycemia control; using a low-fat diet when lipase occurs; positioning the child in the fetal position to minimize tension of the peritoneum; and keeping the child NPO to rest the pancreas.

A mother is alarmed because her 6-week-old boy has begun vomiting almost immediately after every feeding. In the past week, the vomiting has grown more forceful, with the vomit projecting several feet from his mouth. He is always hungry again just after vomiting. At the physician's office, the nurse holds the child and gives him a bottle of water. While he drinks, she notes an olive-size lump in his right abdomen. Which condition should the nurse suspect in this child?

Pyloric stenosis With pyloric stenosis, at 4 to 6 weeks of age, infants typically begin to vomit almost immediately after each feeding. The vomiting grows increasingly forceful until it is projectile, possibly projecting as much as 3 to 4 feet. Infants are usually hungry immediately after vomiting because they are not nauseated. A definitive diagnosis can be made by watching the infant drink. If a pyloric stenosis is present, the sphincter feels round and firm, approximately the size of an olive in the right abdomen. Peptic ulcer disease in neonates usually presents with hematemesis (blood in vomitus) or melena (blood in the stool). Gastroesophageal reflux involves a small (1-2 tsp) volume and is not forceful. Appendicitis typically begins with anorexia for 12 to 24 hours; children do not eat and do not act like their usual selves. Nausea and vomiting may then occur, followed by diffuse abdominal pain.

If an adolescent has hepatitis B, what would be an important nursing action?

Strict enforcement of standard precautions Hepatitis B is spread through contaminated blood. Standard precautions help prevent contact with this.

The nurse is positioning an infant who has just had his left-sided cleft lip repaired. What positions are acceptable for this infant? Select all that apply.

Right side lying Supine It is critical to prevent injury to the facial suture line or to the palatal operative sites. Do not allow the infant to rub the facial suture line. To prevent this, position the infant in a supine or side-lying position.

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

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

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

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

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

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

The nurse is caring for a 6-month-old infant who was admitted to the emergency room 24 hours ago with signs of severe diarrhea. The infant's rectal temperature is 104° F (40° C), with weak and rapid pulse and respirations. The skin is pale and cool. The child is on IV rehydration therapy, but the diarrhea is persisting. The infant has not voided since being admitted. Which is the priority nursing intervention?

Take a stool culture Treatment of severe diarrhea focuses on regulating electrolyte and fluid balance by initiating a temporary rest for the GI tract, oral or IV rehydration therapy, and discovering the organism responsible for the diarrhea. All children with severe diarrhea or diarrhea that persists longer than 24 hours should have a stool culture taken to determine if bacteria are causing the diarrhea, and if so, a definite antibiotic therapy can be prescribed. Because a side effect of many antibiotics is diarrhea, antibiotics should not routinely be used to treat diarrhea without an identifiable bacterial cause. Before the initial IV fluid is changed to a potassium solution, be certain the infant or child has voided—proof that the kidneys are functioning; in this case, the child is not voiding yet. The child should not be fed a cracker, as the GI tract should be rested until the diarrhea stops.

The nurse is assessing a 10-day-old infant for dehydration. Which finding indicates severe dehydration?

Tenting of skin Tenting of skin is an indicator of severe dehydration. Soft and flat fontanels indicate mild dehydration. Pale and slightly dry mucosa indicates mild or moderate dehydration. Blood pressure of 80/42 mm Hg is a normal finding for an infant.

The nurse is caring for a newborn following delivery who has been diagnosed with gastroschisis. Which actions by the nurse indicated knowledge of appropriate care for this disorder?

The nurse assesses the color of the newborns abdominal organs The nurse places the newborn in a radiant warmer to maintain the newborn's temperature The nurse closely monitors the hydration status of the newborn for signs of dehydration Gastroschisis is a herniation of the abdominal contents through an abdominal wall defect, usually to the left or right of the umbilicus.Gastroschisis differs from omphalocele in that there is no peritoneal sac protecting the herniated organs. The color of the protruding organs should be assessed to determine if perfusion is sufficient. The contents should be covered with a sterile, rather than a clean, dressing. Temperature regulation is compromised with the open abdominal wall so a radiant warmer is imperative. The parents should be encouraged to touch and spend time with the newborn to facilitate bonding. IV fluid will be ordered to prevent dehydration so close monitoring of the hydration status is imperative.

The parents of a 4-week-old report that their infant has forceful vomiting but seems very hungry immediately after vomiting. Upon further questioning, the nurse notifies the physician of the findings and pyloric stenosis is suspected. The nurse prepares the parents for the possibility of which diagnostic procedures and treatment?

Upper GI series Pyloric ultrasound Physical examination of the abdomen Surgical repair Frequently a diagnosis is made with the client history and palpation of a hard, moveable "olive" mass in the right upper quadrant. If no mass is palpated the most common diagnostic procedure is a pyloric ultrasound. An upper GI series is sometimes performed, but this test is much more invasive than an ultrasound. Surgical repair is necessary. A CT scan is not warranted.

The nurse is caring for a 6-month-old girl with diarrhea and dehydration. The mother is concerned because the girl has some patches on her tongue. Which feature indicates a geographic tongue rather than thrush?

The patches are light in color on the tongue. A geographic tongue is a benign, noncontagious condition characterized by a reduction in the filiform papillae. Thrush is characterized by thick white plaques that form on the tongue. With thrush, plaques also appear on the buccal mucosa and often occur concomitantly in the diaper area. There would not be any patches on the few teeth the child might have by that age.

What occurs in the gastrointestinal system of the child with Hirschsprung disease?

There is a partial or complete mechanical obstruction in the intestine. Congenital aganglionic megacolon, also called Hirschsprung disease, is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin.

Which assessment finding would suggest that a child's postoperative feeding schedule following pyloric stenosis surgery should be slowed?

Vomiting Vomiting after a feeding suggests the pyloric valve is not yet able to accommodate feedings well, possibly from edema.

A 6-month-old boy is diagnosed with pyloric stenosis. When you take a health history from his mother, which symptom would you expect to hear her describe?

Vomiting immediately after feeding A narrowing of the pyloric valve leads to projectile vomiting soon after eating.

Noah is an 18-month-old who is brought to the ER with flu-like symptoms. He is diagnosed with pneumonia secondary to aspiration of stomach contents. The nurse explains to the parents that pneumonia is a condition that often occurs secondary to:

gastroesophageal reflux disease. The child with gastroesophageal reflux disease may present with the physical findings of pneumonia secondary to aspiration of refluxed stomach contents.

A 3-year-old child has been brought to the clinic for assessment because of frequent episodes of constipation. After ruling an out an organic cause, the child's plan of care should prioritize:

administering over the counter stool softeners on a temporary basis. Once any organic process is ruled out as a cause, constipation may initially be managed with dietary manipulation such as increasing fiber and fluids. However, behavior modification is necessary for most children. Children need to relearn to allow bowel evacuation when stool is present. Medications are used when other measures have failed. Frequent toileting may or may not be beneficial.

In caring for an infant diagnosed with pyloric stenosis, the nurse would anticipate that she would:

prepare the infant for surgery. A surgical procedure called a pyloromyotomy (also known as a Fredet-Ramstedt operation) is the treatment of choice for pyloric stenosis.

You care for a 12-year-old girl with Crohn disease. A primary assessment you would want to make when caring for her would be to note if:

she has a temperature. Because Crohn disease leads to patches of inflammation in the bowel, the temperature increases if more patches become involved.

The caregiver of a child diagnosed with celiac disease tells the nurse that the child has large amounts of bulky stools and what looks like fat in his stools. The clinical manifestation this caregiver is describing is:

steatorrhea. Steatorrhea (fatty stools) is a classic symptom of celiac disease. Currant jelly stools are a sign of intussusception. Projectile vomiting is a sign of pyloric stenosis.

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

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