PEDS: Prep-U Chapter 45: Nursing Care of a Family when a child has a Gastrointestinal Disorder

The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with Kwashiorkor. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of Kwashiorkor?

"It is important to increase the intake of protein for these children." Explanation: Kwashiorkor results from severe deficiency of protein with an adequate caloric intake. It accounts for most of the malnutrition in the world's children today. The highest incidence is in children 4 months to 5 years of age. Although strenuous efforts are being made around the world to prevent this condition, its causes are complex.

How will the nurse respond to parents who express regret that they did not seek care for their young child early enough to prevent perforation of the child's appendix?

"Symptoms are not always clear to any of us. Also the thin wall of the appendix in a child perforates readily." Explanation: The statement about the symptoms and the thin appendiceal wall in a young child are true and give the parents information as well as help to relieve guilt feelings. "Don't feel bad...." and "Everything will be OK..." offer false assurance without information. The statement about antibiotics is not true.

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

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

A nurse is teaching parents of an adolescent who developed salmonella-caused gastroenteritis. The nurse determines that the teaching was successful when the parents state which? Select all that apply.

"We will cook eggs well, for at least 3 minutes." "We will make sure to wash our hands well before preparing any foods." "We'll make sure that he avoids deli-prepared salads." Explanation: To prevent salmonella-caused gastroenteritis, appropriate measures include the following: cooking eggs, including cooking soft-boiled or poached eggs, for at least 3 minutes; avoiding soft cheeses such as feta but allowing processed cheeses such as cream cheese; making sure to wash hands well before preparing any food; preparing chicken last after preparing other foods; and avoiding delicatessen counter-prepared salads.

The nurse is determining maintenance fluid requirements for a child who weighs 25 kg. How much fluid would the child need per day?

1,600 mL Explanation: Using the following formula of 100 mL/kg for the first 10 kg, plus 50 mL/kg for the next 10 kg, and then 20 mL/kg for the remaining kg, the child would require (100 × 10) + (50 × 10) + (20 × 5) = 1,000 + 500 + 100 = 1,600 mL in 24 hours.

A child weighs 15 kg. How many milliliters of fluid per 24 hours does this child require? Record your answer using a whole number.

1250 Explanation: Fluid requirement is based on weight. A child weighing between 11-20 kg requires 1,000 ml + 50 ml/kg for each additional kilogram over 10 kg. 1,000 ml/kg + (5 × 50 ml/kg) = 1,000 ml/kg + 250 ml/kg = 1250 ml/kg

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

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

The nurse is providing care for a child who has been diagnosed with rickets. What is the nurse's priority intervention?

Administration of adequate vitamin D Explanation: Rickets results from inadequate vitamin D; supplements are necessary. There is no direct need to increase calorie, thiamine or protein intake.

The nurse is caring for an infant with a temporary ileostomy. As part of the plan of care, the nurse monitors for skin breakdown around the stoma. If redness occurs, what would be most appropriate to promote healing and prevent further skin breakdown?

Apply a barrier/healing cream or paste on the skin. Explanation: The nurse should use a barrier/healing cream or paste on the skin around the stoma to promote healing and prevent further skin breakdown. Diaper wipes that contain fragrance or alcohol can sting if used on nonintact skin and can worsen skin breakdown. The barrier wafer would be helpful, but does not address the skin breakdown.

The nurse completes a 1-month-old's feeding and sits the infant up to burp. The infant vomits back the feeding. Which is the nurse's primary concern?

Aspiration Explanation: The primary concern for the nurse is that the infant aspirates vomit into the lungs. Aspiration after vomiting may lead to respiratory concerns such as apnea and pneumonia. Nutritional deficiencies may occur if the vomiting continues. This is a concern but not the primary concern. Stomach irritation and stunted growth is not a typical concern at this time.

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

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

A nurse is providing care to a child who has had surgery for a ruptured appendix. Which of the following would alert the nurse to the development of peritonitis?

Boardlike abdomen Explanation: Signs of peritonitis include a boardlike abdomen, shallow respirations, and increased temperature. Right lower quadrant pain is associated with appendicitis.

The nurse recognizes that in the disorder referred to as rickets, the child has a lack of vitamin D. Because of the lack of vitamin D, the absorption of which of the following is decreased?

Calcium and phosphorus Explanation: Rickets, a disease affecting the growth and calcification of bones, is caused by a lack of vitamin D. The absorption of calcium and phosphorus is diminished because of the lack of vitamin D, which is needed to regulate the use of these minerals. The absorption of the other nutrients is not affected by the lack of vitamin D.

The nurse performs an abdominal assessment of an infant and observes a prominent venous pattern. The nurse documents the findings and anticipates that this is a sign of which?

Cirrhosis of the liver Explanation: Upon assessment, a prominent venous pattern may be seen in children with cirrhosis of the liver. Peristalsis may be visible in the thin, malnourished infant or in the infant with obstruction caused by pyloric stenosis.

In understanding the disease of marasmus when seen in children, the nurse recognizes that the disease is caused because of which of the following?

Deficiency of protein and calories Explanation: Marasmus is a deficiency in calories as well as protein. Scurvy is caused by inadequate intake of vitamin C, and anemia is caused by lack of iron. Excess calories add to the concern of obesity in children. Excess vitamin C is excreted, and it is unusual to have an excess of iron or protein in the diet of children; those nutrients are more often inadequate in children's diets.

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

Do not rub or put pressure on the abdomen. Explanation: The nurse would instruct the child/parent to not rub or put pressure on the abdomen as palpating an inflamed appendix may cause it to rupture. A child with appendicitis will be NPO for surgery and therefore not instructed to drink. Heat to the abdomen may also cause the inflamed appendix to rupture. Ice is not an effective intervention.

The nurse admits an infant who is nutritionally deprived. The infant is weak and seems somewhat uninterested in food. In developing the infant's plan of care, how often will the nurse most likely plan to feed this infant?

Every 2 or 3 hours Explanation: For the child who is nutritionally deprived, scheduling feedings every 2 or 3 hours is best because most weak babies can handle frequent, small feedings better than feedings every 4 hours. Feeding every hour would not give the weak child an adequate amount of time to rest and sleep between feedings.

The pH of blood is normally slightly acidic, ranging from 6.85 to 6.95.

False Explanation: The pH of blood is normally slightly alkaline, ranging from 7.35 to 7.45.

The parents of a child diagnosed with celiac disease ask the nurse what types of food they can offer their child. What recommendation would the nurse include in the teaching plan?

Fruit juice Explanation: For the child with celiac disease, foods containing gluten such as frozen yogurt, rye bread, and creamed vegetables should be avoided. Fruit juice would be an appropriate suggestion in a gluten-free diet.

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

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

The parents of a 6-week-old boy come to the clinic for evaluation because the infant has been vomiting. The parents report that the vomiting has been increasing in frequency and forcefulness over the last week. The mother says, "Sometimes, it seems like it just bursts out of his mouth." A diagnosis of hypertrophic pyloric stenosis is suspected. When performing the physical examination, what would the nurse most likely find?

Hard, moveable, olive-shaped mass in the right upper quadrant Explanation: With hypertrophic pyloric stenosis, a hard, moveable, olive-shaped mass would be palpated in the right upper quadrant. A sausage-shaped mass in the upper midabdomen would suggest intussusception. Tenderness over the McBurney point would be associated with appendicitis. Epigastric or umbilical pain would be associated with peptic ulcer disease.

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

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

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

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

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

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

A young child has presented to the pediatric unit with a swollen abdomen, edema, thin patchy hair, and irritability with growth retardation and muscle wasting. The nurse suspects a malnutrition disorder. The nurse identifies this child to most likely have which condition?

Kwashiorkor Explanation: The symptoms presented are classic signs of Kwasiorkor due to the protein deficiency.

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

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

A nurse is caring for a child who had a liver transplant earlier in the day. Which would the nurse include in the plan of care? Select all that apply.

Nasogastric tube care T-tube care Continuous cardiac monitoring Explanation: Care immediately following a liver transplant includes supine positioning for the first 24 hours to prevent cerebral emboli. A nasogastric tube is inserted during surgery and attached to low intermittent suction. So the nurse needs to provide nasogastric tube care. A T-tube is inserted into the bile duct for drainage. Serum glucose levels are monitored every hour, and continuous cardiac monitoring is necessary to detect hyperkalemia.

The nurse is discussing the disease known as pellagra. This disease is due to a deficiency in which of the following?

Niacin Explanation: Niacin insufficiency in the diet causes a disease known as pellagra, which presents with GI and neurologic symptoms. A diet deficient in thiamine causes beriberi. Lack of vitamin C causes scurvy, and lack of iron causes anemia.

Which type of nutrition does the nurse anticipate initiating when an infant with gastroenteritis and dehydration begins solid foods?

Oral rehydration solutions Explanation: The nurse is correct to anticipate that oral rehydration fluids such as Pedialyte, Rehydralyte or Infalyte are initiated. Once the infant is able to tolerate the solution, either a half-strength formula or full strength formula will be considered. Typical clear liquids such as apple juice or broths are not part of the rehydration diet.

When examining the abdomen of a child, which technique would the nurse use last?

Palpation Explanation: Palpation should be the last part of the abdominal examination. Inspection, auscultation, and percussion should be done before palpation.

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

Persistent constipation Explanation: Congenital aganglionic megacolon, also called Hirschsprung disease, is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Prolonged bleeding is a manifestation of hemophilia. A chronic cough is noted in the child with cystic fibrosis. Irregular breathing occurs in children with seizures.

The incidence of vitamin D deficiency in the United States is less than in many countries. What is the most likely reason for this?

Some foods in the U.S. have been fortified with vitamin D. Explanation: Whole milk and evaporated milk fortified with 400 U of vitamin D per quart are available throughout the United States, which decreases the vitamin D deficiency of children in the U.S. Vitamin D can be administered orally in the form of fish liver oil or synthetic vitamin, but this is not common for children in the U.S. Water is not fortified with vitamin D, and some communities in the U.S. do not get adequate sunshine to meet vitamin D needs.

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

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

The nurse is collecting data on a child who has been nutritionally deprived. The nurse notes that the child is irritable and listless. The foster caregiver reports that the child says she is not hungry and has been vomiting. It is discovered that the child has beriberi. This disease is due to a deficiency in which of the following?

Thiamine Explanation: Children whose diets are deficient in thiamine exhibit irritability, listlessness, loss of appetite, and vomiting. A severe lack of thiamine in the diet causes beriberi, a disease characterized by cardiac and neurologic symptoms. Beriberi does not occur when balanced diets that include whole grains are eaten. Lack of vitamin C causes scurvy, lack of niacin causes pellagra, and lack of iron causes anemia.

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

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

A 7-year-old boy has experienced severe diarrhea resulting from an intestinal virus. The nurse is concerned that the child will develop an acid-base imbalance. Which of the following blood test results would indicate that the boy is experiencing metabolic acidosis?

pH of 7.25, HCO3 of 20 mEq/L Explanation: The pH of blood is normally slightly alkaline, ranging from 7.35 to 7.45. The level of bicarbonate (HCO3) in arterial blood is normally 22 to 26 mEq/L. Metabolic acidosis results from diarrhea as a great deal of sodium is lost with stool. With metabolic acidosis, arterial blood gas analysis will reveal a decreased pH (under 7.35) and a low HCO3 value (near or below 22 mEq/L). With metabolic alkalosis, pH will be elevated (near or above 7.45), and HCO3 level will be near or above 28 mEq/L.

A group of students are reviewing information about fluid balance and losses in children in comparison to adults. The students demonstrate a need for additional review when they state that:

the infant's immature kidneys have a tendency to overconcentrate urine. Explanation: The young infant's renal immaturity does not allow the kidneys to concentrate urine as well as in older children and adults, placing them at risk for dehydration or overhydration. Children do have a proportionately greater amount of body water than adults, and fever is important in promoting insensible fluid losses in infants and children because children become febrile more readily and their fevers are higher than those in adults. Children also experience a higher metabolic rate, which accounts for increased insensible fluid losses and increased need for water for excretory function.

The nurse is doing teaching with the caregivers of toddler and preschool aged-children. One of the caregivers tells the group that her child had diarrhea and she was told that it was caused by giardiasis. Which statement made by the caregiver indicates the most likely situation in which the child contacted the disorder?

"He attends a day care center four days a week while I am at work." Explanation: Giardiasis is caused by the protozoan parasite Giardia lamblia. It is a common cause of diarrhea and is prevalent in children who attend day care centers and other types of residential facilities; it may be found in contaminated mountain streams or pools frequented by diapered infants. Bubble baths can lead to urinary tract infections, but are not the cause of Giardiasis infestations. It is not related to either C. Diff or pinworms.

The school nurse is working with a 10-year-old girl with recurrent abdominal pain. The girl's teacher has been less than understanding about the frequent absences and trips to the nurse's office. How should the nurse respond?

"The pain she is having is real." Explanation: It is important to educate the teacher that this recurrent abdominal pain is a true pain that the child feels and it is not "in her mind." Telling the teacher not to add to the family's stress or that the family is working toward improvement does not teach. The nurse must have the permission of the family to discuss the girl's medication.

The novice nurse is discussing the diagnosis of intussusception with a group of peers. What statement demonstrates the nurse's appropriate understanding regarding this disorder?

"The stools of the infant are called currant jelly stools and consist of blood and mucus." Explanation: In the child with intussusception, the stools consist of blood and mucus, thereby earning the name currant jelly stools. There is a telescoping of the upper portion of the bowel slipping over the lower portion. The condition occurs more often in boys than in girls and the highest incidence occurs in infants between the ages of 4 and 10 months. The infant who previously appeared healthy and happy suddenly becomes pale, cries out sharply, and draws up the legs in a severe colicky spasm of pain. This spasm may last for several minutes, after which the infant relaxes and appears well until the next episode, which may occur 5, 10, or 20 minutes later.

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

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

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

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

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

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

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

Crohn disease Explanation: Intermittent abdominal pain, anorexia, diarrhea, growth delays, and perianal lesions are characteristic of Crohn disease. In ulcerative colitis, the pain is continuous with bloody diarrhea, but anorexia, weight loss, and growth delay are mild. Food poisoning is an acute condition and may result in weight loss but not growth delays. In Hirschsprung disease the bowel lacks nerve innervation, so it lacks motility and fecal output.

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

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

A 10-year-old girl with an intestinal virus has been vomiting and has become dehydrated. She says she is mildly thirsty, her skin turgor is poor, and her skin is dry and cool. Her serum sodium level is normal. The nurse recognizes that she has which type of dehydration?

Isotonic Explanation: Signs and symptoms of isotonic dehydration include the following: mild thirst; poor skin turgor; dry, cool skin; decreased urine output; irritability; and a normal sodium level. Signs and symptoms of hypotonic dehydration include the following: moderate thirst; very poor skin turgor; clammy, cool skin; decreased urine output; lethargy; and a reduced sodium level. Signs and symptoms of hypertonic dehydration include the following: extreme thirst; moderate skin turgor; warm skin; decreased urine output; extreme lethargy; and an increased sodium level. Acidotic is not a type of dehydration.

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

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

A child with chronic hepatitis develops cirrhosis. Which would the nurse indicate as a progression of the disease on shift hand-off? Select all that apply.

Pallor Abdominal distention Prominent abdominal veins Petechaie and bruising Explanation: Children with cirrhosis have large, fatty stools and symptoms of hemorrhage such as bruising from decreased clotting ability. Their abdomens are distended, and abdominal veins appear prominent and tortuous. Anemia is also present, often manifested by pallor.

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

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

Which congenital condition leads to the infant being hungry, irritable, losing weight and rapidly becoming dehydrated with the potential of metabolic alkalosis?

Pyloric stenosis Explanation: This clinical picture includes assessment findings consistent with pyloric stenosis. Theses infants are very hungry yet once they eat, regurgitate the feeding leading to the infant being irritable, losing weight, and decoming dehydrated. The infant with aganglionic megacolon has a main symptom of constipation. Intussusception is a painful telescoping of the bowel. Colic has similar symptoms but primarily includes bouts of abdominal pain.

The nurse is caring for an infant immediately after a pyloromyotomy surgery has been performed to treat pyloric stenosis. The infant's parents are understandably anxious about their child. Given the situation, what is the most appropriate way for the nurse to position the infant during the anesthesia recovery period?

Support him and place him on his side. Explanation: Postoperatively the child should be placed on his side to prevent aspiration of mucus or vomitus, especially during the anesthesia recovery period. After fully waking from the surgery, he can be held by a family caregiver in a position that does not interfere with IV infusions and is comforting to both caregiver and child.

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

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

A child with severe diarrhea cannot drink and requires intravenous rehydration. After beginning the therapy, the nurse determines that potassium can be added to the intravenous fluid because which of the following has occurred?

The child has voided. Explanation: Potassium cannot be given until it is established that the child is not in renal failure. Giving potassium IV when the body has no outlet for excessive potassium can lead to excessively high potassium levels and heart block. Before initial IV fluid is changed to a potassium solution, the nurse must be certain that the infant or child has voided—proof that the kidneys are functioning.

The nurse is caring for a child admitted with acute appendicitis. Prior to the child going to the operating room for emergency surgery, which nursing intervention would the nurse most likely perform?

The nurse encourages the child and family to express their fears. Explanation: The child facing an emergency surgery may be extremely frightened and also may be in considerable pain. The family caregiver may be apprehensive about impending surgery. Explain to the child and the family what is happening and why, and encourage them to express their fears. Laxatives and enemas are contraindicated because they increase peristalsis, which increases the possibility of rupturing an inflamed appendix. Oral fluids are withheld and the child is NPO before surgery. A heating pad is contraindicated because of the danger of rupture of the appendix.

Which type of nutrition would the nurse expect to administer to a preterm infant who was born at 34 weeks' gestation and has developed necrotizing enterocolitis (NEC)?

Total parenteral nutrition (TPN) Explanation: Total parenteral nutrition (TPN) should be administered to preterm infants with necrotizing enterocolitis. In NEC, there is acute inflammation of the bowel associated with ischemia. This can lead to bowel necrosis and perforation. Preterm infants are at higher risk of developing NEC, due to gastric immaturity and an increased risk of infections. When NEC is detected in the preterm infant, TPN should be administered and enteral feeding should be withheld until the condition stabilizes. Gavage feeding and trophic feeding are different forms of enteral feeding given to preterm infants, but not to those having NEC. Oral breastfeeding should also be withheld in NEC. NEC is treated with IV fluids, antibiotics, blood transfusion and surgical resection of the segment.

A nurse caring for patients in a free women's health clinic counsels women on infant nutrition and formula preparation. Which of the following is an appropriate guideline for the proper use of infant formula?

Use a soy-based formula for infants with lactase deficiency. Explanation: Soy-based infant formulas use a soy protein instead of cow's milk protein and are designed for infants with lactase deficiency, galactosemia, or allergy to cow's milk protein. The amount of water used to mix the formula may be varied to alter the caloric and nutrient density of infant formulas. Mixing powdered infant formula with oral electrolyte or rehydrating solutions can cause electrolyte imbalance. Normal caloric density of infant formula is 20 calories per ounce.

Nurses will need to teach the parents of the infant being treated for Hirschsprung disease (aganglionic megacolon) to

care for a temporary colostomy. Explanation: The aganglionic portion of the infant's colon will need to be removed. In most cases, bowel is allowed to rest and recoil for a period of time, necessitating a temporary colostomy. Later the colostomy can be closed and the two ends of the intestine rejoined. Thickening feedings will not relieve the colon distention and obstruction with stool. Pacifiers may be used and are soothing. Monitoring heart rate should not be necessary.

Pyloric stenosis has been diagnosed in a 3-week-old male infant who has frequent vomiting after feedings. An important preoperative nursing intervention is:

maintaining NPO status while restoring hydration and electrolyte balance. Explanation: NPO is needed to avoid vomiting and aspiration during surgery. Hydration and electrolyte replacement is often needed because of the history of vomiting, which causes loss of both fluid and electrolytes. Feeding when surgery is pending would not be safe. Hourly abdominal assessment would not yield needed information and would further disturb the infant. Pain is not the source of crying. The infant is hungry.