NCLEX Child Health- GI

A child is admitted to the pediatric unit with a diagnosis of acute gastroenteritis. The nurse monitors the child for signs of hypovolemic shock as a result of fluid and electrolyte losses that have occurred in the child. Which finding would indicate the presence of compensated shock?

Capillary refill time greater than 2 seconds.

A newborn infant is diagnosed with esophageal atresia. Which assessment finding should the nurse typically find in this client?

Continuous drooling

The parents of a 6-month-old report that the infant has been screaming and drawing the knees up to the chest and has passed stools mixed with blood and mucus that are jelly-like. The nurse recognizes these manifestations as indicative of which disorder?

Intussusception

A child is admitted to the pediatric unit with a diagnosis of celiac disease. Based on this diagnosis, the nurse expects that the child's stools will have which characteristic?

Malodorous

The nurse is caring for a child following cleft palate repair. To reduce the risk of aspiration after feeding the child, what is the best position for the nurse to place the child in?

Right side in semi-fowler's

The nurse is preparing to care for a child with acute gastroenteritis who is having diarrhea. What actions are appropriate in the care of the child? Select all that apply.

1. Send stools to the lab for culture 2. Monitor I&O hourly 3. Weigh the diaper after each bowel movement.

The mother of a child with celiac disease asks the nurse how long a special diet is necessary. The nurse provides which instruction to the mother to promote dietary compliance?

A gluten-free diet will need to be followed for life.

The nurse is caring for a child after an inguinal hernia repair. Which finding should indicate that the surgical repair was effective?

Absence of inguinal swelling when the infant is crying

A child with Hirschsprung's disease is beginning to exhibit signs/symptoms of dehydration. Which nursing intervention should be effective in stabilizing the child's hydration status prior to surgery?

Administering intravenous fluids and electrolytes as prescribed.

The nurse is reviewing the laboratory results of an infant suspected of having hypertrophic pyloric stenosis. Which result should the nurse most likely expect to note?

An elevated blood pH

An infant who has been diagnosed with acute chalasia is admitted to the hospital. During the nursing history, the mother tells the nurse, "I am concerned that I am somehow causing my infant to vomit after feeding her." Considering this statement, which problem should the nurse identify for the mother?

An unrealistic expectation of self.

The nurse is providing home care instructions to the parents of an infant who had surgical repair of an inguinal hernia. What should the nurse instruct the parents to do to prevent infection at the surgical site?

Change the diapers as soon as they become damp

The nurse is assigned to care for a child with a diagnosis of irritable bowel syndrome. The nurse reviews the child's medical record, expecting to note documentation of which assessment finding?

Diffuse abdominal pain unrelated to meals or activity.

The nurse develops a plan of care for a 1-month-old infant hospitalized for intussusception. Which nursing measure would be most effective to provide psychosocial support for the parent-child relationship?

Encourage the parents to room-in with their infant.

An infant who has pyloric stenosis is admitted to the hospital. The nurse reviews the admission assessment data and should expect to note which finding documented?

Forceful and projectile vomiting

The nurse is providing dietary instructions to the mother of a child with lactose intolerance. Which food item should the nurse instruct the mother to include in the child's diet?

Green leafy vegetables.

The nurse is performing an assessment on a child, and the parents report the presence of ribbon-like and foul-smelling stools, episodes of constipation since birth, and poor feeding habits. The nurse notes a distended abdomen. Based on these data, the nurse analyzes these signs/symptoms as indicative of which condition?

Hirschsprung's Disease

The mother explains to the nurse that her infant is vomiting after meals, and it is now becoming more frequent and forceful. During the assessment, the nurse notes visible peristaltic waves moving from left to right across the infant's abdomen. On the basis of these findings, which condition should the nurse suspect?

Hypertrophic Pyloric Stenosis

Which comment made by the parents of a male infant who will have a surgical repair of a hernia would require follow-up assessment by the nurse?

I don't know if he will be able to father a child when he grows up.

The clinic nurse provides dietary instructions to the mother of a 3-year-old child who was seen in the health care clinic for a complaint of mild diarrhea. Which statement by the mother indicates a need for further teaching?

I should avoid giving my child foods that are high in starch such as mashed potatoes and noodles.

The nurse instructs a mother on measures to take to reduce the incidence of gastroesophageal reflux disease (GERD) in a child. Which statement by the mother indicates a need for further teaching?

I will buy bottle nipples that have smaller holes for my child.

A preschooler with a history of cleft palate repair comes to the clinic for a routine well-child checkup. To determine whether this child is experiencing a long-term effect of cleft palate, which question should the nurse ask the parent?

Is the child unresponsive when given directions?

A child is diagnosed with celiac disease, and the mother asks the nurse about the cause of the disease. Which response by the nurse is appropriate?

It is the inability to digest fully the protein part of wheat, barley, rye and oats.

The clinic nurse is assessing a child who was brought to the clinic complaining of severe abdominal pain. The child is lying on the examining table with the knees pulled up toward the chest. Following review of the laboratory studies, the child is suspected of having acute appendicitis. What area of the abdomen should the nurse assess by palpation?

Midway between the right anterior superior iliac crest and the umbilicus.

Mineral oil has been prescribed for a child with encopresis. Which instruction should the nurse provide to the mother regarding the administration of the mineral oil?

Mix the mineral oil with chilled chocolate milk before administration.

To meet the preoperative needs of an infant who has pyloric stenosis, how should the nurse plan to intervene?

Monitor intravenous infusion strictly, monitor intake and output, and weigh diapers.

The nurse is planning care for an infant who has a diagnosis of hypertrophic pyloric stenosis and is scheduled for surgery. Which intervention should the nurse include into the plan of care to meet the infant's preoperative needs?

Monitor the IV infusion, intake, output and weight

The nurse is caring for a child with celiac disease. According to the mother, the child has experienced a poor appetite for the past few months. Which assessment finding supports this diagnosis?

Muscle wasting in buttocks and extremities.

A mother brings her 5-month-old daughter into the pediatrician's office with complaints that the child has vomiting during feedings. The mother also states that the child is sometimes very fussy. What would be the initial action by the nurse?

Obtain a complete history of the child's feeding habits.

When obtaining a history from parents of a 5-month-old child suspected of having intussusception, which assessment area should be most important for the nurse to address?

Pattern of abdominal pain.

The clinic nurse is providing home care instructions to the mother of a 3-year-old child with a diagnosis of vomiting and diarrhea caused by gastroenteritis. What should the nurse instruct the mother to give the child to help to maintain hydration status?

Pedialyte

The nurse is caring for an infant after pyloromyotomy performed to treat hypertrophic pyloric stenosis. In which position should the nurse place the infant after surgery?

Prone with the head of the bed elevated

The nurse is providing home-care instructions to a mother of a 12-month-old infant with mild diarrhea. Which should the nurse instruct the mother to do?

Provide an increased intake of water

The parents of an infant with pyloric stenosis ask the nurse why their child developed the disorder. Which statement should the nurse make to the parents?

Pyloric stenosis is caused by a structural problem and there really isn't anything you could have done to prevent it.

The nurse is teaching the parents of a child with celiac disease about dietary measures. In the teaching plan, the nurse should instruct the parents to take which appropriate measure?

Read all label ingredients carefully to avoid hidden sources of gluten.

The nurse is caring for a 9-month-old child after cleft palate repair and has applied elbow restraints to the child. The mother visits the child and asks the nurse to remove the restraints. Which is the appropriate nursing action?

Remove a restraint from one extremity

The nurse is caring for a child with intussusception. During care, the child passes a normal brown stool. Which action should the nurse take at this time?

Report the passage of a normal brown stool to the health care provider.

Which data should the nurse expect to obtain during the admission assessment of a child with the diagnosis of irritable bowel syndrome?

Reports of diffuse abdominal pain unrelated to meals of activity.

The nurse is assigned to care for an infant on the first postoperative day after a surgical repair of a cleft lip. Which nursing intervention is appropriate when caring for this child's surgical incision?

Rinse the incision with sterile water after feeding.

The nurse is assisting in the care of a child who underwent a surgical repair of a cleft lip the previous day. Which safe nursing intervention should the nurse implement when caring for the surgical incision?

Rinse the incision with sterile water after using prescribed solution.

After a cleft lip repair, the nurse instructs the parents about cleaning of the lip repair site. The nurse should plan to use which solution when demonstrating this procedure to the parents?

Sterile water

A home care nurse visits a child with a diagnosis of celiac disease. Which finding best indicates that a gluten-free diet is being maintained and has been effective?

The child is free of diarrhea.

The home care nurse visits a child with a diagnosis of hepatitis B who is being cared for at home. On assessment, the nurse notes that the child's weight has increased and the child is lethargic and confused. Based on these assessment findings, how should the nurse interpret these data?

The child must be seen by the health care provider.

After instructing a mother on how to feed an infant who has a cleft palate, the nurse observes the mother feeding the child. Which observation indicates a need for further teaching?

The mother often interrupts the feeding to check for choking.

The nurse observes a mother providing care to a hospitalized infant who has diarrhea. Which observation should require the nurse's immediate intervention and indicates a need for further teaching to the mother?

The mother uses a damp washcloth to clean the buttocks after a stool.

A child with a diagnosis of umbilical hernia has been scheduled for surgical repair in 2 weeks. The clinic nurse instructs the parents about the signs/symptoms of possible hernia strangulation. The nurse tells the parents that which sign/symptom would require health care provider notification?

Vomiting

A 4-week-old infant is brought to the pediatrician for the first well-baby appointment. The mother is concerned because the child has been vomiting after meals, and the vomiting is becoming more frequent and forceful. The health care provider suspects pyloric stenosis. Which clinical manifestation should the nurse expect to note documented in the infant's record?

Vomitus contains sour undigested food but no bile, the infant is constipated, and visible peristaltic waves move from left to right across the abdomen.

The nurse is providing instructions to the parents of a child with a hernia regarding measures that will aid in reducing the hernia. Which statement by the parents should lead the nurse to determine that the parents understand these measures?

We will provide comfort measure to reduce any crying periods by our child.

A child with Hirschsprung's disease is scheduled for surgery, and a temporary colostomy is performed on the child. Postoperatively, the nurse provides instructions to the parents about colostomy care at home. Which statement by the parents indicates their understanding of the instructions?

We will report signs of skin breakdown.

The nurse provides dietary instruction to the parents of a child with a diagnosis of cystic fibrosis (CF). Which diet should the nurse instruct the parents to select?

High-protein foods

After hydrostatic reduction for intussusception, the nurse should expect to observe which effective response?

Passage of barium or water-soluble contrast with stools.

A child with a diagnosis of hepatitis B is being cared for at home. The mother of the child calls the health care clinic and tells the nurse that the jaundice seems to be worsening. Which response should the nurse make to the mother?

The jaundice my appear to get worse before it gets better.