NCLEX Clinical Week 3 - Pediatrics Gastrointestinal
The nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely manifestation of this condition in the medical record? 1.Incessant crying 2.Coughing at nighttime 3.Choking with feedings 4.Severe projectile vomiting
3.Choking with feedings Any child who exhibits the "3 Cs"—coughing and choking during feedings and unexplained cyanosis—should be suspected of having TEF. Options 1, 2, and 4 are not specifically associated with TEF.
An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. Which is the best position to place this infant at this time? 1.A flat position 2.A prone position 3.On his or her left side 4.On his or her right side
3.On his or her left side After the repair of a cleft lip, the infant should be positioned on the side opposite to the repair to prevent contact of the suture lines with the bed linens. In this case it is best to place the infant on the left side. Additionally, the flat or prone position can result in aspiration if the infant vomits.
The nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided? 1.Rectal 2.Axillary 3.Electronic 4.Tympanic
1.Rectal Rectal temperature measurements should be avoided if diarrhea is present. The use of a rectal thermometer can stimulate peristalsis and cause more diarrhea. Axillary or tympanic measurements of temperature would be acceptable. Most measurements are performed via electronic devices.
The nurse reinforces home care instructions to the parents of an infant following surgical intervention for imperforate anus and tells the parents about the procedure for anal dilation. Which statement by the parents indicates the need for further teaching? 1."I need to use a water-soluble lubricant." 2."I will insert a glycerin suppository before the dilation." 3."I will insert the dilator no more than 1 to 2 cm into the anus." 4."I need to use only dilators supplied by the primary health care provider."
2."I will insert a glycerin suppository before the dilation." Following this surgery, anal dilation at home by the parents is necessary to achieve and maintain bowel patency. Inserting a glycerin suppository before dilation is not a component of this procedure. Options 1, 3, and 4 are accurate instructions and will prevent damage to the rectal mucosa.
The nurse is caring for an 18-month-old child who has been vomiting. Which is the appropriate position to place the child during naps and sleep time? 1.A supine position 2.A side-lying position 3.Prone, with the head elevated 4.Prone, with the face turned to the side
2.A side-lying position The vomiting child should be placed in an upright or side-lying position to prevent aspiration. Options 1, 3, and 4 will place the child at risk for aspiration if vomiting occurs.
The nurse is monitoring for fluid volume deficit in an infant who is vomiting and having diarrhea. The nurse weighs the infant's diaper after each voiding and stool and carefully calculates fluid volume based on which knowledge? 1.Each gram of diaper weight is equivalent to 0.5 mL of urine. 2.Each gram of diaper weight is equivalent to 1 mL of urine. 3.Each gram of diaper weight is equivalent to 2 mL of urine. 4.Each gram of diaper weight is equivalent to 2.5 mL of urine.
2.Each gram of diaper weight is equivalent to 1 mL of urine. When monitoring for fluid volume deficit, the nurse should weigh the infant's diaper after each voiding and stool. Each gram of diaper weight is equivalent to 1 mL of urine. Therefore, options 1, 3, and 4 are incorrect.
A mother brings her 5-month-old daughter into the pediatrician's office with complaints that the child has been vomiting during feedings. The mother also states that the child is sometimes very fussy. Which should be the nurse's initial action? 1.Assess the child's growth status. 2.Obtain a complete history of the child's feeding habits. 3.Assess whether any other children in the family have had the same problem. 4.Explain to the mother that the primary health care provider will prescribe a barium swallow and upper gastrointestinal (GI) series.
2.Obtain a complete history of the child's feeding habits. In most situations, a complete history and physical examination of the child is the initial step in diagnosing gastroesophageal reflux disease. The child's feeding habits will give the nurse an indicator of the growth status. The child is weighed and measured after the initial interview is completed with the parent. Hereditary factors are not the priority. Further diagnostic studies may be prescribed but only after a complete history is obtained.
The nurse is reinforcing instructions to the parents of a child with a hernia regarding measures that will promote reducing the hernia. The nurse determines that the parents understand these measures if they make which statement? 1."We will encourage our child to cough every few hours on a daily basis." 2."We will make sure that our child participates in physical activity every day." 3."We will provide comfort measures to reduce any crying periods by our child." 4."We will be sure to give our child a Fleet enema every day to prevent constipation."
3."We will provide comfort measures to reduce any crying periods by our child." A warm bath and comfort measures to reduce crying periods are all simple measures to promote reducing a hernia. Coughing and crying increase the strain on the hernia. Likewise, physical activities and enemas of any type would increase the strain on the hernia.
A 1-year-old child is diagnosed with intussusception. The mother of the child asks the nurse to describe the disorder. The nurse should base the response on which description of this disorder? 1.An acute bowel obstruction 2.A condition that causes an acute inflammatory process in the bowel 3.A condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel 4.A condition in which a distal segment of the bowel prolapses into a proximal segment of the bowel
3.A condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel Rationale: Intussusception occurs when a proximal segment of the bowel prolapses into a distal segment of the bowel. It is a common cause of acute bowel obstruction in infants and young children. It is not an inflammatory process.
The nurse is collecting data on an infant with a diagnosis of suspected Hirschsprung's disease. Which question to the mother will most specifically elicit information regarding this disorder? 1."Does your infant have diarrhea?" 2."Is your infant constantly vomiting?" 3."Does your infant constantly spit up feedings?" 4."Does your infant have foul-smelling, ribbon-like stools?"
4."Does your infant have foul-smelling, ribbon-like stools?" Chronic constipation, beginning in the first month of life and resulting in pellet-like or ribbon-like stools that are foul smelling, is a clinical manifestation of Hirschsprung's disease. Delayed passage or absence of meconium stool in the neonatal period is the cardinal sign. Bowel obstruction, especially in the neonatal period, abdominal pain and distention, and failure to thrive are also signs and symptoms. Options 1, 2, and 3 are not specific signs and symptoms of this disorder.
A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces instructions to the parents about the signs of possible incarcerated hernia. The nurse tells the parents that which manifestation requires primary health care provider (PHCP) notification by the parents? 1.Pain 2.Diarrhea 3.Constipation 4.Increased flatus
1.Pain The parents of a child with a hernia need to be instructed about the signs of an incarcerated hernia. These signs include irritability, tenderness at the site of the hernia, anorexia, abdominal distension, and difficulty defecating. The parents should be instructed to contact the PHCP immediately if an incarcerated hernia is suspected. These signs may lead to a complete intestinal obstruction and gangrene. Diarrhea, increased flatus and constipation are not associated with an incarcerated hernia.
A mother of an infant diagnosed with Hirschsprung's disease asks the nurse about the disorder. The nurse plans to base the response on which information? 1.It is a complete small intestinal obstruction. 2.It is a congenital aganglionosis or megacolon. 3.It is a severe inflammation of the gastrointestinal tract. 4.It is a condition that causes the pyloric valve to remain open.
2.It is a congenital aganglionosis or megacolon. Hirschsprung's disease, also known as "congenital aganglionosis" or "megacolon," is the result of an absence of ganglion cells in the rectum and to varying degrees upward in the colon. Options 1, 3, and 4 are incorrect.
The nurse is assisting in admitting to the hospital a 4-month-old infant with a diagnosis of vomiting and dehydration. The nurse assists in developing a plan of care for the infant and suggests which position for the infant? 1.Prone position 2.Side-lying position 3.Modified Trendelenburg's position 4.Infant car seat with the head of the seat in a flat position
2.Side-lying position The vomiting infant or child should be placed in an upright or side-lying position to prevent aspiration. The positions identified in options 1, 3, and 4 will increase the risk of aspiration if vomiting occurs.
A 2-year-old child is diagnosed with constipation due to encopresis. Which description is a characteristic of this disorder? 1.Anorexia in the evening 2.Incomplete development of the anus 3.The infrequent and difficult passage of dry stools 4.Invagination of a section of the intestine into the distal bowel
3.The infrequent and difficult passage of dry stools Constipation can affect any child at any time, although its incidence peaks at ages 2 to 3 years. Option 3 describes encopresis, which can develop as a result of constipation and is one of the major concerns regarding constipation. Encopresis generally affects preschool and school-age children. Option 1 is not associated with encopresis. Option 2 describes imperforate anus, which is diagnosed in the neonatal period. Option 4 describes intussusception, which is the most common cause of bowel obstruction in children ages 3 months to 6 years.
The nurse is admitting a child with a diagnosis of lactose intolerance. Which finding does the nurse expect to note? 1.Frothy stools 2.Foul-smelling ribbon stools 3.Profuse, watery diarrhea and vomiting 4.Diffuse abdominal pain unrelated to meals or activity
1.Frothy stools Lactose intolerance causes frothy stools. Abdominal distention, crampy abdominal pain, and excessive flatus may also occur. Option 2 is a clinical manifestation of Hirschsprung's disease. Option 3 is a clinical manifestation of celiac disease. Option 4 is a symptom of irritable bowel syndrome.
The nurse prepares to administer a pancreatic enzyme powder to the child with cystic fibrosis (CF). Which food item should the nurse mix with the medication? 1.Tapioca 2.Applesauce 3.Hot oatmeal 4.Mashed potatoes
2.Applesauce Pancreatic enzyme powders are not to be mixed with hot foods or foods containing tapioca or other starches. Enzyme powder should be mixed with nonfat, nonprotein foods such as applesauce. Pancreatic enzymes are inactivated by heat and are partially degraded by gastric acids.
A 4-year-old child is hospitalized for severe gastroenteritis. The child is crying and clinging to the mother. The mother becomes very upset and is afraid to leave the child. Which nursing intervention would be most appropriate to alleviate the child's fears and the mother's anxiety? 1.Reassure the mother that the child will be fine after she leaves. 2.Ask the mother if she would like to stay overnight with the child. 3.Give the mother the telephone number of the pediatric unit, and tell the mother to call at any time. 4.Tell the mother to bring the child's favorite toys the next time she comes to the hospital to visit.
2.Ask the mother if she would like to stay overnight with the child. Although a 4-year-old may already be spending some time away from his or her parents at a day care center or preschool, illness adds a stressor that makes separation more difficult. The only option that addresses the mother's anxiety and alleviates the fears of the child is option 2. Options 1, 3, and 4 do not address the fears and anxieties of the mother and child.
The nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data should the nurse expect to note as having been documented in the child's record? 1.Watery diarrhea 2.Projectile vomiting 3.Increased urine output 4.Vomiting large amounts of bile
2.Projectile vomiting Signs and symptoms of pyloric stenosis include projectile, nonbilious vomiting; irritability; hunger and crying; constipation; and signs of dehydration, including a decrease in urine output.
The nurse is monitoring a newborn with a suspected diagnosis of imperforate anus. Which assessment finding is unassociated with this diagnosis? 1.The presence of stool in the urine 2.Failure to pass a rectal thermometer 3.The passage of currant jelly-like stool 4.Failure to pass meconium in the first 24 hours after birth
3. The passage of currant jelly-like stool During the newborn assessment, imperforate anus should be easily identified visually. However, a rectal thermometer or tube may be necessary to determine patency if meconium is not passed in the first 24 hours after birth. The presence of stool in the urine or vagina should be reported immediately as an indication of abnormal anorectal development. Currant jelly-like stool is not a symptom of this disorder.
The nurse is reviewing the health record of an infant with a diagnosis of gastroesophageal reflux. Which signs/symptoms of this disorder should the nurse expect to note documented in the record? 1.Excessive oral secretions 2.Bowel sounds heard over the chest 3.Hiccupping and spitting up after a meal 4.Coughing, wheezing, and short periods of apnea
3.Hiccupping and spitting up after a meal Clinical manifestations of all types of gastroesophageal reflux include vomiting (spitting up) after a meal, hiccupping, and recurrent otitis media related to pooled secretions in the nasopharynx during sleep. Option 1 is a clinical manifestation of esophageal atresia and tracheoesophageal fistula. Option 2 is a clinical manifestation of congenital diaphragmatic hernia. Option 4 is a clinical manifestation of hiatal hernia.
The nurse is caring for a child who is scheduled for an appendectomy. When the nurse reviews the primary health care provider's preoperative prescriptions, which should be questioned? 1.Administer a Fleet enema. 2.Maintain nothing per mouth (NPO) status. 3.Maintain intravenous (IV) fluids as prescribed. 4.Administer preoperative medication on call to the operating room
1.Administer a Fleet enema. In the preoperative period, enemas or laxatives should not be administered. No heat should be applied to the abdomen because this may increase the chance of perforation secondary to vasodilation. IV fluids would be started and the child would be NPO. Prescribed preoperative medications most likely would be administered on call to the operating room.
The nurse is caring for a 1-year-old child following a cleft palate repair. Which solution should the nurse use after feedings to cleanse the child's mouth? 1.Sterile water 2.Diluted hydrogen peroxide 3.A soft lemon glycerin swab 4.Half-strength povidone-iodine solution
1.Sterile water Following a cleft palate repair, the mouth is rinsed with water after feedings to clean the palate repair site. Rinsing food and residual sugars from the suture line reduces the risk of infection. Options 2, 3, and 4 are incorrect because the solutions identified in these options should not be used.
Dustin who was diagnosed with Hirschsprung's disease has a fever and watery explosive diarrhea. Which of the following would Nurse Joyce do first? 1. Administer an anti-diarrheal 2. Notify the physician immediately 3. Nothing-these findings are normal in Hirschsprungs 4. Monitor the child every 30 min
2. Notify the physician immediately For the child with Hirschsprung's disease, fever and explosive diarrhea indicate enterocolitis, a life-threatening situation. Therefore, the physician should be notified directly.
Will is being assessed by Nurse Lucas for possible intussusception; which of the following would be least likely to provide valuable information? 1. Abdominal Palpation 2. Pain Pattern 3. Family history 4. Stool inspection
3. Family History Because intussusception is not believed to have familial tendency, obtaining a family history would provide the least amount of information.
A child is diagnosed with intussusception. The nurse collects data on the child, knowing that which is a characteristic of this disorder? 1.The presence of fecal incontinence 2.Incomplete development of the anus 3.The infrequent and difficult passage of dry stools 4.Invagination of a section of the intestine into the distal bowel
4.Invagination of a section of the intestine into the distal bowel Intussusception is an invagination of a section of the intestine into the distal bowel. It is the most common cause of bowel obstruction in children age 3 months to 6 years. Option 1 describes encopresis. Option 2 describes imperforate anus, and this disorder is diagnosed in the neonatal period. Option 3 describes constipation. Constipation can affect any child at any time, although it peaks at ages 2 to 3 years. Encopresis generally affects preschool and school-age children.
The nurse is assisting a primary health care provider with an assessment of a child with a diagnosis of suspected appendicitis. In assessing the intensity and progression of the pain, the primary health care provider palpates the child at McBurney's point. What response does the nurse expect the child to have during the examination? 1.Pain in the upper right side 2.Pain when extending the leg 3.Pain when the right thigh is drawn up 4.Pain in the lower right side between the umbilicus and the iliac crest
4.Pain in the lower right side between the umbilicus and the iliac crest Pain in the lower right side, halfway between the umbilicus and the crest of the ileum at McBurney's point is the best known symptom of appendicitis. Extending the leg causes pain but is not the McBurney's point. The client may rest with the right thigh drawn up to relieve pain.
The nurse provides feeding instructions to a mother of an infant diagnosed with gastroesophageal reflux (GER). To assist in reducing the episodes of emesis, which instruction should the nurse provide the mother 1.Provide less frequent, larger feedings. 2.Burp 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.
4.Thicken the feedings by adding rice cereal to the formula. Small, more frequent feedings with frequent burping are often tried as the first line of treatment in gastroesophageal reflux. Feedings thickened with rice cereal may reduce episodes of emesis. However, thickened feedings do not affect reflux time. If thickened formula is prescribed, 1 to 3 teaspoons of rice cereal per ounce of formula is most commonly used and may require cross-cutting the nipple. Options 1, 2, and 3 are incorrect.
A child is diagnosed with lactose intolerance. The child's mother asks the nurse about the disease. Which statement is the appropriate nursing response? 1."It is the inability to tolerate sugar found in dairy products." 2."It results from the absence of ganglion cells in the rectum." 3."It results from increased bowel motility that leads to spasm and pain." 4."It is the inability to fully digest the protein part of wheat, barley, rye, and oats."
1."It is the inability to tolerate sugar found in dairy products." Lactose intolerance is the inability to tolerate lactose, the sugar found in dairy products. It results from absence or deficiency of lactase, an enzyme found in the secretions of the small intestine required for the digestion of lactose. Option 2 describes Hirschsprung's disease. Option 3 describes irritable bowel syndrome. Option 4 describes celiac disease.
The nurse is assigned to assist in caring for a newborn with a colostomy that was created during surgical intervention for imperforate anus. When the newborn returns from surgery, the nurse checks the stoma and notes that it is red and edematous. Which is the appropriate nursing intervention? 1.Elevate the buttocks. 2.Apply ice immediately. 3.Document the findings. 4.Notify the registered nurse immediately.
3.Document the findings. A fresh colostomy stoma will be red and edematous, but this will decrease with time. The colostomy site will then be pink without evidence of abnormal drainage, swelling, or skin breakdown. The nurse would document these findings because this is a normal expectation. Options 1, 2, and 4 are inappropriate interventions.
A newborn infant is diagnosed with gastroesophageal reflux (GER). The mother of the infant asks the nurse to explain the diagnosis. The nurse plans to base the response on which description of this disorder? 1.Gastric contents regurgitate back into the esophagus. 2.The esophagus terminates before it reaches the stomach. 3.Abdominal contents herniate through an opening of the diaphragm. 4.A portion of the stomach protrudes through the esophageal hiatus of the diaphragm.
1.Gastric contents regurgitate back into the esophagus. Gastroesophageal reflux is regurgitation of gastric contents back into the esophagus. Option 2 describes esophageal atresia. Option 3 describes a congenital diaphragmatic hernia. Option 4 describes a hiatal hernia
