Chapter 20

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

The nurse is talking with a woman who is in her 2nd trimester of pregnancy who has been diagnosed with polyhydramnios. 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."

The nurse is teaching the mother of an infant with a temporary ileostomy about stoma care. What is the most important instruction to emphasize to the mother to avoid an emergency situation?

"Call the doctor immediately if the stoma is not pink/red and moist."

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 nurse is caring for a child following surgery due to a motor vehicle accident. The child suffered extensive damage to the small intestine resulting in short bowel syndrome. The parents voice concern to the nurse that their child will "never be the same." Which is the best response by the nurse?

"I cannot imagine what you are going through. We are here to support and educate you on your child's condition and treatments."

The nurse has performed client education for 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 has occurred?

"I have to be careful because I am prone to not absorbing nutrients."

The nurse is caring for a teenager diagnosed with acute pancreatitis. Which order would the nurse question?

PO pain management

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

"Symptoms of celiac disease include diarrhea, steatorrhea, anemia, and dental disorders." "The only treatment for celiac disease is a strict gluten-free diet." "Gluten is found in most wheat products, rye, barley and possibly oats."

The nurse is collecting data on a 2-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 your child has been having."

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."

The nurse is preparing a client for surgery and the client asks, "What does it mean when they say they are going to reduce my abdominal hernia?" Which response by the nurse is most appropriate?

"This means the hernia contents will be manipulated back into your peritoneal cavity during surgery."

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."

The nurse is caring for a child prescribed vancomycin 15 mg/kg IV every 6 hours for peritonitis. The child weights 45 lb (20.5 kg). How many milligrams will the nurse administer to this child in 24 hours?

1230

The child has been diagnosed with severe dehydration. The health care provider has prescribed a bolus of 20 mL/kg of normal saline over a 2-hour period. The child weighs 63.5 lb (28.8 kg). At which mL/hour should the nurse set the child's intravenous administration pump? Record your answer using a whole number.

288

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 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 congenital aganglionic megacolon?

A partial or complete intestinal obstruction occurs.

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 accurately related to the diagnosis of pyloric stenosis?

A thickened, elongated muscle causes an obstruction at the end of the stomach.

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

Tenting of skin

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

The adolescent will become fatigued easily.

The nurse observes the interactions of parents with their infant who was born with a cleft lip. The mother is attempting to feed the baby, but does not make eye contact. The father is watching television with his back turned to the mother and baby. What psychosocial nursing intervention would be most helpful to this family?

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

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

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

Barium enema

A child presents with intermittent abdominal pain, severe anorexia, and diarrhea. The child's height and weight are significantly behind standards for age. There is skin breakdown in the anal region. The nurse explains that this presentation is consistent with which diagnosis?

Crohn disease

A child is admitted with a temperature, 101.2°F (38.4°C); pulse rate 100 beats/min; respirations 24 breaths/min. On admission the pain is localized in right lower quadrant. Legs are drawn up against the abdomen. Bowel sounds are sluggish. Rebound tenderness is present. White blood cell count of 17,000/mm3. Ultrasound confirms appendicitis. Which instruction would the nurse give to the child and the parent?

Do not rub or put pressure on the abdomen.

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.

A parent brings the 2-week-old newborn to the office because the infant has been experiencing gastroesophageal reflux over the past week. Which intervention(s) should the nurse recommend to the parent at this point? Select all that apply.

Feed the infant a formula thickened with rice cereal. Feed the infant while holding the infant in an upright position. Keep the infant upright in an infant chair/car seat for 30 minutes after feeding.

A parent brings a 2-year-old child to the health clinic with reports of diarrhea, vomiting, and abdominal pain. The father tells the nurse that he is a single parent and his child is enrolled in a local day care center. Based on this information, what gastrointestinal condition might the nurse suspect?

Gastroenteritis

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.

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 is caring for a neonate who has undergone an intestinal pull-through procedure for an imperforate anus. Which action would be most important for the nurse to do postoperatively?

Listening for bowel sounds

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

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

Persistent constipation

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.

In caring for an infant diagnosed with pyloric stenosis the nurse would anticipate which intervention?

Prepare the infant for surgery.

A nurse explains to the family of an infant with an inguinal hernia that the surgeon will attempt manual reduction prior to surgical repair. Which statement describes this technique?

The client is sedated, the lower torse is elevated, and the incarcerated contents of the hernia are manipulated back into the peritoneal cavity.

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 oral candidiasis (thrush)?

The patches are light in color on the tongue.

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

There is a partial or complete mechanical obstruction in the intestine.

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

Vomiting

A 6-week-old infant is diagnosed with pyloric stenosis. When taking a health history from the parent, which symptom would the nurse expect to hear described?

Vomiting immediately after feeding

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

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

detect Helicobacter pylori

A nurse examining a neonate is unable to identify the fetal stomach. The nurse knows that this sign strongly indicates which condition?

esophageal atresia (EA)

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)

The nurse is caring for a 12-year-old child with Crohn disease. What assessment finding will the nurse report to the health care provider when caring for the child?

fever

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

The nurse is providing discharge teaching regarding oral fluid rehydration to a mother who brought her child to the clinic because of vomiting over the past 2 days. The child is mildly dehydrated. Which comments by the mother indicated learning occurred?

"I should not give my child any fluids for 1 to 2 hours after an episode of vomiting." "Oral rehydration solutions (ORS) are good sources of fluids for rehydration." "I should be sure my child receives 50 to 100 ml/kg of oral rehydration solution (ORS) over 4 hours."

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 nurse is caring for an infant recently diagnosed 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."

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."

The nurse is caring for a child with gastrointestinal concerns. What statement by the parent would indicate a need for the nurse to further assess the child for constipation?

"My child has such large bowl movements that it clogs the toilet."

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." rationale: 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 a 4-year-old with oral vesicles and ulcers from herpangina. The child is refusing fluids due to the pain and the mother is concerned about his hydration status. Which of the suggestions would be most appropriate?

"Offer 'magic mouthwash' followed by a popsicle."

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

A child is hospitalized with dehydration as a result of rotavirus. When reviewing the plan of treatment, what can the nurse anticipate will be included? Select all that apply.

IV fluid administration monitor of intake and output daily weight assessment

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

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.

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

A 3-month-old girl is found to have an umbilical hernia at a well visit. On examination, the nurse discovers that the fascial ring through which the intestine protrudes is about 1 cm in diameter. Which statement by the nurse to the girl's father would indicate the likely intervention required to correct this condition?

No intervention is needed, as the opening will most likely close spontaneously.

A 12-year-old boy has just undergone a liver transplantation and is recovering. After performing a fingerstick 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

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

The nurse is caring for a 2-year-old child with a gastrointestinal infection resulting in 4 to 5 liquid stools per day over the past 3 days. Based on this information, which nursing diagnoses should the nurse include in the child's care plan? Select all that apply.

Risk for deficient fluid volume Diarrhea Risk for impaired skin integrity

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

An 18-month-old infant is brought to the emergency department with flu-like symptoms. The infant 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

A child with severe vomiting for 3 days presents with hypopnea and hypokalemia. The nurse reports to the provider that this child is exhibiting signs of which condition?

metabolic alkalosis

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

The nurse teaches a parent to differentiate between regurgitation and vomiting in the infant. The parent correctly states which characteristic of regurgitation? Select all that apply.

occurs with feeding no appearance of distress

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.

A parent brings a 10-year-old child to the emergency room with reports 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 suspect?

pancreatitis

A 3-month-old is admitted with severe diarrhea. Yesterday, the infant weighed 11 pounds (5 kg). Today, this infant weighs 9 pounds, 8 ounces (4.3 kg). Based on this information the nurse documents that the infant has:

severe dehydration.

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

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 the stools. The clinical manifestation this caregiver is describing is:

steatorrhea.

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