Perry Ch 41 Practice Questions
Which should be the nurse's immediate action when a newborn begins to cough and choke and becomes cyanotic while feeding? a) Inform the physician of the situation b) Have the mother stoop feeding the infant and observe to see if the choking episode resolves on its own c) Immediately determine the infant's oxygen saturation, and have the mother stop feeding the infant d) Take the infant from the mother, and administer blow-by-oxygen while obtaining the infant's oxygen saturation
D 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 nurse is caring for an infant whose cleft lip was repaired. Important aspects of this infant's postoperative care include: a) Arm restraints b) Cleansing of suture line, supine and side-lying positions, and arm restraints c) Mouth irrigations, prone position, and cleansing of suture line d) Supine and side-lying positions, postural drainage, and arm restraints
B The suture line should be cleansed gently after feeding. The child should be positioned on back or side or in an infant seat. Elbows are restrained to prevent the child from accessing the operative site.
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? a) Reassure the parents that this is an expected finding and not uncommon b) Call a code for potential cardiac arrest, and stay w/ the infant c) Immediately obtain all vital signs w/ a quick head-to-toe assessment d) Obtain a stool sample for occult blood
C All vital signs need to be evaluated because the child w/ 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.
The nurse is caring for an infant newly diagnosed w/ Hirschsprung disease. What does the nurse understand about this infant's condition? a) There is a lack of peristalsis in the large intestine and an accumulation of bowel contents, leading to abdominal distention b) There is excessive peristalsis throughout the intestine, leading to abdominal distention c) There is a small-bowel obstruction, leading to ribbon-like stools d) There is inflammation throughout the large intestine, leading to accumulation of intestinal contents and abdominal distention
C 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.
What food choice by the parent of a 2 y/o child w/ celiac disease indicates a need for further teaching? a) Oatmeal b) Rice cake c) Corn muffin d) Meat patty
A The child with celiac disease is unable to fully digest gluten, the protein found in wheat, barley, rye, and oats. Oatmeal contains gluten and is not an appropriate food selection.
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. a) Right side-lying b) Left-side lying c) Supine d) Prone
C The supine position is preferred because there is decrease risk of the infant rubbing the suture line.
A young child is brought to the ED w/ severe dehydration secondary to acute diarrhea and vomiting. Therapeutic management of this child will begin with a) IV fluids b) ORS c) Clear liquids, 1-2oz at a time d) Administration of antidiarrheal medication
A IV fluids are initiated in children w/ severe dehydration.
How much fluid per day should a 3 year old that weighs 36 pounds get?
Answer: 1318 mL/day 36 lb / 2.2 kg = 16.36 kg 10 kg x 100 mL/kg = 1000 mL 6.36 kg x 50 mL/hr= 318 mL
Therapeutic management of most children w/ Hirschsprungs disease is primarily: a) Daily enemas b) Low-fiber diet c) Permanent colostomy d) Surgical removal of affected section of bowel
D Most children w/ Hirschprungs disease require surgical rather than medical management. Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter.
Caring for the newborn with a cleft lip and palate before surgical repair includes: a) Gastrostomy feedings b) Keeping the infant in near-horizontal position during feedings c) Allowing little or no sucking d) Providing satisfaction of sucking needs.
D Using special or modified nipples for feeding techniques helps to meet the infant's sucking needs.
A child is admitted to the hospital w/ diarrhea, vomiting, and dehydration. One week earlier, the child weighed 5.6 kg. On admission to the hospital, the child weighs 4.9 kg. What percentage weight loss has the child experienced. Calculate to the tenths place.
Answer: 12.5% 5.6 kg previous weight - 4.9 kg new weight = 0.7 difference (0.7 / 5.6) x 100 = 0.125 x 100 = 12.5 % Subtract the most recent weight from the previous weight. Divide the difference by the previous weight. Multiply the result by 100.
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 mother about the child's symptoms? a) Watery diarrhea b) Projectile vomiting c) Increased urine output d) Vomiting large amounts of bile
B Clinical manifestations of pyloric stenosis include projectile vomiting, irritability, hunger and crying, constipation, and signs of dehydration, including a decrease in urine output.
A 4-month-old has GERD but is thriving without other complications. What should the nurse suggest to minimize reflux? a) Place in Trendelenburg position after eating b) Thicken formula w/ rice cereal c) Give continuous NG tube feedings d) Give larger, less frequent feedings
B Giving small frequent feedings of formula combined w/ 1 teaspoon to 1 tablespoon of rice cereal per ounce of formula has been recommended.
How much fluid per day should a 7 year old that weighs 62 pounds get?
Answer: 1663 mL/day 62 lb / 2.2 kg = 28.18 kg 10 kg x 100 mL/kg = 1000 mL 10 kg x 50 mL/kg = 500 mL 8.18 kg x 20 mL/kg = 163.6 mL
How much fluid a day should a 2 year old that weighs 13 pounds get?
Answer: 591 mL/day
A 2-month-old infant w/ a cleft lip is transferred to the pediatric flood immediately following surgical repair of the defect. Which of the following interventions should the nurse perform? a) Assess placement of elbow restraints b) Assess placement of the gastrostomy tube c) Monitor the child for signs of hypokalemia d) Monitor the child for passage of tarry stools
A Because babies often put their hands in their mouths, it is important that they be fitted w/ elbow restraints, but they must be applied correctly and removed frequently.
A one-month-old baby has been admitted to the pediatric unit w/ a diagnosis of pyloric stenosis. Which of the following assessments is highest priority for the nurse to report to the baby's primary HCP? a) Sunken fontanel b) Undigested emesis c) Apical HR of 156 bpm d) Serum potassium of 3.6 mEq/L
A It is highest priority for the nurse to report a sunken fontanel (dehydration).
The nurse is caring for a newborn w/ esophageal atresia. When reviewing the mother's history, which would the nurse expect to find? a) Maternal polyhydramnios b) Pregnancy lasting more than 38 weeks c) Poor nutrition during pregnancy d) Alcohol consumption during pregnancy
A Maternal polyhydramnios is present because the infant cannot swallow and absorb the amniotic fluid in utero.
An important nursing consideration in the care of a child w/ celiac disease is to: a) Refer to a nutritionist for detailed dietary instructions and education b) Help child and family understand that diet restrictions are usually only temporary c) Teach proper hand washing and Standard Precautions to prevent disease transmission d) Suggest ways to cope more effectively w/ stress to minimize symptoms
A The main consideration is helping the child adhere to dietary management (i.e. avoiding gluten).
A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician explained the plan of therapy and its expected good results. However, the mother refuses to see or hold her baby. Initial therapeutic approach to the mother should be to: a) Restate what the physician has told her about plastic surgery b) Encourage her to express her feelings c) Emphasize the normalcy of her baby and the baby's need for mothering d) Recognize that negative feelings toward the child continue throughout childhood
B For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse must place emphasis not only on the infants physical needs but also on the parents emotional needs.
The nurse is caring for a newborn who has just been diagnosed w/ tracheoesophagela fistula and is scheduled for surgery. Which should the nurse expect to do in the pre-operative period? a) Keep the child in a monitored crib, obtain frequent vital signs, and allow the parents to visit but not hold their infant b) Administer IV fluids and antibiotics c) Place the infant on 100% oxygen via non-rebreather mask d) Have the mother feed the infant slowly in an monitored area, stopping all feedings 4-6 hours before the surgery
B IV fluids are administered to prevent dehydration because the infant is NPO. IV antibiotics are administered to prevent pneumonia because aspiration of secretions is likely.
An infant is brought to the emergency department with poor skin turgor, weight loss, lethargy, and tachycardia. This is suggestive of a) Overhydration b) Dehydration c) Sodium excess d) Calcium excess
B These clinical manifestations indicate dehydration.
A mother who intended to breastfeed has given birth to an infant with a cleft palate. Nursing interventions should include (Select all that apply): a) Giving medication to suppress lactation b) Encouraging and helping mother to breastfeed c) Teaching mother to feed breast milk by gavage d) Recommending use of a breast pump to maintain lactation until infant can suck
B, D The mother who wishes to breastfeed may need encouragement and support because the defect does present some logistical issues.
The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia w/ tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record? a) Incessant crying b) Coughing at bedtime c) Choking w/ feedings d) Severe projectile vomiting
C Any child who exhibit the "3 Cs" - coughing and choking w/ feedings and unexplained cyanosis - should be suspected to have tracheoesophageal fistula.
For what clinical manifestation should a nurse be alert when suspecting a diagnosis of esophageal atresia? a) A radiograph in the prenatal period indicates abnormal development b) It is visually identified at the time of delivery c) A nasogastric tube fails to pass at birth d) The infant has a low birth weight
C Atresia is suspected when a nasogastric tube fails to pass 10 to 11 cm beyond the gum line. Abdominal radiographs will confirm the diagnosis.
The nurse is caring for a 5-month-old infant w/ a diagnosis of intussusception. The infant has periods of irritability during which the knees are brought to the chest and the infant cries, alternating w/ periods of lethargy. VS are stable and within age-appropriate limits. The physician elects to give an enema. The parents ask the purpose of the enema. Select the nurse's most appropriate response. a) "The enema will confirm the diagnosis. If the test result is positive, your child will need to have surgery to correct the intussusception." b) "The enema will confirm the diagnosis. Although very unlikely, the enema may also help fix the intussusception so that your child will not immediately need surgery." c) "The enema will help confirm the diagnosis and has a good chance of fixing the intussusception." e) "The enema will help confirm the diagnosis and may temporarily fix the intussusception. If the bowel returns to normal, there is a strong likelihood that the intussusception will recur."
C In most cases of intussusception in young children, an enema is successful in reducing the intussusception.
The nurse is explaining to a parent how to care for a child w/ vomiting associated w/ a viral illness. The nurse should include: a) Avoiding carbohydrate-containing liquids b) Giving nothing by mouth for 24hrs c) Brushing teeth or rinsing mouth after vomiting d) Giving plain water until vomiting ceases for at least 24hrs
C It's important to emphasize the need for the child to brush the teeth or rinse the mouth after vomiting to dilute the hydrochloric acid that comes in contact w/ the teeth.
The nurse is caring for an infant w/ pyloric stenosis. The parent asks if any future children will likely have pyloric stenosis. Select the nurse's best response. a) "You seem worried; would you like to discuss your concerns?" b) "It's very rare for a family to have more than one child w/ pyloric stenosis." c) "Pyloric stenosis can run in families. It's more common among males." d) "Although there can be a genetic link, it's very unusual for girls to have pyloric stenosis."
C Pyloric stenosis can run in families and it's more common in males.
What is the most important information to be included in the discharge planning for an infant w/ gastroesophageal reflux? a) Teach parents to position the infant on the left side b) Reinforce the parents knowledge of the infants developmental needs c) Teach the parents how to do infant cardiopulmonary resuscitation (CPR) d) Have the parents keep an accurate record of intake and output
C Risk of aspiration is a priority nursing diagnosis for the infant w/ gastroesophageal reflux.
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 doesn't produce tears when crying. Which task will help confirm the diagnosis of dehydration? a) Urinalysis obtained by bagged specimen b) Urinalysis obtained by sterile catheterization c) Analysis of serum electrolytes d) Analysis of CSF
C The analysis of serum electrolytes offers the most information and assists w/ the diagnosis of dehydration.
The nurse is giving discharge instructions to the parent of a 1-month-old infant w/ tracheoesophageal fistula and a G-tube. The nurse knows the mother understands the discharge teaching when she states: a) "I will give my baby feedings through the GT but place liquid medications in the corner of the mouth to be absorbed." b) "I will flush the GT w/ 2 oz of water after each feeding to prevent the GT from clogging." c) "I will clean the area around the GT w/ soap and water every day." d) "I will place petroleum jelly around the GT if any redness develops."
C The area around the GT should be cleaned w/ soap and water to prevent any infection.
A 3 y/o child w/ Hirschprungs disease is hospitalized for surgery. A temporary colostomy will be necessary. The nurse should recognize that preparing this child psychologically is: a) Not necessary because of child's age b) Not necessary because the colostomy is temporary c) Necessary because it will be an adjustment d) Necessary because the child must deal w/ a negative body image
C The child's age dictates the type and extent of psychologic preparations.
A 6 y/o child is being assessed by a nurse for possible signs of dehydration. Which of the following assessments should the nurse perform? a) Patellar reflexes b) Anterior fontanel tension c) Skin turgor d) Pupil reactivity to light
C The child's skin turgor should be assessed.
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? a) Prone position b) On the stomach c) Left lateral position d) Right lateral position
C The nurse positions the infant on the side lateral to the repair on the back upright and positions the infant to prevent airway obstruction.
During the first few days after surgery for cleft lip, which intervention should the nurse do? a) Leave infant in crib at all times to prevent suture strain b) Keep infant heavily sedated to prevent suture strain c) Remove restraints periodically to cuddle infant d) Alternate position from prone to side-lying to supine
C The nurse should remove restraints periodically, while supervising the infant, to allow him or her to exercise arms and to provide cuddling and tactile stimulation.
A baby, w/ history of CF, is admitted to the ED. The baby is crying loudly and drawing his legs up toward his abdomen. A diagnosis of intussusception is made. Which of the following orders would the nurse expect to receive at this time? a) To administer a corticosteroid medication b) To prepare the baby for abdominal surgery c) To prepare the baby for an air enema d) To administer an antispasmodic medication
C The nurse would expect to prepare the baby for an air enema. It's the usual therapy for a baby w/ intussusception.
The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis? a) Abdominal rigidity and pain on palpation b) Rounded abdomen and hypoactive bowel sounds c) Visible peristalsis and weight loss d) Distention of lower abdomen and constipation
C Visible gastric peristaltic waves that move from left to right across the epigastrium are observed in pyloric stenosis, as is weight loss.
The nurse preparing to care for a child w/ a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented? a) Water diarrhea b) Ribbon-like stools c) Profuse projective vomiting d) Bright red blood and mucus in the stools
D Bright red blood and mucus are passed through the rectum and commonly are described as currant jelly stools.
The clinic nurse reviews the record of an infant and notes that the HCP 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? a) Diarrhea b) Projectile vomiting c) Regurgitation of feedings d) Foul-smelling ribbon-like stools
D 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 this disorder.
The nurse in the delivery room suspects that a newly birthed baby may have an esophageal atresia w/ tracheoesophageal fistula because the baby is exhibiting which of the following S&S? a) Palpable mass in left lower quadrant b) Blood-tinged vomitus c) Pseudostrabismus d) Copious amounts of oral mucus
D Copious amounts of oral mucus is a classic sign of esophageal atresia w/ tracheoesophageal fistula.
A baby is admitted w/ a diagnosis of intussusception. Which of the following signs/symptoms would the nurse expect to see? a) Projectile vomiting b) Acute constipation c) Explosive flatus d) Currant jelly stools
D Currant jelly stools often are seen in babies w/ intussusception.
The nurse provides feeding instructions to a parent of an infant diagnosed w/ GERD. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis? a) Provide less frequent, larger feedings b) Burp the infant less frequently during feedings c) Thin the feedings by adding water to the formula d) Thicken the feedings by adding rice cereal to the forumla
D Feedings thickened w/ rice cereal may reduce episodes of emesis.
The nurse will soon receive a 4-month-old who has been diagnosed w/ intussusception. The infant is diagnosed as very lethargic w/ the following vital signs: T 101.8, 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? a) Prepare to accompany the infant to a CT scan to confirm the diagnosis b) Prepare to accompany the infant to radiology department for a reducing enema c) Prepare to start a second IV line to administer fluids and antibiotics d) Prepare to get the infant ready for immediate surgical correction
D Intussusception w/ peritonitis is a surgical emergency, so preparing the infant for surgery is the nurse's top priority.
The nurse is caring for an 8-week-old male who has just been diagnosed w/ Hirschsprung disease. The parents ask what they should expect. Select the nurse's best response. a) "It is really an easy disease to manage. Most children are placed on stool softeners to help w/ constipation until it resolves." b) "A permanent stool diversion, called a colostomy, will be placed by the surgeon to bypass the narrowed area." c) "Daily bowel irrigations will help your child maintain regular bowel habits." d) "Although your child will require surgery, there are different ways to manage the disease, depending on how much bowel is involved."
D 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 3 y/o child is being seen for a possible diagnosis of dehydration. Two weeks ago, the child weighed 34 lb 8 oz. The child's current weight is 32 lb 4 oz. Please calculate the percentage of weight loss for this child. Calculate to the tenths place.
Answer: 6.5 % 34.5 lb - 32.35 lb = 2.25 lb difference (2.25 / 34.5) x 100 = 0.065 x 100 = 6.5 %
The parents of a newborn diagnosed w/ cleft lip and palate ask the nurse when the child's lip and palate will most likely be repaired. Select the nurse's best response. a) "The palate and lip are usually repaired in the first few weeks of life so that the baby can grow and gain weight" b) "The palate the lip are usually not repaired until the baby is about 6 months old so that the mouth has had enough time to grow" c) "The lip is repaired in the first few months of life, but the palate is not usually repaired until the child is 3 years old" d) "The lip is repaired in the first few weeks of life, but the palate is not usually repaired until the child is 18 months old"
D The lip is repaired in the first few weeks of life, but the palate is not usually repaired until the child is 18 months old.
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. a) Right side-lying b) Left side-lying c) Supine d) Prone
C The supine position is preferred because there is decreased risk of the infant rubbing the suture line.
A child has been diagnosed w/ Hirschsprung's disease. Which of the following findings would the nurse expect the parents to report in the child's history? Select all that apply. a) Ribbon-like stools b) Chronic constipation c) Black and tarry stools d) Distended abdomen e) Delayed meconium passage
A, B, D, E (Self-explanatory)
An 11-month-old child is seen in the primary HCP's office with a chief complaint of loose stools. The child's temperature, heart rate, and respiratory rate are 98.9 F, 148 bpm, and 46 bpm, respectively. Which of the following factors places this child at high risk for the nursing diagnosis: Deficient Fluid Volume? Select all that apply. a) Age b) HR c) Temperature d) Chief complaint e) RR
A, B, D, E All these things place the child at high risk for deficient fluid volume.
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. a) Allow the infant to have familiar items of comfort such as a favorite stuffed animal and a "sippy" cup b) Once liquids have been tolerated, encourage a bland diet such as soup, Jell-O, and saltine crackers c) Administer pain medication on a regular schedule, as opposed to an as-needed schedule d) Use a Yankauer suction catheter on the infant's mouth to decrease the risk of aspiration of oral secretions e) When discharged, remove elbow restraints
A, C The child should not be allowed to use anything that creates suction in the mouth, such as pacifiers or straws. "Sippy" cups are acceptable. Pain medication should be administered regularly to avoid crying, which places stress on the suture line.
A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem? a) Diarrhea b) Metabolic acidosis c) Metabolic alkalosis d) Hyperactive bowel sounds
C Vomiting causes the loss of hydrochloric acid and subsequent metabolic alkalosis.
The nurse is caring for an infant diagnosed w/ Hirschsprung disease. The mother states she is pregnant w/ a boy and wants to know if her new baby will likely have the disorder. Select the nurse's best response. a) "Genetics play a small role in Hirschsprung disease, so there is a chance the baby will develop it as well." b) "There is no evidence to support a genetic link, so it is very unlikely the baby will also have it." c) "It's rarely seen in boys, so it's not likely your new baby will have Hirschsprung disease." d) "Hirschsprung disease is seen only in girls, so your new baby will not be at risk."
A There is a genetic component to Hirschsprung disease, so any future siblings are also at risk.
The parents of a child, whose weight is 64 lb, are advised to make sure that the child consumes the minimum fluid needed to maintain a normal hydration status. The nurse calculates the amount for the full day. Calculate the child's needs to the nearest whole number.
Answer: 1682 mL/day 64 lb / 2.2kg = x kg x = 29.09 kg 10 kg x 100 mL/kg = 1000 mL 10 kg x 50 mL/kg = 500 mL 9.09 kg x 20 mL/kg = 181.8 mL Note that the child's weight is above 20 kg. The first 10 kg are multiplied by 100 mL. The second kg are multiplied by 50 mL. The remainder of the child's weight is multiplied by 20 mL. The volumes are then added together to determine the child's minimum daily volume requirements.
A baby who weights 4.8 kg is in the hospital. The child's hydration status is WNL. The nurse is calculating the minimum amount of fluid the child needs per hour to maintain normal hydration status. Calculate the baby's needs to the nearest whole number.
Answer: 20 mL/hr 4.8 kg x 100 mL/kg = 480 mL, daily minimum fluid needs 480 mL/24 hr = x mL/hr x = 20 mL/hr Because the child's weight is under 10 kg, the practitioner must simply multiply the child's weight times 100 mL to determine the 24hr minimum fluid needs for the child. To determine the hourly needs, the total daily must be divided by 24.
A child is admitted to the hospital with a diagnosis of dehydration. The child's last recorded weight was 37.25 lb. The child's current weight is 34.5. What is the child's percentage of weight loss?
Answer: 7.4 % % of weight loss= 37.25 lb - 34.5 lb / 37.25 lb x 100 = (2.75 / 37.25) x 100 = 0.074 x 100 = 7.4% weight loss
Therapeutic management of the child w/ acute diarrhea and dehydration usually begins with a) Clear liquids b) Adsorbents such as kaolin and pectin c) Oral rehydration solution (ORS) d) Antidiarrheal medications such as paregoric
C ORS is the first treatment for acute diarrhea.
Which should the nurse include in the plan of care to decrease symptoms of GER in a 2-month-old? Select all that apply. a) Place the infant in an infant seat immediately after feedings b) Place the infant in the prone position after feeding to decrease the risk of aspiration c) Encourage the parents not to worry because most infants outgrow GER within the first year of life d) Encourage the parents to hold the infant in an upright position for 30 minutes following a feeding e) Suggest that the parents burp the infant after every 1-2oz consumed
D, E Keeping the infant in an upright position is the best way to decrease the symptoms of GER. Burping the infant frequently may help decrease spitting up by expelling air from the stomach more often.
A baby, 12 hours old, has been diagnosed w/ esophageal atresia w/ tracheoesophageal fistula. Which of the following assessments is highest priority for the nurse to make? a) Quantity of nasogastric secretions b) Oxygen saturation levels c) Apical heart rate d) Weight of wet diapers
B Assessing oxygen saturation levels is highest priority.
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. Select the nurse's best response. a) "Your infant will need to have some tests in the ER to determine if anything serious is going on." b) "Try feeding your infant in about 30 minutes; in the event of repeat vomiting, bring the infant to the ER for some tests and IV rehydration." c) "Many infants display these symptoms when they develop an allergy to the formula they are receiving; try switching to a soy-based formula." d) "Don't worry about the blood and mucus in the stool; it's not unusual for infants to have blood in their stools because their intestines are more sensitive."
A The infant is displaying signs of intussusception. This is an emergency that needs to be evaluated to prevent ischemia and perforation.
The nurse is caring for a boy with probable intussusception. He had diarrhea before admission but, while waiting for administration of air pressure to reduce the intussusception, he passes a normal brown stool. The most appropriate nursing action is to: a) Notify the practitioner b) Measure abdominal girth c) Auscultate for bowel sounds d) Take vital signs, including blood pressure
A Passage of a normal brown stool indicates that the intussusception has reduced itself.
Which description of a stool is characteristic of Hirschprungs disease? a) Ribbon-like stools b) Hard stools positive for guaiac c) Currant jelly stools d) Loose, foul-smelling stools
A Ribbon-like stools are characteristic of Hirschprungs disease.
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 w/ this diagnosis? a) "The baby is a very fussy eater and just doesn't want to eat." b) "The baby tends to have a very forceful vomiting episode about 30 minutes after most feedings." c) "The baby is always hungry after vomiting so I refeed." d) "The baby is happy in spite of getting really upset after spitting up."
C Infants w/ pyloric stenosis are always hungry and often appear malnourished.
