PEDS GI

The nurse is interviewing the parents of a 6-year-old who has been experiencing constipation. Which could be a causative factor? Select all that apply. 1. Hypothyroidism. 2. Muscular dystrophy. 3. Myelomeningocele. 4. Drinks a lot of milk. 5. Active in sports.

1, 2, 3, 4. 1. Hypothyroidism can be a causative factor in constipation. 2. Weakened abdominal muscles can be seen in muscular dystrophy and can lead to constipation. 3. Myelomeningocele affects the innervation of the rectum and can lead to constipation. 4. Excessive milk consumption can lead to constipation.

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

1, 2, 3, 4. 1. The lights in phototherapy increase insensible fl uid loss, requiring the nurse to monitor fl uid status closely. 2. The infant with pyloric stenosis is likely to be dehydrated as a result of persistent vomiting. 3. A 2-year-old with pneumonia may have increased insensible fl uid loss as a result of tachypnea associated with respiratory illness. The nurse needs to monitor fl uid status cautiously because fl uid overload can result in increased respiratory distress. 4. The child with a burn experiences extensive extracellular fl uid loss and is at great risk for dehydration. The younger child is at greater risk because of greater proportionate body surface area.

A child is admitted with a tentative diagnosis of shigella. The nurse performs which interventions? Select all that apply. □ 1. Assess the child for nausea and vomiting. □ 2. Collect a stool specimen for white blood cells (WBCs). □ 3. Place the child on airborne precautions. □ 4. Monitor the child for signs and symptoms of dehydration. □ 5. Initiate an intake and output record.

1, 2, 4, 5. Shigella is caused by the Shigella organism. Clinical manifestations of shigella include fever, nausea and vomiting, some cramping, headache, seizures, rectal prolapse, and loose, watery stools containing pus, mucus, and blood. The nurse should assess the child for these symptoms on an ongoing basis. Shigella is spread via direct contact with the organism, which is found in the stool. A stool specimen will show increased numbers of WBCs, blood, and mucus. Vomiting and loose stools can result in severe dehydration and electrolyte imbalance. Thus, the nurse should record intake, output, and daily weights. There is no need for strict isolation; masks are not needed as shigella is not transmitted by airborne methods.

Which signs or symptoms suggest that an infant with diarrhea is dehydrated? Select all that apply. □ 1. tacky mucous membranes □ 2. sunken anterior fontanelle □ 3. salty saliva □ 4. restlessness □ 5. increased urine output

1, 2, 4. Diarrhea in infants is a serious condition as it can proceed rapidly to dehydration. Clinical signs of dehydration are irritability and restlessness, weakness, stupor, loss of body weight, poor skin turgor, and sunken fontanelles. The urine output is decreased in dehydrated infants. The saliva decreases with dehydration and is not salty.

What should the nurse assess in a newborn diagnosed with an anorectal malformation? Select all that apply. □ 1. abdominal distention □ 2. loose stools □ 3. vomiting □ 4. meconium in the urine □ 5. meconium stools

1, 3, 4. Anorectal malformations present with lack of stool or evidence of meconium in the urine through a fistula. Meconium is not found in the stool. Because stool does not pass, abdominal distention and vomiting occur.

A child is admitted with constipation and a diagnosis of possible appendicitis. The child is in acute pain. Which nursing interventions would be appropriate prior to surgery to decrease pain? Select all that apply. □ 1. Offer an ice pack. □ 2. Apply a heating pad. □ 3. Assume a position of comfort. □ 4. Limit the child's activity. □ 5. Request a prescription for a cathartic.

1, 3, 4. Cold is a vasoconstrictor and supplies some degree of anesthesia. The child is usually more comfortable on his side with his legs flexed to take the strain off the inflamed appendix. Limiting the child's activity puts less stress on the inflamed appendix and lessens the discomfort. Heat increases circulation to an area, causing more engorgement and pain and, possibly, rupture of the appendix. Heat is contraindicated in any situation where rupture or perforation is a possibility. A cathartic is contraindicated when appendicitis is suspected. Increasing peristalsis can cause the appendix to rupture.

A 9-month-old is admitted because of dehydration. How should the nurse go about accurately monitoring fluid intake and output? Select all that apply. □ 1. weighing and recording all wet diapers □ 2. changing breastfeedings to bottle-feedings □ 3. obtaining an accurate daily weight □ 4. restricting fluids prior to weighing the child □ 5. obtaining an accurate stool count

1, 3, 5. Accurate intake and output recording includes noting all intake, including IV fluids; noting output, such as emesis and stool; weighing diapers; measuring weight daily; measuring urine specific gravity; monitoring serum electrolytes; and monitoring for signs of dehydration. Children who are dehydrated must receive sufficient fluid intake, but having a breastfeeding child switch to bottle-feeding will not promote intake. Restricting fluids just prior to weighing the child will not alter the accuracy of the weight, and the nurse should continue to encourage fluids for this dehydrated child.

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

1, 3. 1. The child should not be allowed to use anything that creates suction in the mouth, such as pacifiers or straws. "Sippy" cups are acceptable. 3. Pain medication should be administered regularly to avoid crying, which places stress on the suture line.

The nurse is caring for an infant newly diagnosed with Hirschsprung disease. What does the nurse understand about this infant ' s condition? Select all that apply. 1. There is a lack of peristalsis in the large intestine and an accumulation of bowel contents, leading to abdominal distention. 2. There is excessive peristalsis throughout the intestine, resulting in abdominal distention. 3. There is a small-bowel obstruction, leading to ribbon-like stools. 4. There is infl ammation throughout the large intestine, leading to accumulation of intestinal contents and abdominal distention. 5. There is an accumulation of bowel contents, leading to non-passage of stools.

1, 5. 1. In Hirschsprung disease, a portion of the large intestine has an area lacking in ganglion cells. This results in a lack of peristalsis as well as an accumulation of bowel contents and abdominal distention. 5. There is accumulation of stool above the aganglionic bowel, which does not allow stool to pass through.

On the 2nd postoperative day after repair of a cleft palate, what should the nurse use to feed a toddler? □ 1. cup □ 2. straw □ 3. rubber-tipped syringe □ 4. large-holed nipple

1. A cup is the preferred drinking or eating utensil after repair of a cleft palate. At the age when repair is done, the child is ordinarily able to drink from a cup. Use of a cup avoids having to place a utensil in the mouth, which would increase the potential for injury to the suture lines.

Which foods should be offered to a child with hepatitis? 1. A tuna sandwich on whole wheat bread and a cup of skim milk. 2. Clear liquids, such as broth, and Jell-O. 3. A hamburger, French fries, and a diet soda. 4. A peanut butter sandwich and a milkshake.

1. A diet that is high in protein and carbohydrates helps maintain caloric intake and protein stores while preventing muscle wasting. A low-fat diet prevents abdominal distention.

Eight hours ago, an infant with Hirschsprung's disease had surgery to create a colostomy. Which finding should alert the nurse to notify the health care provider (HCP) immediately? □ 1. a 3-cm increase in abdominal circumference □ 2. periods of occasional fussiness □ 3. absence of bowel sounds since surgery □ 4. appearance of a bright red stoma

1. Abdominal circumference is measured to monitor for abdominal distention. An increase of 3 cm in 8 hours would require notification of the HCP ; it would indicate a substantial degree of abdominal distention, possibly from fluid or gas accumulation. Normally, after surgery, an infant experiences occasional periods of fussiness. However, as long as the infant is able to be quiet by himself or with the aid of a pacifier, the HCP does not need to be contacted. Absence of bowel sounds would be expected after surgery because of the effects of anesthesia. It takes approximately 48 hours for gastric motility to resume. New stomas are typically bright red or pink.

Which client action would the nurse judge to be a healthy coping behavior for a male adolescent after an appendectomy? □ 1. insisting on wearing a T-shirt and gym shorts rather than pajamas □ 2. avoiding interactions with other adolescents on the nursing unit □ 3. refusing to fill out the menu and allowing the nurse to do so □ 4. not taking telephone calls from friends so he can rest

1. Adolescents struggle for independence and identity, needing to feel in control of situations and to conform to peers. Control and conformity are often manifested in appearance, including clothing, and this carries over into the hospital experience. The adolescent feels best when he is able to look and act as he normally does, for example, wearing a T-shirt and gym shorts. Adolescents normally want to interact with peers and commonly seek every opportunity to do so. Avoiding other adolescents on the nursing unit or not taking phone calls from friends might suggest ineffective coping behavior. Refusing to fill out the menu and allowing the nurse to do so demonstrate dependent behavior, not a healthy coping mechanism.

When developing the postoperative plan of care for an adolescent who has undergone an appendectomy for a ruptured appendix, in which position should the nurse expect to place the client during the early postoperative period? □ 1. semi-Fowler's position □ 2. supine □ 3. lithotomy position □ 4. prone

1. After an appendectomy for a ruptured appendix, assuming semi-Fowler's or a right side-lying position helps localize the infection. These positions promote drainage from the peritoneal cavity and decrease the incidence of subdiaphragmatic abscess.

The stool culture of a child with profuse diarrhea reveals Salmonella bacilli. After the nurse teaches the parent about the course of Salmonella, which statement by the parent indicates effective teaching? □ 1. "Some people become carriers and stay infectious for a long time." □ 2. "After the acute stage passes, the organism is usually not present in the stool." □ 3. "Although the organism may be alive indefinitely, in time it will be of no danger to anyone." □ 4. "If my child continues to have the organism in the stool, an antitoxin can help destroy the organism."

1. After having S. enteritidis, some clients become chronic carriers of the causative organism and remain infectious for a long time as the organism continues to be shed from the body. During this time, the child is still considered infectious. No antitoxin is available to treat or prevent Salmonella infections.

Which measure would be most effective in helping the infant with a cleft lip and palate to retain oral feedings? □ 1. Burp the infant at frequent intervals. □ 2. Feed the infant small amounts at one time. □ 3. Place the end of the nipple far to the back of the infant's tongue. □ 4. Maintain the infant in a supine position while feeding.

1. An infant with a cleft lip and palate typically swallows large amounts of air while being fed and therefore should be burped frequently. The soft palate defect allows air to be drawn into the pharynx with each swallow of formula. The stomach becomes distended with air, and regurgitation, possibly with aspiration, is likely if the infant is not burped frequently. Feeding frequently, even in small amounts, would not prevent swallowing of large amounts of air. A nipple placed in the back of the mouth is likely to cause the infant to gag and aspirate. Holding the infant in a supine position during feedings can also lead to regurgitation and aspiration of formula. The infant should be fed in an upright position

After surgery to correct pyloric stenosis, the nurse instructs the parents about the postoperative feeding schedule for their infant. The parents exhibit understanding of these instructions when they state that they can start feeding the child within which time frame? □ 1. 6 hours □ 2. 8 hours □ 3. 10 hours □ 4. 12 hours

1. Clear liquids containing glucose and electrolytes are usually prescribed 4 to 6 hours after surgery. If significant vomiting does not occur, formula or breast milk then can be gradually substituted for clear liquids until the infant is taking normal feedings.

A 4-month-old is brought to the emergency department with severe dehydration. The heart rate is 198, and her blood pressure is 68/38. The infant ' s anterior fontanel is sunken. The nurse notes that the infant does not cry when the intravenous line is inserted. The child ' s parents state that she has not "held anything down" in 18 hours. The nurse obtains a fi nger-stick blood sugar of 94. Which would the nurse expect to do immediately? 1. Administer a bolus of normal saline. 2. Administer a bolus of D 10 W. 3. Administer a bolus of normal saline with 5% dextrose added to the solution. 4. Offer the child an oral rehydrating solution such as Pedialyte.

1. Dehydration is corrected with the administration of an isotonic solution, such as normal saline or lactated Ringer solution.

A child undergoes rehydration therapy after having diarrhea and dehydration. A nurse is teaching the child's parents about dietary management after rehydration. The nurse understands that the teaching plan has been successful when the parents tell the nurse that they will follow which type of diet? □ 1. regular □ 2. clear liquid □ 3. full liquid □ 4. soft

1. Dietary management following rehydration for diarrhea and mild dehydration would include offering the child a regular diet. Following rehydration, there is no need for the child to be on a special diet, such as a clear liquid, full liquid, or soft diet.

When obtaining the nursing history from the mother of an infant with suspected intussusception, which question would be most helpful? □ 1. "What do the stools look like?" □ 2. "When was the last time your child urinated?" □ 3. "Is your child eating normally?" □ 4. "Has your child had any episodes of vomiting?"

1. For the infant with intussusception, stools characteristically have the appearance of currant jelly because of the intestinal inflammation and hemorrhage resulting from intestinal obstruction. These stools occur later in the course of the disease process. Questions that focus on urination, vomiting, and food intake do not elicit information about the effects of intussusception.

The mother of a toilet-trained toddler who was admitted to the hospital for severe gastroenteritis and subsequent dehydration and is now at home asks the nurse why the child still wets the bed. What would be the nurse's best response? □ 1. "Hospitalization is a traumatic experience for children. Regression is common, and it takes time for them to return to their former behavior." □ 2. "The stress of hospitalization is hard for many children, but usually they have no problems when they return home." □ 3. "After returning home from being hospitalized, children still feel they should be the center of attention." □ 4. "Children do not feel comfortable in their home surroundings once they return home from being hospitalized."

1. Hospitalization is a traumatic time for a child, and it takes some time to readjust to the home environment. The child may regress at home for a period until she feels comfortable. Children normally do not dislike their home environment; in fact, they usually are eager to get home to familiar surroundings where they feel safe.

An infant is to be discharged after surgery for intussusception. What information should the nurse include in the discharge teaching plan? □ 1. The infant will experience a change in the normal home routine. □ 2. The infant can return to the prehospital routine immediately. □ 3. The infant needs to ingest more calories at home than what was consumed in the hospital. □ 4. The infant will continue to experience abdominal cramping for a few days.

1. Infants who have had an interruption in their normal routine and experiences, such as hospitalization and surgery, typically manifest behavior changes when discharged. The infant's normal routine has been significantly altered, so it will take time to reestablish another routine. Calorie requirements at home will continue to be the same as those in the hospital. The infant does not need more calories at home. The surgical procedure corrected the problems, so the infant should not continue to have abdominal cramping.

The nurse is caring for a newborn with esophageal atresia. When reviewing the mother ' s history, which would the nurse expect to fi nd? 1. Maternal polyhydramnios. 2. Pregnancy lasting more than 38 weeks. 3. Poor nutrition during pregnancy. 4. Alcohol consumption during pregnancy.

1. Maternal polyhydramnios is present because the infant cannot swallow and absorb the amniotic fl uid in utero.

Which should the nurse include in the teaching plan for a child started on metoclopramide (Reglan)? 1. The drug increases gastrointestinal motility. 2. The drug decreases tone in the lower esophageal sphincter. 3. The drug prevents diarrhea. 4. The drug induces the release of acetylcholine.

1. Metoclopramide (Reglan) is a gastrointestinal stimulant that increases motility of the gastrointestinal tract, shortens gastric emptying time, and reduces the risk of the esophagus being exposed to gastric content.

The health care provider (HCP) prescribes intravenous fluid replacement therapy with potassium chloride to be added for a child with severe gastroenteritis. Before the nurse hangs the IV fluids with potassium chloride, which assessments would be most important? □ 1. ability to void □ 2. passage of stool today □ 3. baseline electrocardiogram □ 4. serum calcium level

1. Potassium chloride is readily excreted in the urine. Before hanging IV fluids with potassium chloride, the nurse should ascertain whether the child can void; if not, potassium chloride may build up in the serum and cause hyperkalemia. An electrocardiogram could be done during intravenous potassium replacement therapy to evaluate for these changes. Having a stool daily is important, but because potassium is primarily excreted in the urine, the child's ability to void must be verified. Serum calcium levels do not indicate the child's ability to tolerate potassium replacement.

After the nurse teaches the parent of an infant with pyloric stenosis about the condition, which cause, if stated by the parent, indicates effective teaching? □ 1. "an enlarged muscle below the stomach" □ 2. "a telescoping of the large bowel into the smaller bowel" □ 3. "a result of giving the baby more formula than is necessary" □ 4. "a genetically smaller stomach than normal"

1. Pyloric stenosis involves hypertrophy of the pylorus muscle distal to the stomach and obstruction of the gastric outlet resulting in vomiting, metabolic acidosis, and dehydration. Telescoping of the bowel is called intussusception. Overfeeding, feeding too quickly, or underfeeding is not associated with pyloric stenosis. The stomach is obstructed, but it is not smaller than normal.

An adolescent client scheduled for an emergency appendectomy is to be transferred directly from the emergency department to the operating room. Which statement by the client should the nurse interpret as most significant? □ 1. "All of a sudden, it does not hurt at all." □ 2. "The pain is centered around my navel." □ 3. "I feel like I am going to throw up." □ 4. "It hurts when you press on my stomach."

1. Sudden relief of pain in a client with appendicitis may indicate that the appendix has ruptured. Rupture relieves the pressure within the appendix but spreads the infection to the peritoneal cavity. Periumbilical pain (pain centered around the navel), vomiting, and abdominal tenderness on palpation are common findings associated with appendicitis.

Which is an accurate description of a Kasai procedure? 1. A palliative procedure in which the bile duct is attached to a loop of bowel to assist with bile drainage. 2. A curative procedure in which a connection is made between the bile duct and a loop of bowel to assist with bile drainage. 3. A curative procedure in which the bile duct is banded to prevent bile leakage. 4. A palliative procedure in which the bile duct is banded to prevent bile leakage.

1. The Kasai procedure is a palliative procedure in which the bile duct is attached to a loop of bowel to assist with bile drainage.

The nurse is administering bolus gastrostomy feedings to an infant after surgery to correct a tracheoesophageal fistula (TEF). What should the nurse do to prevent air from entering the stomach once the syringe barrel is attached to the gastrostomy tube? □ 1. Unclamp the tube after pouring the complete amount of formula to be administered into the syringe barrel. □ 2. Pour all of the formula to be administered into the syringe barrel after opening the clamp. □ 3. Maintain a continuous flow of formula down the side of the syringe barrel once the clamp is opened. □ 4. Allow a small amount of formula to enter the stomach before pouring more formula into the syringe barrel.

1. The best way to prevent air from entering the stomach when performing a bolus feeding on an infant through a gastrostomy tube is to open the clamp after all the formula has been placed in the syringe barrel. Doing so prevents air from mixing with the formula and thus being introduced into the stomach. Pouring all the formula into the barrel after opening the clamp, maintaining a continuous flow of formula down the side of the barrel after unclamping the tube, and allowing a small amount of formula to enter the stomach before adding more formula to the barrel permit air to enter the stomach.

The parent of a toddler hospitalized for episodes of diarrhea reports that when the toddler cannot have things the way she wants, she throws her legs and arms around, screams, and cries. The mother says, "I don't know what to do!" After the nurse teaches the parent about ways to manage this behavior, which statement by the parent indicates that the nurse's teaching was successful? □ 1. "Next time she screams and throws her legs, I'll ignore the behavior." □ 2. "I'll allow her to have what she wants once in a while." □ 3. "I'll explain why she cannot have what she wants." □ 4. "When she behaves like this, I'll tell her that she is being a bad girl."

1. The child is demonstrating behavior associated with temper tantrums, which are relatively frequent normal occurrences during toddlerhood as the child attempts to develop a sense of autonomy. The development of autonomy requires opportunities for the child to make decisions and express individuality. Ignoring the outbursts is probably the best strategy. Doing so avoids rewarding the behavior and helps the child to learn limits, promoting the development of self-control. However, the mother should intervene in a temper tantrum if the child is likely to injure herself. Allowing the child to have what she wants occasionally would typically add to the problems associated with temper tantrums because doing so rewards the behavior and prevents the child from developing self-control. Toddlers do not possess the capacity to understand explanations about behavior. Expressing disappointment in the child's behavior or telling her that she is being a bad girl reinforces feelings of guilt and shame, thus interfering with the child's ability to develop a sense of autonomy.

Which manifestations should the nurse expect to fi nd in a child in the early stages of acute hepatitis? 1. Nausea, vomiting, and generalized malaise. 2. Nausea, vomiting, and pain in the left upper quadrant. 3. Generalized malaise and yellowing of the skin and sclera. 4. Yellowing of the skin and sclera without any other generalized complaints.

1. The early stage of acute hepatitis is referred to as the anicteric phase, during which the child usually complains of nausea, vomiting, and generalized malaise.

A nasogastric tube inserted during surgical correction of infant's intussusception is no longer freely removing gastric secretions. What should the nurse do next? □ 1. Verify the tube placement. □ 2. Irrigate the tube. □ 3. Increase the level of suction. □ 4. Rotate the tube.

1. The first action is to check the placement of the tube to ensure that it is in the correct position. To check tube position, the nurse should aspirate the tube with a syringe. A return of gastric contents indicates that the end of the tube is in the stomach. Another method is to inject a small amount of air while auscultating with a stethoscope over the epigastric area. The tube is irrigated only after the position of the tube is confirmed. The suction level should not be increased because doing so could damage the mucosa. Rotating the tube could irritate or traumatize the nasal mucosa.

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

1. The inability to digest protein leads to an accumulation of an amino acid that is toxic to the mucosal cells and villi, leading to absorption problems.

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

1. The infant is displaying signs of intussusception. This is an emergency that needs to be evaluated to prevent ischemia and perforation.

Which manifestation would the nurse expect to see in a 4-week-old infant with biliary atresia? 1. Abdominal distention, enlarged liver, enlarged spleen, clay-colored stool, and teacolored urine. 2. Abdominal distention, multiple bruises, bloody stools, and hematuria. 3. Yellow sclera and skin tones, excessively oily skin, and prolonged bleeding times. 4. No manifestations until the disease has progressed to the advanced stage.

1. The infant with biliary atresia usually has an enlarged liver and spleen. The stools appear clay-colored because of the absence of bile pigments. The urine is tea-colored because of the excretion of bile salts.

When the nurse is obtaining the initial health history from a 10-year-old child with abdominal pain and suspected appendicitis, which question would be most helpful in eliciting data to help support the diagnosis? □ 1. "Where did the pain start?" □ 2. "What did you do for the pain?" □ 3. "How often do you have a bowel movement?" □ 4. "Is the pain continuous, or does it let up?"

1. The most helpful question would be to determine the location of the pain when it started. The pain associated with appendicitis usually begins in the periumbilical area and then progresses to the right lower quadrant. After the nurse has determined the location of the pain, asking about what was done for the pain would be appropriate. Asking about the child's usual bowel movement pattern is a general question unrelated to child's condition. Children with appendicitis may have diarrhea or constipation. Additionally, knowledge about the child's usual pattern would not be a priority because the child with appendicitis typically is not hospitalized long enough to reestablish the normal pattern. Although the characteristics of the pain are important, asking if the pain is continuous or intermittent is vague and general because the pain could be associated with numerous conditions. With appendicitis, the client's pain may begin as intermittent, but it eventually becomes continuous.

The parents of a child with a tracheoesophageal fistula express feelings of guilt about their baby's anomaly. Which approach by the nurse would best support the parents? □ 1. helping the parents accept their feelings as a normal reaction □ 2. explaining that the parents did nothing to cause the newborn's defect □ 3. encouraging the parents to concentrate on planning their baby's care □ 4. urging the parents to visit their newborn as often as possible

1. The parents of children born with defects often have feelings of guilt and ask what they might have done to cause the condition or how they might have avoided it. It is important to allow parents to express their feelings and to accept these feelings as normal reactions. Explaining that the parents are not at fault would not be appropriate until they have dealt with their feelings of guilt. Encouraging long-term planning generally is of little benefit to parents who are emotionally distraught. Additionally, the parents may interpret this as ignoring their feelings and confirming that they played a role in causing their child's anomaly. Urging the parents to visit their infant as often as possible would generally be of little help and could appear to the parents as though they are being "talked out" of their feelings.

What should be the priority assessment for an adolescent on return to the nursing unit after an appendectomy? □ 1. the dressings on the surgical sites □ 2. intravenous fluid infusion site □ 3. nasogastric (NG) tube function □ 4. amount of pain

1. The priority assessment after an appendectomy would be the dressing over the surgical site to determine whether there is any drainage or bleeding. If the procedure was done laparoscopically, there may be more than one incision. Any surgical dressings should be clean, dry, and intact. Once the dressing has been assessed, the nurse would assess the intravenous infusion site, assess the NG tube to be sure it is functioning, and finally, determine the degree of pain the client is experiencing.

The nurse teaches the father of an infant hospitalized with gastroenteritis about the next step of the treatment plan once the infant's condition has been controlled. The nurse determines that the father understands when he explains that which intervention will occur with his infant? □ 1. The infant will receive clear liquids for a period of time. □ 2. Formula and juice will be offered. □ 3. Blood will be drawn daily to test for anemia. □ 4. The infant will be allowed to go to the playroom.

1. The usual way to treat an infant hospitalized with gastroenteritis is to keep the infant nothing-by-mouth status to rest the gastrointestinal tract. The resulting fluid volume deficit is treated with intravenous fluids. When the infant's condition is controlled (e.g., when vomiting subsides), clear liquids are then started slowly. Formula and juice will be started once the infant's vomiting has subsided and the infant has demonstrated the ability to tolerate clear liquids for a period of time. In this situation, there is no need to test the infant's blood every day for anemia. Most likely, the infant's serum electrolyte levels would be monitored closely. Typically, an infant is placed in a private room because gastroenteritis is most commonly caused by a virus that is easily transmitted to others.

The nurse is caring for an infant diagnosed with Hirschsprung disease. The mother states she is pregnant with a boy and wants to know if her new baby will likely have the disorder. Which is the nurse ' s best response? 1. "Genetics play a small role in Hirschsprung disease, so there is a chance the baby will develop it as well." 2. "There is no evidence to support a genetic link, so it is very unlikely the baby will also have it." 3. "It is rarely seen in boys, so it is not likely your new baby will have Hirschsprung disease." 4. "Hirschsprung disease is seen only in girls, so your new baby will not be at risk."

1. There is a genetic component to Hirschsprung disease, so any future siblings are also at risk.

After teaching the parent of an infant who has had a surgical repair for a cleft lip about the use of elbow restraints at home, the nurse determines that the teaching has been successful when the parent makes which statement? □ 1. "We will only remove the restrains one at a time to check the skin under them for redness." □ 2. "We will keep the restraints on during the day while he is awake, but take them off when we put him to bed at night." □ 3. "After we get home, we will not have to use the restraints because our child does not suck on his hands or fingers." □ 4. "We will be sure to keep the restraints on all the time until we come to see the care provider for a follow-up visit."

1. To keep the infant from disturbing the suture line by placing fingers or other objects in the mouth, either intentionally or accidentally, the restraints should be in place at all times. They should be removed for a short period, however, so that the underlying skin can be checked for any redness or breakdown. The best approach is to remove one restraint, complete the inspection, and reapply before checking the other arm. While the restraints are removed, the parents should be instructed to manually restrain the hands and arms.

Which intervention would be most appropriate for the nurse to teach the mother of a 6-month-old infant hospitalized with severe diarrhea to help her comfort her infant who is fussy? □ 1. offering a pacifier □ 2. placing a mobile above the crib □ 3. sitting at crib side talking to the infant □ 4. turning the television on to cartoons

1. Typically, an infant hospitalized with severe diarrhea receives fluid replacement intravenously rather than orally. Oral fluids and food are usually withheld. Although activities such as placing a mobile over the crib, speaking to the infant, or turning on the television may provide distraction for or help in calming the infant, a fussy infant receiving nothing by mouth is usually best comforted by providing a pacifier to satisfy sucking needs.

When an infant with pyloric stenosis is admitted to the hospital, which aspect of the plan of care should the nurse implement first? □ 1. Weigh the infant. □ 2. Begin an intravenous infusion. □ 3. Switch the infant to an oral electrolyte solution. □ 4. Orient the mother to the hospital unit.

1. Unless the infant is in hypovolemic shock, obtaining a baseline weight is an important first action because the weight is used to calculate the child's fluid and electrolyte needs. The intravenous fluid rate and the amounts of electrolytes to be added to the fluid are based on the infant's weight. The weight also helps determine the infant's degree of dehydration. The intravenous infusion is initiated once the weight has been obtained. The child with pyloric stenosis typically experiences vomiting and is at risk for fluid volume deficit and metabolic acidosis. As a result, oral food and fluids are withheld, and the infant is allowed nothing by mouth. Fluid replacement is given intravenously. Orientation can wait until treatment is under way.

An adolescent is being seen in the clinic for abdominal pain with a fever. In what order should the nurse assess the abdomen? All options must be used. □ 1. auscultate □ 2. inspect □ 3. palpate □ 4. percuss

2, 1, 4, 3. The nurse should first inspect the abdomen for abnormalities. Auscultation should be done before percussion and palpation as vigorous touching may disturb the intestines. Percussion is next. Palpation is the last step as it is most likely to cause pain.

The health care team has noticed an increase in IV infiltrations on the pediatric floor. As part of a "Plan, Do, Study, Act" quality improvement plan, the team should perform the actions in which order? All options must be used. □ 1. Analyze the data. □ 2. Decide to monitor IV gauges. □ 3. Perform chart audits. □ 4. Write a new IV insertion policy

2, 3, 1, 4. Deciding what to study and how to do it is part of the planning process. Collecting data through chart audits is part of the "do" phase. Once the chart audits are complete, the data may be "studied" or analyzed. The final step of the process, or the "act" phase, is to determine what should be done, which may include writing a new policy.

The nurse is providing discharge instructions to the parents of a child who had an appendectomy for a ruptured appendix 5 days ago. The nurse knows that further education is required when the parent states which of the following? Select all that apply. 1. "We will wait a few days before allowing our child to return to school." 2. "We will wait 2 weeks before allowing our child to return to sports." 3. "We will call the health-care provider ' s offi ce if we notice any drainage around the wound." 4. "We will encourage our child to go for walks every day." 5. "We will encourage our child to eat at every meal and offer snacks."

2,3 2. The child should wait 6 weeks before returning to any strenuous activity. 3. Any signs of infection should be reported to the surgeon.

The nurse is providing discharge instructions to the parents of an infant who has had surgery to open a low imperforate anus. The nurse knows that the discharge instructions have been understood when the child ' s parents say: 1. "We will use an oral thermometer because we cannot use a rectal one." 2. "We will call the health-care provider if the stools change in consistency." 3. "Our infant will never be toilet-trained." 4. "We understand that it is not unusual for our infant ' s urine to contain stool."

2. A change in stool consistency is important to report because it could indicate stenosis of the rectum.

Which instructions for a child diagnosed with encopresis should the nurse question? Select all that apply. 1. Limit the intake of milk. 2. Offer a diet high in protein. 3. Obtain a complete dietary log. 4. Follow up with a child psychologist. 5. After dinner, have the child sit on the toilet for 10 minutes.

2. A diet high in protein will cause more constipation. 4. The child and family would not be encouraged initially to seek counseling unless a psychological component to the encopresis had been identified.

The parents of a child being evaluated for appendicitis tell the nurse the health-care provider said their child has a positive Rovsing sign. They ask the nurse what this means. Which is the nurse ' s best response? 1. "Your child ' s health-care provider should answer that question." 2. "A positive Rovsing sign means the child feels pain in the right side of the abdomen when the left side is palpated." 3. "A positive Rovsing sign means pain is felt when the physician removes the hand from the abdomen." 4. "A positive Rovsing sign means pain is felt in the right lower quadrant when the child coughs."

2. A positive Rovsing sign occurs when the left lower quadrant is palpated and pain is felt in the right lower quadrant.

What would the nurse expect as a normal response from an adolescent who has just returned to her room after an open appendectomy? □ 1. "I will need plastic surgery for this scar." □ 2. "I am worried about the size of my scar." □ 3. "I do not want to have any pain." □ 4. "What will my boyfriend say about the scar?"

2. Adolescents are concerned about the immediate state and functioning of their bodies. The adolescent needs to know whether any changes (e.g., illness, trauma, surgery) will alter her lifestyle or interfere with her quest for physical perfection. Having a scar may be devastating to the adolescent. The need for plastic surgery cannot be determined at this point. The adolescent has just returned from surgery and has yet to see the scar. Healing has yet to occur. Typically, scars become smaller and fade over time. The desire for no pain is unrealistic. Although adolescents are worried about pain and how they will respond, they typically are discharged within 24 hours after an appendectomy with pain well controlled by oral analgesics. The immediate concern of adolescents is the state and functioning of their bodies. After concerns about themselves, then adolescents are concerned about their peer group and their responses. Although the boyfriend's response will matter, this concern would be more common later in the course of the adolescent's recovery.

An adolescent who has had an appendectomy and developed peritonitis has nausea. Which intervention should the nurse do first? □ 1. Administer an antiemetic. □ 2. Irrigate the nasogastric (NG) tube. □ 3. Notify the surgeon. □ 4. Take the blood pressure.

2. After an appendectomy, the client who develops peritonitis typically has an NG tube in place. When a client has nausea, the nurse would first check to ensure that the NG tube is functioning correctly because the client's nausea may be related to a blockage of the NG tube. If the tube is clogged, it can be irrigated with normal saline. An antiemetic may be given, but only after the nurse has determined that the NG tube is functioning properly. Postoperative prescriptions usually include an antiemetic. Typically, the nurse would notify the surgeon if the client did not obtain relief from irrigation of the NG tube or administration of a prescribed antiemetic. Although taking the client's blood pressure is an important postoperative nursing activity, it is unrelated to relieving the client's nausea.

After teaching the parents of a neonate diagnosed with a tracheoesophageal fistula (TEF) about this anomaly, the nurse determines that the teaching was successful when the parent describes the condition in which way? □ 1. "The muscle below the stomach is too tight, causing the baby to vomit forcefully." □ 2. "There is a blind upper pouch and an opening from the esophagus into the airway." □ 3. "The lower bowel is lacking certain nerves to allow normal function." □ 4. "A part of the bowel is on the outside without anything covering it."

2. Although a TEF can include several different structural anomalies, the most common type involves a blind upper pouch and a fistula from the esophagus into the trachea. Other types include a blind pouch at the end of the esophagus with no connection to the trachea and a normal trachea and esophagus with an opening that connects them. A tightened muscle below the stomach and projectile vomiting of normal amounts of formula are characteristic of pyloric stenosis. Aganglionic megacolon is a lack of autonomic parasympathetic ganglion cells in a portion of the lower intestine. Gastroschisis occurs when the bowel herniates through a defect in the abdominal wall and no membrane covers the exposed bowel.

Which assessment would be the most important for the nurse to include in the plan of care for an infant experiencing severe diarrhea? □ 1. monitoring the total 8-hour formula intake □ 2. weighing the infant each day □ 3. checking the anterior fontanelle every shift □ 4. monitoring abdominal skin turgor every shift

2. Because an infant experiencing severe diarrhea is at high risk for a fluid volume deficiency, the nurse needs to evaluate the infant's fluid balance status by weighing the infant at least every day. Body weight is the best indicator of hydration status because a higher proportion of an infant's body weight is water, compared with an adult. Initially, the infant with severe diarrhea is not allowed liquids but is given fluids intravenously. Therefore, monitoring the oral intake of formula is inappropriate. Although checking the anterior fontanelle for depression or bulging provides information about hydration status, this method is not considered the best indicator of the infant's fluid balance. Monitoring skin turgor can provide information about fluid volume status. The abdomen is commonly used to assess skin turgor in an infant because it is a large surface area and can be accessed quickly. However, weight is the best indicator of fluid balance.

The nurse is caring for an infant who has been diagnosed with short bowel syndrome (SBS). The parent asks how the disease will affect the child. Which is the nurse ' s best response? 1. "Because your child has a shorter intestine than most, your child will likely experience constipation and will need to be placed on a bowel regimen." 2. "Because your child has a shorter intestine than most, he will not be able to absorb all the nutrients and vitamins in food and will need to get nutrients in other ways." 3. "Unfortunately, most children with this diagnosis do not do very well." 4. "The prognosis and course of the disease have changed because hyperalimentation is available."

2. Because the intestine is used for absorption, children with SBS usually need alternative forms of nutrition such as hyperalimentation.

Which manifestation suggests that an infant is developing necrotizing enterocolitis (NEC)? 1. Absorption of bolus orogastric feedings at a faster rate than previous feedings. 2. Bloody diarrhea. 3. Increased bowel sounds. 4. Appears hungry right before a scheduled feeding.

2. Bloody diarrhea can indicate that the infant has NEC.

The nurse is caring for a 3-year-old who had an appendectomy 2 days ago. The child has a fever of 101.8°F (38.8°C) and breath sounds are slightly diminished in the right lower lobe. Which action is most appropriate? 1. Teach the child how to use an incentive spirometer. 2. Encourage the child to blow bubbles. 3. Obtain an order for intravenous antibiotics. 4. Obtain an order for acetaminophen (Tylenol).

2. Blowing bubbles is a developmentally appropriate way to help the preschooler take deep breaths and cough.

The mother of an infant with a cleft lip asks when the repair will be scheduled. What is the nurse's best response? □ 1. at birth □ 2. during the first 6 months of life □ 3. after 6 months of age □ 4. at 1 year of age

2. Cleft lips are typically repaired during the first 6 months of life. This allows the child to form a better seal around the nipple of a bottle for feeding and strengthens muscles needed for speech. If the surgery is delayed until after 6 months, the child may have possible dental issues and problems with sucking. The repair is not done at birth because the infant must first gain weight to safely undergo surgery. The palate should be closed by 18 months to protect the formation of tooth buds and allow the infant to develop more normal speech patterns.

Which assessment should be the priority for an infant who has had surgery to correct an intussusception and is now at risk for development of a paralytic ileus postoperatively? □ 1. measurement of urine specific gravity □ 2. auscultation of bowel sounds □ 3. inspection of the first stool passed □ 4. measurement of gastric output

2. Development of a paralytic ileus postoperatively is a functional obstruction of the bowel. Bowel sounds initially may be hyperactive, but then they diminish and cease. Measurement of urine specific gravity provides information about fluid and electrolyte status. The first stool and the amount of gastric output provide information about the return of gastric function.

When developing the plan of care for a neonate who was diagnosed with an anorectal malformation and who subsequently underwent surgery, what intervention would be most helpful in facilitating parent-infant bonding? □ 1. explaining to the parents that they can visit at any time □ 2. encouraging the parents to hold their infant □ 3. asking the parents to help monitor the infant's intake and output □ 4. helping the parents plan for their infant's discharge

2. Encouraging the parents to hold their neonate promotes parent-infant attachment. Parent-infant bonding is based on a relationship that begins when the parent first touches the infant. Both the parents and the infant have predictable steps that they go through in this process. Explaining that the parents can visit at any time promotes bonding only if they do visit with, talk to, and hold the newborn. Asking the parents to help monitor intake and output at this time may be too anxiety producing, thus interfering with bonding. Helping the parents plan for the infant's discharge involves them in the newborn's care and is important. However, it is not the first step in the development of bonding.

What would the nurse identify as a priority nursing problem for an infant just admitted to the hospital with a diagnosis of gastroenteritis? □ 1. pain related to repeated episodes of vomiting □ 2. deficient fluid volume related to excessive losses from severe diarrhea □ 3. impaired parenting related to infant's loss of fluid □ 4. impaired urinary elimination related to increased fluid intake feeding pattern

2. Given this infant's history of gastroenteritis, the priority problem would be fluid volume deficit. With gastroenteritis, vomiting and diarrhea occur, leading to the loss of fluids. This loss of fluids is problematic in infants because a higher proportion of their body weight is water. Pain is not a priority problem, although the nurse should continue to assess the infant for pain. There are no data to indicate impaired parenting. Impaired urinary elimination is related to the infant's fluid volume deficit resulting from vomiting and diarrhea associated with gastroenteritis. If the infant's fluid volume deficit is not corrected, then this nursing diagnosis may become the priority.

The nurse is providing discharge teaching to the parents of an infant with an umbilical hernia. Which should be included in the plan of care? 1. If the hernia has not resolved on its own by the age of 12 months, surgery is generally recommended. 2. If the hernia appears to be more swollen or tender, seek medical care immediately. 3. To help the hernia resolve, place a pressure dressing over the area gently. 4. If the hernia is repaired surgically, there is a strong likelihood that it will return.

2. If the hernia appears larger, swollen, or tender, the intestine may be trapped, which is a surgical emergency.

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

2. In addition to giving fl uids intravenously and keeping the infant NPO, an NGT is placed to decompress the stomach.

During physical assessment of a 4-month-old infant with Hirschsprung's disease, the nurse would most likely note which finding? □ 1. scaphoid-shaped abdomen □ 2. weight less than expected for height and age □ 3. cyanosis of the fingers and toes □ 4. hyperactive deep tendon reflexes

2. Infants with Hirschsprung's disease typically display failure to thrive, with poor weight gain due to malabsorption of nutrients. Therefore, the nurse would expect to see a child who weighs less than that which is expected for height and age. A distended, rather than a scaphoid-shaped, abdomen would be noted. Cyanosis of fingers and toes is associated with congenital heart disease. Hyperactive deep tendon reflexes are associated with upper motor neuron problems, such as cerebral palsy.

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

2. Intravenous fl uids are administered to prevent dehydration because the infant is NPO. Intravenous antibiotics are administered to prevent pneumonia because aspiration of secretions is likely.

Which child can be discharged without further evaluation? 1. A 2-year-old who has had 24 hours of watery diarrhea that has changed to bloody diarrhea in the past 12 hours. 2. A 3-year-old who had a relapse of one diarrhea episode after restarting a normal diet. 3. A 6-year-old who has been having vomiting and diarrhea for 2 days and has decreased urine output. 4. A 10-year-old who has just returned from a Scout camping trip and has had several episodes of diarrhea.

2. It is common for children to have a relapse of diarrhea after resuming a regular diet.

Which assessment finding should alert the nurse to suspect appendicitis in a male adolescent with severe abdominal pain? □ 1. The abdomen appears slightly rounded. □ 2. Bowel sounds are heard twice in 2 minutes. □ 3. All four abdominal quadrants reveal tympany. □ 4. The client demonstrates a cremasteric reflex.

2. Manifestations of appendicitis include decreased or absent bowel sounds. Normally, bowel sounds are heard every 10 to 30 seconds. Therefore, bowel sounds heard twice in 2 minutes suggests appendicitis. Normally, the contour of the male adolescent abdomen is flat to slightly rounded, and tympany is typically heard when auscultating over most of the abdomen. A cremasteric reflex is normal for male adolescents.

The nurse prepares to teach an adolescent scheduled for an appendectomy about what to expect. The adolescent says, "I would rather look this up on the Internet." What should the nurse do? □ 1. Explain that completing a teaching checklist is required by the hospital. □ 2. Help the client find information on the Internet. □ 3. Provide the client with written information instead. □ 4. Explain that information found on the Internet cannot be trusted.

2. Part of providing client-centered care is to honor the client's preferred method of learning. The nurse should help the adolescent find accurate information about the procedure. By assisting with the information search, the nurse can verify learning. Teaching straight from a checklist does not encourage customization. If the client has requested to use the Internet, it is unlikely that written information will be read. While it is true that some information on the Internet is not accurate, the nurse can take this opportunity to help the client learn how to determine if a source is reliable.

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

2. Some mothers are able to breastfeed their infants who have a cleft lip and palate. The breast can help fi ll in the cleft and help the infant create suction.

The nurse knows that Nissen fundoplication involves which of the following? 1. The fundus of the stomach is wrapped around the inferior stomach, mimicking a lower esophageal sphincter. 2. The fundus of the stomach is wrapped around the inferior esophagus, mimicking a cardiac sphincter. 3. The fundus of the stomach is wrapped around the middle portion of the stomach, decreasing the capacity of the stomach. 4. The fundus of the stomach is dilated, decreasing the likelihood of refl ux.

2. The Nissen fundoplication involves wrapping the fundus of the stomach around the inferior esophagus, creating a lower esophageal, or cardiac, sphincter.

The hospital is responding to a mass casualty disaster with adult and pediatric victims. What should the charge nurse on the pediatric floor do after reallocating staff? □ 1. Ask parents to leave to free up areas for incoming victims. □ 2. Review the census for candidates for early discharge. □ 3. Initiate paper charting backup. □ 4. Change taking all vital signs to every 8 hours.

2. The charge nurse can anticipate needing beds for incoming victims. Any client who can go home should go home. Parents are a child's primary care givers and should not be asked to leave. If computers were not affected by the disaster, charting in the electronic health record is safer. Some routine procedures are altered during a disaster, but clients who are unstable will still need frequent assessments; reducing vital sign frequency must be considered on a case-to-case basis.

A 3-year-old with dehydration has vomited 3 times in the last hour and continues to have frequent diarrhea stools. The child was admitted 2 days ago with gastroenteritis caused by rotavirus. The child weighs 22 kg, has a normal saline lock in his right hand, and has had 30 mL of urine output in the last 4 hours. Using the situation-background-assessment-recommendation (SBAR) technique for communication, the nurse calls the health care provider (HCP) with the recommendation for which prescription? □ 1. giving a dose of loperamide □ 2. starting a fluid bolus of normal saline □ 3. beginning an IV antibiotic □ 4. establishing an indwelling catheter

2. The child is dehydrated, is not able to retain oral fluids, and continues to have diarrhea. A normal saline bolus should be given followed by maintenance of IV fluids. Antidiarrheal medications are not recommended for children and will prolong the illness. The child has gastroenteritis caused by a viral illness. IV antibiotics are not indicated for viral illnesses. Strict I&O is important in all children with gastroenteritis.

A 10-year-old male is 24 hours postappendectomy. He is awake, alert, and oriented. He tells the nurse that he is experiencing pain. He has a prescription for morphine 1 to 2 mg PRN for pain. What is the priority nursing action in managing the child's pain? □ 1. Change the child's position in bed. □ 2. Obtain vital signs with a pain score. □ 3. Administer 1 mg morphine as prescribed. □ 4. Perform a head-to-toe assessment.

2. The child is in pain and needs intervention, but before the nurse can determine how to proceed, it is essential to know the client's pain score to determine the appropriate morphine dose. In addition, the nurse cannot evaluate the effectiveness of the pain medication if there is no pain score prior to administering the medication. Changing the child's position and administering pain medication may be helpful to relieve the child's pain, but the nurse must first know the severity of the pain before determining the appropriate intervention. The nurse must perform a head-to-toe assessment, but it is not the priority in managing the child's pain.

An infant diagnosed with Hirschsprung's disease undergoes surgery with the creation of a temporary colostomy. Which statement by the parent regarding the colostomy indicates the need for further teaching? □ 1. "The colostomy is only temporary." □ 2. "The colostomy will give time for the nerves to return to normal." □ 3. "The colostomy may include two separate abdominal openings." □ 4. "Right after the procedure, the stoma may appear purple."

2. The goal of the surgery is to remove the aganglionic portion of the intestine. The remaining intestines should have normal innervation. Colostomies are used to relieve the obstruction and allow the remaining intestines to return to normal size. A temporary loop or double-barreled colostomy has stomas for both the proximal and distal portion of the bowel. The final surgical repair is usually done when the infant is around 20 lb (9.1 kg). A new stoma is frequently swollen and bruised after surgery.

When assessing a 4-month-old infant diagnosed with possible intussusception, the nurse should expect the parent to relate which information about the infant's crying and episodes of pain? □ 1. constant accompanied by leg extension □ 2. intermittent with knees drawn to the chest □ 3. shrill during ingestion of solids □ 4. intermittent while being held in the mother's arms

2. The infant with intussusception experiences acute episodes of colic-like abdominal pain. Typically, the infant screams and draws the knees to the chest. Between these episodes of acute abdominal pain, the infant appears comfortable and normal. Feeding does not precipitate episodes of pain. Additionally, a 4-month-old infant typically would not be ingesting solid foods. Pain exhibited by crying that occurs when the infant is placed in a reclining position, as in the mother's arms, is not associated with intussusception. This type of cry may indicate that the infant wants attention, wants to be held, or needs to have a diaper change.

After completing diagnostic testing, the surgeon has scheduled a newborn with the diagnosis of an imperforate anus for surgery the next day. The infant's parents do not want the surgery to take place unless the infant has first been baptized. What should the nurse ask the parents? □ 1. "Are you worried your baby might die?" □ 2. "How can I arrange the baptism?" □ 3. "Do you want to speak with the social worker?" □ 4. "Would you prefer to wait for the surgery?"

2. The nurse should honor the parent's belief system and help arrange to have the infant baptized. This may be done through the hospital's chaplaincy department or by the family's clergy. The parents may indeed be worried that the infant may die during surgery. Having the infant baptized would help address the family's spiritual needs. At this time, there is an immediate need for chaplaincy, not social service. While surgery may be postponed briefly, the infant cannot begin feeding until an outlet for stool has been established. Therefore, it is not advisable to postpone the surgery for a prolonged period of time.

The mother of a toddler who has just been admitted with severe dehydration secondary to gastroenteritis says that she cannot stay with her child because she has to take care of her other children at home. Which of the responses by the nurse would be most appropriate? □ 1. "You really shouldn't leave right now. Your child is very sick." □ 2. "I understand, but feel free to visit or call anytime to see how your child is doing." □ 3. "It's really not necessary to stay with your child. We will take very good care of him." □ 4. "Can you find someone to stay with your children? Your child needs you here."

2. The nurse's best course of action would be to support the mother. This is best done by conveying understanding and encouraging the mother to visit or call. Telling the mother that she should not leave and that the child is very sick is critical and insensitive. Additionally, it implies guilt should the mother leave. Commenting that the child does not need anyone is not appropriate or true. Toddlers, in particular, need family members present because of the stresses associated with hospitalization. They experience separation anxiety, a normal aspect of development, and need constancy in their environment. Asking the mother to find someone else to stay with her children is inappropriate. The children at home also need the support of the mother and/or other family members to minimize the disruptions in family life resulting from the toddler's hospitalization and to maintain consistency.

Which behavior exhibited by the parent of an infant with pyloric stenosis should the nurse correctly interpret as a positive indication of parental coping? □ 1. telling the nurse that they have to get away for a while □ 2. discussing the infant's care realistically □ 3. repeatedly asking if their child is normal □ 4. exhibiting fear that they will disturb the infant

2. The parents' ability to verbalize the infant's care realistically indicates that they are working through their fears and concerns. This behavior demonstrates an understanding of the infant's condition and needs. Without further data, the fact that the parents have to get away could be interpreted as ineffective coping, possibly suggesting that they are unable to handle the situation. Continuing to ask about the child's general condition even after answers have been given does not suggest effective coping. The parents are demonstrating that they are unsure of themselves as parents or are hoping for positive information. Exhibiting fear that they will disturb the infant does not suggest effective coping. This behavior indicates that they are uncertain or lack knowledge about infants.

The nurse caring for a neonate with an anorectal malformation notes that the infant has not passed any stool per rectum but that the infant ' s urine contains meconium. The nurse can make which assumption? 1. The child likely has a low anorectal malformation. 2. The child likely has a high anorectal malformation. 3. The child will not need a colostomy. 4. This malformation will be corrected with a nonoperative rectal pull-through.

2. The presence of stool in the urine indicates that the anorectal malformation is high.

The nurse is caring for an infant with biliary atresia. The parents ask why the child is receiving cholestyramine. Which is the nurse ' s best response? 1. To lower the infant ' s cholesterol. 2. To relieve the infant ' s itching. 3. To help the infant gain weight. 4. To help feedings be absorbed in a more effi cient manner.

2. The primary reason cholestyramine is administered to the child with biliary atresia is to relieve pruritus.

The nurse is administering omeprazole (Prilosec) to a 3-month-old with gastroesophageal reflux (GER). The child ' s parents ask the nurse how the medication works. Which is the nurse ' s best response? 1. "Prilosec is a proton pump inhibitor that is commonly used for reflux in infants." 2. "Prilosec decreases stomach acid, so it will not be as irritating when your child spits up." 3. "Prilosec helps food move through the stomach quicker, so there will be less chance for refl ux." 4. "Prilosec relaxes the pressure of the lower esophageal sphincter."

2. This accurate description gives the parents information that is clear and concise.

A child with Hirschsprung's disease is to be discharged 1 or 2 days after a colostomy takedown surgery. After teaching the infant's parents about the overall effects of their infant's surgery, the nurse determines that the teaching has been effective when the parents make which statement? □ 1. "His abdomen will be large for a while." □ 2. "Toilet training may be difficult." □ 3. "We need to limit his intake of dairy products." □ 4. "We will give him vitamin supplements until he is an adolescent."

2. Toilet training is commonly more difficult for children who have undergone surgery for Hirschsprung's disease than it is for other children. This is because of the trauma to the area and the associated psychological implications. Abdominal distention is an early sign of infection, and therefore the parents need to report it to the health care provider (HCP) . Typically, dietary restrictions are not required, but fiber is encouraged. Usually, the infant is placed on an age-appropriate diet. Vitamin supplementation is not necessary if the infant's dietary intake is adequate.

When teaching the mother of an infant who has received a temporary colostomy for treatment of Hirschsprung's disease about how the stoma should normally appear, the nurse should include which description about the stoma's appearance in the teaching? □ 1. becoming dark brown in 2 months □ 2. staying deep red in color □ 3. changing to several shades of pink □ 4. turning almost purple in color

2. Typically, the stoma should remain deep red in color as long as the infant has the colostomy. A dark red to purplish color may indicate impaired circulation to the stoma.

Which finding would indicate that an infant with a tracheoesophageal fistula (TEF) most needs suctioning? □ 1. barking cough □ 2. substernal retractions □ 3. decreased activity level □ 4. increased respiratory rate

2. With a TEF, overflow of secretions into the larynx leads to laryngospasm. This obstruction to inspiration stimulates the strong contraction of accessory muscles of the thorax to assist the diaphragm in breathing. This produces substernal retractions. The laryngospasm that occurs with a TEF resolves quickly when secretions are removed from the oropharynx area. A barking cough is related to a relatively constant laryngeal narrowing, usually caused by edema seen with croup. It is not an indication of the need to suction. A decreased activity level and an increased respiratory rate in an infant with a TEF are usually the result of hypoxia, a relatively long-term and constant phenomenon in infants with a TEF.

When the nurse is developing the plan of care for an infant with a cleft lip before corrective surgery is performed, what should be a priority? □ 1. maintaining skin integrity in the oral cavity □ 2. using techniques to minimize crying □ 3. altering the usual method of feeding □ 4. preventing the infant from putting fingers in the mouth

3 Before corrective surgery for a cleft lip, the infant needs to consume formula or breast milk. Methods for feeding may need to be adjusted to fit the infant's needs because the infant with a cleft lip experiences a decreased ability to suck, which interferes with the infant's ability to compress the nipple. A special feeder may be used to feed the infant to ensure adequate caloric intake. Problems with infection and skin integrity in the mouth are uncommon because the areas of the defect are not open areas. Although crying may cause the infant to swallow more air because of the defect, crying poses no harm to the infant. There is no need to keep the infant's fingers out of the mouth preoperatively. The fingers will not harm the defect or cause an infection.

Which would the nurse expect to be included to make the diagnosis of celiac disease in a child? 1. Obtain complete blood count and serum electrolytes. 2. Obtain complete blood count and stool sample; keep child NPO. 3. Obtain stool sample and prepare child for jejunal biopsy. 4. Obtain complete blood count and serum electrolytes; monitor child ' s response to gluten-containing diet.

3. A stool sample for analysis of fat and a jejunal biopsy can confirm the diagnosis.

A child is diagnosed with chronic constipation that has been unresponsive to dietary and activity changes. Which pharmacological measure is most appropriate? 1. Natural supplements and herbs. 2. Stimulant laxative. 3. Osmotic agent. 4. Pharmacological measures are not used in pediatric constipation.

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

The nurse is caring for a 3-month-old being evaluated for possible Hirschsprung disease. His parents call the nurse and show her his diaper containing a large amount of mucus and bloody diarrhea. The nurse notes that the infant is irritable and his abdomen appears very distended. Which should be the nurse ' s next action? 1. Reassure the parents that this is an expected fi nding and not uncommon. 2. Call a code for a potential cardiac arrest and stay with the infant. 3. Immediately obtain all vital signs with a quick head-to-toe assessment. 4. Obtain a stool sample for occult blood.

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

Which finding would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload? □ 1. a drop in blood pressure □ 2. change to slow, deep respirations □ 3. auscultation of moist crackles □ 4. marked increase in urine output

3. An early sign of circulatory overload is moist rales or crackles heard when auscultating over the chest wall. Elevated blood pressure, engorged neck veins, a wide variation between fluid intake and output (with a higher intake than output), shortness of breath, increased respiratory rate, dyspnea, and cyanosis occur later.

When developing the plan of care for a school-age child with a suspected diagnosis of appendicitis who has severe abdominal pain, the nurse should expect to include which measure in the child's plan of care? □ 1. application of a heating pad □ 2. insertion of a rectal tube □ 3. application of an ice bag □ 4. administration of an intravenous narcotic

3. Application of an ice bag may help to relieve pain by decreasing circulation to the area. A heating pad is contraindicated because heat may increase circulation to the appendix, possibly leading to rupture. Rectal tubes are contraindicated because they stimulate bowel motility and can exacerbate abdominal pain. Also, they would be ineffective because accumulation of gas in the lower bowel is not likely to be the cause of the child's discomfort. Because narcotics can mask the child's symptoms, such as pain and discomfort, and they also decrease bowel motility, they are not given until after a definitive diagnosis has been made.

When developing the preoperative plan of care for an infant with Hirschsprung's disease, the nurse should include which intervention? □ 1. administering a tap water enema □ 2. inserting a gastrostomy tube □ 3. restricting oral intake to clear liquids □ 4. using povidone-iodine solution to prepare the perineum

3. Before intestinal surgery, dietary intake is limited to clear liquids for 24 to 48 hours. A clear liquid diet meets the child's fluid needs and avoids the formation of fecal material in the intestine. Typically, repeated saline enemas, not tap water enemas, are given to empty the bowel. Soapsuds enemas are contraindicated for infants, as are tap water enemas. A nasogastric tube may be inserted for gastric decompression. Insertion of a gastrostomy tube is outside the scope of nursing practice. Because the perineal area is not involved in the surgery, it does not need to be prepared.

The nurse is caring for a 9-month-old with diarrhea secondary to rotavirus. The child has not vomited and is mildly dehydrated. Which is likely to be included in the discharge teaching? 1. Administer loperamide (Imodium) as needed. 2. Administer bismuth subsalicylate (Kaopectate) as needed. 3. Continue breastfeeding per routine. 4. The infant may return to day care 24 hours after antibiotics have been started.

3. Breastfeeding is usually well tolerated and helps prevent death of intestinal villi and malabsorption.

An infant diagnosed with Hirschsprung's disease is scheduled to receive a temporary colostomy. When the nurse is initially discussing the diagnosis and treatment with the parents, which action by the nurse would be most appropriate? □ 1. assessing the adequacy of their coping skills □ 2. reassuring them that their child will be fine □ 3. encouraging them to ask questions □ 4. giving them printed material on the procedure

3. By encouraging parents to ask questions during information-sharing sessions, the nurse can clarify misconceptions and determine the parents' understanding of information. A better understanding of what is happening allows the parents to feel some control over the situation. Assessing the adequacy of the parents' coping skills is important but secondary to encouraging them to express their concerns. The questions they ask and their interactions with the nurse may provide clues to the adequacy of their coping skills. The nurse should never give false reassurance to parents. At this point, there is no way for the nurse to know whether the child will be fine. Written materials are appropriate for augmenting the nurse's verbal communication. However, these are secondary to encouraging questions.

When obtaining a history from the parents of a child diagnosed with diarrhea due to Salmonella, the nurse should ask the parents if the child has been exposed to which possible source of infection? □ 1. nonrefrigerated custard □ 2. a pet canary □ 3. undercooked eggs □ 4. unwashed fruit

3. Diarrhea related to Salmonella bacilli is commonly spread by raw or undercooked fowl and eggs, pet turtles, and kittens. Food poisoning caused by Staphylococcus species is commonly spread by inadequately cooked or refrigerated custards, cream fillings, or mayonnaise. Psittacosis, a respiratory illness, may be spread by canaries. Contaminated, unwashed fruit is associated with typhoid fever (caused by Salmonella typhi), a disorder rarely seen in the United States.

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

3. In most cases of intussusception in young children, an enema is successful in reducing the intussusception.

The parents of a 4-year-old ask the nurse how to manage their child ' s constipation. Select the nurse ' s best response. 1. "Add 2 ounces of apple or pear juice to the child ' s diet." 2. "Be sure your child eats a lot of fresh fruit such as apples and bananas." 3. "Encourage your child to drink more fl uids." 4. "Decrease bulky foods such as whole-grain breads and brown rice."

3. Increasing fl uid consumption helps to decrease the hardness of the stool.

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

3. Infants with pyloric stenosis are always hungry and often appear malnourished.

The nurse is caring for a 1-month-old term infant who experienced an anoxic episode at birth. The health-care team suspects that the infant is developing necrotizing enterocolitis (NEC). Which would the nurse expect to be included in the plan of care? 1. Immediately remove the feeding nasogastric tube (NGT) from the infant. 2. Obtain vital signs every 4 hours. 3. Prepare to administer antibiotics intravenously. 4. Change feedings to half-strength, administer slowly via a feeding pump.

3. Intravenous antibiotics are administered to prevent or treat sepsis.

The nurse is caring for a 3-month-old infant who has short bowel syndrome (SBS) and has been receiving parenteral nutrition (PN). The parents ask if their child will ever be able to eat. Which is the nurse ' s best response? 1. "Children with SBS are never able to eat and must receive all of their nutrition in intravenous form." 2. "You will have to start feeding your child because children cannot be on PN longer than 6 months." 3. "We will start feeding your child soon so that the bowel continues to receive stimulation." 4. "Your child will start receiving tube feedings soon but will never be able to eat by mouth."

3. It is important to begin feedings as soon as the bowel is healed so that it receives stimulation and does not atrophy.

The nurse is assisting another member of the health care team who is placing a peripherally inserted central catheter in a 10-year-old with peritonitis from a ruptured appendix. The family is present in the treatment room to support the child. The nurse observes that the other team member has contaminated a sterile glove. What should the nurse do next? □ 1. Discuss the incident with the team member after the event. □ 2. Report the incident to the nursing unit manager. □ 3. Tell the team member the glove is contaminated. □ 4. Ask the family to leave before confronting the team member.

3. It is the responsibility of all health care members to protect the client. The team member may honestly not have realized that the glove was contaminated. Therefore, the nurse needs to alert the team member to the situation. Waiting until after the procedure to address the problem puts the child at unnecessary risk for infection. Asking the parents to leave could invoke anxiety in both the child and the parents. Alerting the team member does not need to be confrontational. If done with a calm approach, the result is most likely to be gratitude instead of embarrassment.

The nurse is caring for a 5-year-old who has just returned from having an appendectomy. Which is the optimal way to manage pain? 1. Intravenous morphine as needed. 2. Liquid acetaminophen (Tylenol) with codeine as needed. 3. Morphine administered through a PCA pump. 4. Intramuscular morphine as needed.

3. Morphine administered through a PCA pump offers the child control over managing pain. The PCA pump also has the benefi t of offering a basal rate as well as an as-needed rate for optimal pain management.

A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The health care provider (HCP) has prescribed IV fluids of dextrose water with sodium and potassium. The baby's admission potassium level is 3.4 mEq/L (3.4 mmol/L). What should the nurse do first? □ 1. Notify the HCP. □ 2. Administer the prescribed fluids. □ 3. Verify that the infant is urinating. □ 4. Have the potassium level redrawn.

3. Normal serum potassium levels are 3.5 to 4.5 mEq/L (3.5 to 4.5 mmol/L). Elevated potassium levels can cause life-threatening cardiac arrhythmias. The nurse must verify that the client has the ability to clear potassium through urination before administering the drug. Infants with pyloric stenosis frequently have low potassium levels due to vomiting. A level of 3.4 mEq/L (3.4 mmol/L) is not unexpected and should be corrected with the prescribed fluids. The lab value does not need to be redrawn as the findings are consistent with the infant's condition.

The parent of a 5-year-old states that the child has been having diarrhea for 24 hours, vomited twice 2 hours ago, and now claims to be thirsty. The parent asks what to offer the child because the child is refusing Pedialyte. Which is the nurse ' s most appropriate response? 1. "You can offer clear diet soda such as Sprite and ginger ale." 2. "Pedialyte is really the best thing for your child, who, if thirsty enough, will eventually drink it." 3. "Pedialyte is really the best thing for your child. Allow your child some choice in the way to take it by offering small amounts in a spoon, medicine cup, or syringe." 4. "It really does not matter what your child drinks as long as it is kept down. Try offering small amounts of fl uids in medicine cups."

3. Pedialyte is the fi rst choice, as recommended by the American Academy of Pediatrics. Offering the child appropriate choices may allow the child to feel empowered and less likely to refuse the Pedialyte. Small, frequent amounts are usually better tolerated.

A parent of a 7-year-old child with Hirschsprung's disease and chronic constipation asks about increasing dietary fiber in the child's diet. Which food could the nurse recommend? □ 1. fruit juice □ 2. white bread □ 3. popcorn □ 4. pancakes

3. Popcorn is high in fiber. Foods high in fiber help the bowels move. Constipation may be managed initially with increased fiber and fluids. White bread, fruit juice, and pancakes are foods that are not high in fiber.

The nurse is caring for a 2-year-old child who was admitted to the pediatric unit for moderate dehydration due to vomiting and diarrhea. The child is restless with periods of irritability. The child is afebrile with a heart rate of 148 and a blood pressure of 90/42. Baseline laboratory tests reveal the following: Na 152, Cl 119, and glucose 115. The parents state that the child has not urinated in 12 hours. After establishing a saline lock, the nurse reviews the physician ' s orders. Which order should the nurse question? 1. Administer a saline bolus of 10 mL/kg, which may be repeated if the child does not urinate. 2. Recheck serum electrolytes in 12 hours. 3. After the saline bolus, begin maintenance fl uids of D5 ¼ NS with 10 mEq KCl/L. 4. Give clear liquid diet as tolerated.

3. Potassium is contraindicated because the child has not yet urinated. Potassium is not added to the maintenance fl uid until kidney function has been verifi ed.

The nurse works with the health care team to establish a policy regarding sleep positions for infants with gastroesophageal reflux. What information should the nurse search for first? □ 1. policies from other hospitals □ 2. data from retrospective studies □ 3. published national standards □ 4. expert opinions

3. Published national standards are based on the best evidence and, when available, should serve as the foundation for nursing unit policies. Policies from other hospitals may or may not be evidence based. Retrospective studies and expert opinions should only be used to form policy when data from experimental studies or national standards are not available.

The nurse is caring for an infant with pyloric stenosis. The parent asks if any future children will likely have pyloric stenosis. Which is the nurse ' s best response? 1. "You seem worried; would you like to discuss your concerns?" 2. "It is very rare for a family to have more than one child with pyloric stenosis." 3. "Pyloric stenosis can run in families. It is more common among males." 4. "Although there can be a genetic link, it is very unusual for girls to have pyloric stenosis."

3. Pyloric stenosis can run in families, and it is more common in males.

The nurse is caring for a 4-month-old with gastroesophageal refl ux (GER). The infant is due to receive rantadine (Zantac). Based on the medication ' s mechanism of action, when should this medication be administered? 1. Immediately before a feeding. 2. 30 minutes after the feeding. 3. 30 minutes before the feeding. 4. At bedtime.

3. Rantadine (Zantac) decreases gastric acid secretion and should be administered 30 minutes before a feeding.

On a home visit following discharge from the hospital after treatment for severe gastroenteritis, the parent tells the nurse that a toddler answers "No!" and is difficult to manage. After discussing this further with the parent, the nurse explains that the child's behavior is most likely the result of which factor? □ 1. beginning leadership skills □ 2. inherited personality trait □ 3. expression of individuality □ 4. usual lack of interest in everything

3. The "no" behavior demonstrated by a toddler is typical of this age group as the child attempts to be self-assertive as an individual. The negativism does not demonstrate an inherited personality trait or disinterest. Rather, it reflects the developmental task of establishing autonomy. The toddler is attempting to exert control over the environment. It is too early to assess leadership qualities in a toddler.

Which finding would most likely alert the nurse to the possibility that a preschooler is experiencing moderate dehydration? □ 1. deep, rapid respirations □ 2. diaphoresis □ 3. absence of tear formation □ 4. decreased urine specific gravity

3. The absence of tears is typically found when moderate dehydration is observed as the body attempts to conserve fluids. Other typical findings associated with moderate dehydration include a dry mouth, sunken eyes, poor skin turgor, and an increased pulse rate. Deep, rapid respirations are associated with severe dehydration. Decreased perspiration, not diaphoresis, would be seen with moderate dehydration. The specific gravity of urine increases with decreased output in the presence of dehydration.

A 4-month-old has had vomiting and diarrhea for 24 hours. The infant is fussy, and the anterior fontanel is sunken. The nurse notes the infant does not produce tears when crying. Which task will help confi rm the diagnosis of dehydration? 1. Urinalysis obtained by bagged specimen. 2. Urinalysis obtained by sterile catheterization. 3. Analysis of serum electrolytes. 4. Analysis of cerebrospinal fl uid.

3. The analysis of serum electrolytes offers the most information and assists with the diagnosis of dehydration.

The nurse is giving discharge instructions to the parent of a 1-month-old infant with tracheoesophageal fi stula and a gastrostomy tube (GT). The nurse knows the mother understands the discharge teaching when she states: 1. "I will give my baby feedings through the GT but place liquid medications in the corner of the mouth to be absorbed." 2. "I will fl ush the GT with 2 ounces of water after each feeding to prevent the GT from clogging." 3. "I will clean the area around the GT every day." 4. "I will place petroleum jelly around the GT if any redness develops."

3. The area around the GT should be cleaned daily to prevent an infection.

The nurse is caring for a newborn with an anorectal malformation and a colostomy. The nurse knows that more education is needed when the infant ' s parent states which of the following? 1. "I will make sure the stoma is red." 2. "There should not be any discharge or irritation around the outside of the stoma." 3. "I will keep a bag attached to avoid the contents of the small intestine coming in contact with the baby ' s skin." 4. "As my baby grows, a pattern will develop over time, and there should be predictable bowel movements."

3. The colostomy contains stool from the large intestine; an ileostomy contains the very irritating stool from the small intestine.

The parents report that their 1-day-old is drooling and having choking episodes with excessive amounts of mucus and color changes, especially during feedings. The nurse should contact the health care provider (HCP) to further assess the baby and request which prescription? □ 1. a lactation consultation □ 2. an arterial blood gas □ 3. an X-ray for gastric tube placement □ 4. a serum blood glucose

3. The drooling and excessive mucus production is highly suggestive of a tracheoesophageal fistula (TEF). The initial diagnosis is made when a gastric tube cannot be passed to the stomach. A lactation consult would be warranted only after determining feedings were safe to continue. While cyanosis can be a sign of sepsis and hypoglycemia, the cyanosis is most likely related to the excessive secretions and airway patency. A blood gas may be needed, but only after ruling out a TEF.

A nurse is caring for a 10-month-old, weighing 8 kg, who was admitted for dehydration. The infant has an IV of D5W 0.45% normal saline infusing at the maintenance rate of 100 mL/kg/day for children weighing 10 kg or less. The infant has vomited 5 times in the last 3 hours and has had no wet diapers in the last 8 hours. The nurse informs the health care provider (HCP). Which prescription should the nurse question? □ 1. Increase the intravenous fluids to 45 mL/h for 24 hours. □ 2. Keep NPO while vomiting persists. □ 3. Administer a 10 mL/kg fluid bolus of dextrose 25%. □ 4. Maintain strict intake and output, weighing all diapers.

3. The infant is in need of a fluid bolus. A fluid bolus should consist of an isotonic fluid such as normal saline or lactated Ringer's. Dextrose 25% is not an appropriate bolus for dehydrated children because it could cause a fluid shift that may result in cerebral edema and death; thus, the nurse should question the prescription. D5W0.45% normal saline is an appropriate IV fluid for infants. The rate is 1.5 times maintenance for this child and is appropriate for the first 24 hours if the child is dehydrated. Once hydration is adequate, the infant's IV rate should be reduced to a maintenance rate. Vomiting is persistent, so it is appropriate for the child to be NPO. Strict I and O is an appropriate prescription for all dehydrated children.

The father of a neonate scheduled for gastrointestinal surgery asks the nurse how newborns respond to painful stimuli. What is the nurse's best response? □ 1. "Newborns cry and cannot be distracted to stop crying." □ 2. "When faced with a pain, newborns try to roll away from it." □ 3. "Newborns typically move their whole body in response to pain." □ 4. "Pain causes the newborn to withdraw the affected part."

3. The neonate responds to pain with total body movement and brief, loud crying that ceases with distraction. After the age of 6 months, an infant reacts to pain with intense physical resistance and tries to escape by rolling away. A toddler reacts to pain by withdrawing the affected part.

After teaching the parents of an infant diagnosed with Hirschsprung's disease, the nurse determines that the parents understand the diagnosis when the parent makes which statement? □ 1. "There are congenital polyps obstructing the colon." □ 2. "A section of the colon is constricted." □ 3. "The nerves at the end of the large colon are missing." □ 4. "There is weakened area in the colon that is inflamed.

3. The primary defect in Hirschsprung's disease is an absence of autonomic parasympathetic ganglion cells in the distal portion of the colon. Thus, the nerves at the end of the large colon are missing. Constipation is caused by decreased peristalsis, not a physical obstruction like polyps. The colon typically enlarges giving rise to the name "megacolon" versus being constricted. Weakened areas of the colon are associated with diverticulosis. Absence of a rectal opening refers to an imperforate anus. A tube between the trachea and esophagus refers to a tracheoesophageal fistula. Presence of a tight muscle below the stomach refers to pyloric stenosis.

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

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

The mother of a newborn asks the nurse why the infant has to nurse so frequently. Which is the best response? 1. Formula tends to be more calorically dense, and formula-fed babies require fewer feedings than breastfed babies. 2. The newborn ' s stomach capacity is small, and peristalsis is slow. 3. The newborn ' s stomach capacity is small, and peristalsis is more rapid than in older children. 4. Breastfed babies tend to take longer to complete a feeding than formula-fed babies.

3. The small-stomach capacity and rapid movement of fl uid through the digestive system account for the need for small, frequent feedings.

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

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

A 4-week-old infant admitted with the diagnosis of hypertrophic pyloric stenosis presents with a history of vomiting. The nurse should anticipate that the infant's vomitus would contain gastric contents and which other body substances? □ 1. bile and streaks of blood □ 2. mucus and stool □ 3. mucus and streaks of blood □ 4. stool and bile

3. The vomitus of an infant with hypertrophic pyloric stenosis contains gastric contents, mucus, and streaks of blood. The vomitus does not contain bile or stool because the pyloric constriction is proximal to the ampulla of Vater.

The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant? 1. Diarrhea 2. Projectile vomiting 3. Regurgitation of feedings 4. Foul-smelling ribbon-like stools

4 Rationale: Hirschsprung's disease is a congenital anomaly also known as congenital aganglionosis or aganglionic megacolon. It occurs as the result of an absence 1000of ganglion cells in the rectum and other areas of the affected intestine. Chronic constipation beginning in the first month of life and resulting in pellet-like or ribbonlike stools that are foul-smelling is a clinical manifestation of this disorder. Delayed passage or absence of meconium stool in the neonatal period is also a sign. Bowel obstruction, especially in the neonatal period; abdominal pain and distention; and failure to thrive are also clinical manifestations. Options 1, 2, and 3 are not associated specifically with this disorder.

Which should the nurse include in the plan of care to decrease symptoms of gastroesophageal refl ux (GER) in a 2-month-old? Select all that apply. 1. Place the infant in an infant seat immediately after feedings. 2. Place the infant in the prone position immediately after feeding to decrease the risk of aspiration. 3. Encourage the parents not to worry because most infants outgrow GER within the fi rst year of life. 4. Encourage the parents to hold the infant in an upright position for 30 minutes following a feeding. 5. Suggest that the parents burp the infant after every 1-2 ounces consumed.

4, 5. 4. Keeping the infant in an upright position is the best way to decrease the symptoms of GER. The infant can also be placed in the supine position with the head of the crib elevated. A harness can be used to keep the child from sliding down. 5. Burping the infant frequently may help decrease spitting up by expelling air from the stomach more often.

When teaching the parent of an infant with Hirschsprung's disease who received a temporary colostomy about the types of foods the infant will be able to eat, which diet would the nurse recommend? □ 1. high-fiber diet □ 2. low-fat diet □ 3. high-residue diet □ 4. regular diet

4. A regular diet would be recommended for the child with a colostomy; no special diet is needed. A high-fiber diet is not necessary. Fat is necessary for brain growth in the first year of life. A high-residue diet would result in bulkier stools and increased gas production, which will collect in the colostomy bag. Therefore, a high-residue diet is not indicated.

More education about necrotizing enterocolitis (NEC) is needed in a nursing in-service when one of the participants states: 1. "Encouraging the mother to pump her milk for the feedings helps prevent NEC." 2. "Some sources state that the occurrence of NEC has increased because so many preterm infants are surviving." 3. "When signs of sepsis appear, the infant will likely deteriorate quickly." 4. "NEC occurs only in preemies and low-birth-weight infants."

4. Although much more common in preterm and low-birth-weight infants, NEC is also seen in term infants as well.

Which finding would be most important in an 8-month-old infant admitted with severe diarrhea? □ 1. bowel sounds every 5 seconds □ 2. pale yellow urine □ 3. normal skin elasticity □ 4. depressed anterior fontanelle

4. An infant with severe diarrhea will experience some degree of dehydration. In an 8-month-old child, the anterior fontanelle has not closed. Therefore, a depressed anterior fontanelle would be an important finding. Additionally, the infant would exhibit dry mucous membranes, lethargy, hyperactive bowel sounds, dark urine, and sunken eyeballs. Skin turgor would be decreased or delayed (e.g., slow to return when pinched). Bowel sounds every 5 seconds would not be considered abnormal for an infant.

The nurse is caring for a 14-year-old with celiac disease. The nurse knows that the patient understands the diet instructions by ordering which of the following meals? 1. Eggs, bacon, rye toast, and lactose-free milk. 2. Pancakes, orange juice, and sausage links. 3. Oat cereal, breakfast pastry, and nonfat skim milk. 4. Cheese, banana slices, rice cakes, and whole milk.

4. Cheese, banana slices, rice cakes, and whole milk do not contain gluten.

When performing discharge teaching with the parents of a neonate who has successfully undergone surgery to repair a low anorectal anomaly, which parent statement about the child's prognosis indicates teaching has been successful? □ 1. "My child will need to wear protective pads until puberty." □ 2. "My child will need extra fluids to prevent constipation." □ 3. "My child will probably always need a high-fiber diet." □ 4. "My child has a good chance of being potty trained."

4. Children who undergo surgical correction for low anorectal anomalies as infants usually are continent. Fecal continence can be expected after successful correction of anal membrane atresia. Therefore, this child probably has a good chance of being potty trained and will not need to wear protective pads. Extra fluids and a high-fiber diet are not required to prevent constipation. Children with high anorectal anomalies may or may not achieve continence.

A 6-month-old has had a pyloromyotomy to correct a pyloric stenosis. Three days after surgery, the parents have placed their infant in his own infant seat. What should the nurse do? 1. Reposition the infant to the left side. □ 2. Ask the parents to put the infant back in his crib. □ 3. Remind the parents that the infant cannot use a pacifier now. □ 4. Tell the parents they have positioned their infant correctly.

4. Following pyloromyotomy, the infant should be positioned with the head elevated and slightly on the right side to promote gastric emptying; the parents have positioned their infant correctly. The infant should be positioned on the right side, not the left side. When the child is in a crib, the head can be elevated, and the infant can be propped on the right side. The infant can use a pacifier if needed.

Immediately after the first oral feeding after corrective surgery for pyloric stenosis, a 4-week-old infant is fussy and restless. Which action would be most appropriate at this time? □ 1. Encourage the parents to hold the infant. □ 2. Hang a mobile over the infant's crib. □ 3. Give the infant more to eat. □ 4. Give the infant a pacifier to suck on.

4. Giving the infant a pacifier would help meet nonnutritive sucking needs and ensure oral gratification. Additionally, sucking aids in calming the infant. Holding the infant to decrease fussiness and restlessness is more effective in an older infant. Also, the reason for the infant's fussiness needs to be explored. Hanging a mobile over the crib frequently does not decrease fussiness. After surgery to correct pyloric stenosis, feeding the infant more formula would lead to vomiting, putting additional stress on the operative site.

The nurse is to receive a 4-year-old from the recovery room after an appendectomy. The parents have not seen the child since surgery and ask what to expect. Which is the nurse ' s best response? 1. "Your child will be very sleepy, have an intravenous line in the hand, and have a nasal tube to help drain the stomach. If your child needs pain medication, it will be given intravenously." 2. "Your child will be very sleepy, have an intravenous line in the hand, and have white stockings to help prevent blood clots. If your child needs pain medication, we will give it intravenously or provide a liquid to swallow." 3. "Your child will be wide awake and will have an intravenous line in the hand. If your child needs pain medication, we will give it intravenously or provide a liquid to swallow." 4. "Your child will be very sleepy and have an intravenous line in the hand. If your child needs pain medication, we will give it intravenously."

4. In the immediate postoperative period, the child is usually sleepy but can be roused. The child usually has an intravenous line for hydration and pain medication.

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

4. Intussusception with peritonitis is a surgical emergency, so preparing the infant for surgery is the nurse ' s top priority.

The nurse receives a call from the parent of a 10-month-old who has vomited three times in the past 8 hours. The parent describes the baby as playful and wanting to drink. The parent asks the nurse what to give the child. Select the nurse ' s best response. 1. "Replace the next feeding with regular water, and see if that is better tolerated." 2. "Do not allow your baby to eat any solids; give half the normal formula feeding, and see if that is better tolerated." 3. "Do not let your baby eat or drink anything for 24 hours to give the stomach a chance to rest." 4. "Give your child ½ ounce of Pedialyte every 10 minutes. If vomiting continues, wait an hour, and then repeat what you previously gave."

4. Offering small amounts of clear liquids is usually well tolerated. If the child vomits, make NPO for an hour to allow the stomach to rest and then restart fl uids. The child in this scenario is described as playful and therefore does not appear to be at risk for dehydration.

Which would be an appropriate activity for the nurse to recommend to the parent of a preschooler just diagnosed with acute hepatitis? 1. Climbing in a "playscape." 2. Kicking a ball. 3. Playing video games in bed. 4. Playing with puzzles in bed.

4. Playing with puzzles is a developmentally appropriate activity for a preschooler on bedrest.

After undergoing surgical correction of pyloric stenosis, an infant is returned to the room in stable condition. While standing by the crib, the mother says, "Perhaps if I had brought my baby to the hospital sooner, the surgery could have been avoided." What is the nurse's best response? □ 1. "Surgery is the most effective treatment for pyloric stenosis." □ 2. "Try not to worry; your baby will be fine." □ 3. "Do you feel that this problem indicates that you are not a good mother?" □ 4. "Do you think that earlier hospitalization could have avoided surgery?"

4. Restating or rephrasing a mother's response provides the opportunity for clarification and validation. It also helps to focus on what the mother is saying and address her concerns and feelings. Although surgery is the most effective treatment for pyloric stenosis, stating this ignores the mother's feelings and does not give her an opportunity to express them. Telling the mother not to worry also ignores the mother's feelings. Additionally, this type of statement gives the mother premature reassurance, which may turn out to be false. Asking the mother if she thinks the problem indicates that she is not a good mother implies such an idea. It does not allow her to express her concerns and feelings and therefore is not a therapeutic response.

The parent of a newborn asks, "Will my baby spit out the formula if it is too hot or too cold?" Which is the nurse's best response? 1. "Babies have a tendency to reject hot fluids but not cold fluids, which could result in abdominal discomfort." 2. "Babies have a tendency to reject cold fluids but not hot fluids, which could result in esophageal burns." 3. "Your baby would most likely spit out formula that was too hot, but your baby could swallow some of it, which could result in a burn." 4. "Your baby is too young to be physically capable of spitting out fluids and will automatically swallow anything."

4. Swallowing is a refl ex in infants younger than 6 weeks. TEST-TAKING HINT: Swallowing is a refl ex that is present until the age of 6 weeks. The test taker should eliminate answers 1, 2, and 3 because they suggest that the infant is capable of selectively rejecting fl uids.

The nurse is caring for an 8-week-old male who has just been diagnosed with Hirschsprung disease. The parents ask what they should expect. Which is the nurse ' s best response? 1. "It is really an easy disease to manage. Most children are placed on stool softeners to help with constipation until it resolves." 2. "A permanent stool diversion, called a colostomy, will be placed by the surgeon to bypass the narrowed area." 3. "Daily bowel irrigations will help your child maintain regular bowel habits." 4. "Although your child will require surgery, there are different ways to manage the disease, depending on how much bowel is involved."

4. The aganglionic portion needs to be removed. Although most children have a temporary colostomy placed, many infants are able to bypass the colostomy and have the bowel immediately reattached.

A 10-year-old is being evaluated for possible appendicitis and complains of nausea and sharp abdominal pain in the right lower quadrant. An abdominal ultrasound is scheduled, and a blood count has been obtained. The child vomits, fi nds the pain relieved, and calls the nurse. Which should be the nurse ' s next action? 1. Cancel the ultrasound and obtain an order for oral ondansetron (Zofran). 2. Cancel the ultrasound and prepare to administer an intravenous bolus. 3. Prepare for the probable discharge of the patient. 4. Immediately notify the health-care provider of the child ' s status.

4. The health-care provider should be notifi ed immediately, because a sudden change or loss of pain often indicates a perforated appendix.

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

4. The infant should be taken from the mother and placed in the crib where the nurse can assess the baby. Oxygen should be administered immediately, and vital signs should be obtained.

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

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

After surgery to repair a tracheoesophageal fistula, an infant receives gastrostomy tube feedings. The nurse continues holding the infant for about 15 minutes after the feeding primarily to help accomplish what need? □ 1. Promote intestinal peristalsis. □ 2. Prevent regurgitation of formula. □ 3. Relieve pressure on the surgical site. □ 4. Associate eating with a pleasurable experience.

4. The nurse can help meet the psychological needs of an infant being fed through a gastrostomy tube by rocking the infant after a feeding. The infant soon learns to associate eating with a pleasurable experience and learns to trust the caregiver. Rocking the infant will not promote peristalsis or prevent regurgitation. Holding the baby will not relieve pressure on the surgical site. However, holding the child right after feeding promotes comfort and pleasure.

A typically developing preschool child is experiencing pain after an appendectomy. Which data collection tool is the most appropriate for the nurse to use to assess the pain? □ 1. visual analog scale □ 2. FLACC scale □ 3. numerical pain scale □ 4. FACES pain rating scale

4. The nurse should use the FACES pain rating scale for children aged 3 or older. The visual analog and numerical scales are used preferred with adults or older children who count well. The faces, legs, activity, cry, consolability (FLACC) scale is a behavioral scale that is appropriate for very small children or nonverbal children.

An expectant mother asks the nurse if her new baby will have an umbilical hernia. The nurse bases the response on the fact that it occurs: 1. More often in large infants. 2. In white infants more often than in African American infants. 3. Twice as often in male infants. 4. More often in premature infants.

4. Umbilical hernias occur more often in premature infants.

A newborn who had a surgical repair of a tracheoesophageal fistula (TEF) is started on oral feedings. What should the nurse include in the teaching plan for the parent about oral feedings? □ 1. They are better tolerated when larger but less frequent feedings are offered. □ 2. They should be offered on a feeding schedule to help the infant accept the feedings more readily. □ 3. They are best accepted by the infant when offered by the same nurse or by the infant's parent. □ 4. They are best planned in conjunction with observations of the infant's behavioral cues.

4. When initiating oral feedings after surgical repair of a TEF, it is best to follow a plan of care in conjunction with observation of the infant's needs and behavior known as cue-based feedings. When sticking to a strict feeding schedule that overlooks the infant's readiness, plans are likely to be unsatisfactory and are more likely to meet the nurse's needs rather than the infant's needs. After a surgical procedure, infants initially tolerate small amounts of fluids offered more frequently better than larger amounts offered less often. Smaller amounts cause less bloating as the infant becomes used to feeding again. Although infants accept feedings more readily from their mother or from someone who feeds the infant repeatedly, the priority is to meet the infant's nutritional needs based on the infant's behavior.

The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet? 1. Rice 2. Oatmeal 3. Rye toast 4. Wheat bread

Answer: 1 Rationale: Celiac disease also is known as gluten enteropathy or celiac sprue and refers to intolerance to gluten, the protein component of wheat, barley, rye, and oats. The important factor to remember is that all wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn, rice, or millet. Vitamin supplements—especially the fat-soluble vitamins, iron, and folic acid—may be needed to correct deficiencies. Dietary restrictions are likely to be lifelong.

Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select all that apply. 1. Providing a low-fat, well-balanced diet. 2. Teaching the child effective hand-washing techniques. 3. Scheduling playtime in the playroom with other children. 4. Notifying the primary health care provider (PHCP) if jaundice is present. 5. Instructing the parents to avoid administering medications unless prescribed. 6. Arranging for indefinite home schooling because the child will not be able to return to school.

Answer: 1, 2, 5 Rationale: Hepatitis is an acute or chronic inflammation of the liver that may be caused by a virus, a medication reaction, or another disease process. Because hepatitis can be viral, standard precautions should be instituted in the hospital. The child should be discouraged from sharing toys, so playtime in the playroom with other children is not part of the plan of care. The child will be allowed to return to school 1 week after the onset of jaundice, so indefinite home schooling would not need to be arranged. Jaundice is an expected finding with hepatitis and would not warrant notification of the PHCP. Provision of a low-fat, well-balanced diet is recommended. Parents are cautioned about administering any medication to the child, because normal doses of many medications may become dangerous owing to the liver's inability to detoxify and excrete them. Hand washing is the most effective measure for control of hepatitis in any setting, and effective hand washing can prevent the immunocompromised child from contracting an opportunistic type of infection.

The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parent about the child's symptoms? 1. Watery diarrhea 2. Projectile vomiting 3. Increased urine output 4. Vomiting large amounts of bile

Answer: 2 Rationale: In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. Clinical manifestations of pyloric stenosis include projectile vomiting, irritability, hunger and crying, constipation, and signs of dehydration, including a decrease in urine output.

An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time? 1. Prone position 2. On the stomach 3. Left lateral position 4. Right lateral position

Answer: 3 Rationale: A cleft lip is a congenital anomaly that occurs as a result of failure of soft tissue or bony structure to fuse during embryonic development. After cleft lip repair, the nurse avoids positioning an infant on the side of the repair or in the prone position, because these positions can cause rubbing of the surgical site on the mattress. The nurse positions the infant on the side lateral to the repair or on the back upright and positions the infant to prevent airway obstruction by secretions, blood, or the tongue. From the options provided, placing the infant on the left side immediately after surgery is best to prevent the risk of aspiration if the infant vomits.

The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder? 1. Bile-stained fecal emesis 2. The passage of currant jelly-like stools 3. Failure to pass meconium stool in the first 24 hours after birth 4. Sausage-shaped mass palpated in the upper right abdominal quadrant

Answer: 3 Rationale: Imperforate anus is the incomplete development or absence of the anus in its normal position in the perineum. During the newborn assessment, this defect should be identified easily on sight. However, a rectal thermometer or tube may be necessary to determine patency if meconium is not passed in the first 24 hours after birth. Other assessment findings include absence or stenosis of the anal rectal canal, presence of an anal membrane, and an external fistula to the perineum. Options 1, 2, and 4 are findings noted in intussusception.

The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record? 1. Incessant crying 2. Coughing at nighttime 3. Choking with feedings 4. Severe projectile vomiting

Answer: 3 Rationale: In esophageal atresia and tracheoesophageal fistula, the esophagus terminates before it reaches the stomach, ending in a blind pouch, and a fistula is present that forms an unnatural connection with the trachea. Any child who exhibits the "3 Cs"—coughing and choking with feedings and unexplained cyanosis—should be suspected to have tracheoesophageal fistula. Options 1, 2, and 4 are not specifically associated with tracheoesophageal fistula.

A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem? 1. Diarrhea 2. Metabolic acidosis 3. Metabolic alkalosis 4. Hyperactive bowel sounds

Answer: 3 Rationale: Vomiting causes the loss of hydrochloric acid and subsequent metabolic alkalosis. Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate. Diarrhea might or might not accompany vomiting. Hyperactive bowel sounds are not associated with vomiting.

The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux disease. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis? 1. Provide less frequent, larger feedings. 2. Burp the infant less frequently during feedings. 3. Thin the feedings by adding water to the formula. 4. Thicken the feedings by adding rice cereal to the formula.

Answer: 4 Rationale: Gastroesophageal reflux is backflow of gastric contents into the esophagus as a result of relaxation or incompetence of the lower esophageal or cardiac sphincter. Small, more frequent feedings with frequent burping often are prescribed in the treatment of gastroesophageal reflux. Feedings thickened with rice cereal may reduce episodes of emesis. If thickened formula is used, cross-cutting of the nipple may be required.

The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented? 1. Watery diarrhea 2. Ribbon-like stools 3. Profuse projectile vomiting 4. Bright red blood and mucus in the stools

Answer: 4 Rationale: Intussusception is a telescoping of 1 portion of the bowel into another. The condition results in an obstruction to the passage of intestinal contents. A child with intussusception typically has severe abdominal pain that is crampy and intermittent, causing the child to draw in the knees to the chest. Vomiting may be present, but is not projectile. Bright red blood and mucus are passed through the rectum and commonly are described as currant jelly-like stools. Watery diarrhea and ribbon-like stools are not manifestations of this disorder.