Ricci Chapter 42 - Test Bank - 4th Edition

30. The nurse is preparing to administer intravenous fluids to manage a child with dehydration. The medical record indicates the child weighs 60 lb (27.2 kg). How many milliliters will initially be administered? Record your answer using two decimal places.

Ans: 545.45 Feedback: Nursing goals for the infant or child with dehydration are aimed at restoring fluid volume and preventing progression to hypovolemia. Provide oral rehydration to children for mild to moderate states of dehydration. Children with severe dehydration should receive intravenous fluids. Initially, administer 20 mL/kg of normal saline or lactated Ringer, and then reassess the hydration status.

18. An 8-month-old infant is brought to the clinic for evaluation. The mother tells the nurse that she has noticed some white patches on the infant's tongue that look like curdled milk after breastfeeding. The nurse suspects oral candidiasis (thrush). Which question would the nurse use to help confirm this suspicion? A) "Are you having breast pain when you nurse the baby?" B) "Has he had any dairy problems recently?" C) "Is he experiencing any vomiting lately?" D) "How have his stools been this past week?"

Ans: A Feedback: The infant may develop thrush from the mother if the mother has a fungal infection of the breast. Asking the mother about breast pain would be important because this type of infection can cause the mother a great deal of pain with nursing. Dairy products are not associated with oral candidiasis but are associated with the development of infectious diarrhea in infants. Vomiting is unrelated to thrush. The infant also may have candidal diaper rash, but this would be manifested on the skin as a beefy-red rash with satellite lesions, not in his stools.

10. 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? A) "Be patient; she is trying some new medication." B) "The pain she is having is real." C) "The family is working toward improvement." D) "Please do not add to this family's stress."

Ans: B Feedback: 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.

9. The nurse is caring for a 2-month-old with a cleft palate. The child will undergo corrective surgery at age 3 months. The mother would like to continue breastfeeding the baby after surgery and wonders if it is possible. How should the nurse respond? A) "There is a good chance that you will be able to breastfeed almost immediately." B) "Breastfeeding is likely to be possible but check with the surgeon." C) "After the suture line heals, breastfeeding can resume." D) "We will have to wait and see what happens after the surgery."

Ans: B Feedback: Postoperatively, some surgeons allow breastfeeding to be resumed almost immediately. However, the nurse needs to advise the mother to check with the surgeon to determine when breastfeeding can resume. Telling the mother that she has to wait until the suture line heals may be inaccurate. Telling her to wait and see does not answer her question.

5. 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? A) Clean the area well with a scented diaper wipe. B) Apply a barrier/healing cream or paste on the skin. C) Use a barrier wafer to attach the appliance. D) Sanitize the area with an alcohol wipe after each diaper change.

Ans: B Feedback: 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.

13. The nurse is determining maintenance fluid requirements for a child who weighs 25 kg. How much fluid would the child need per day? A) 1,560 mL B) 1,600 mL C) 1,650 mL D) 1,700 mL

Ans: B Feedback: 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.

19. 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? A) Sausage-shaped mass in the upper midabdomen B) Hard, moveable, olive-shaped mass in the right upper quadrant C) Tenderness over the McBurney point in the right lower quadrant D) Abdominal pain in the epigastric or umbilical region

Ans: B Feedback: 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.

28. The nurse is caring for a 6-month-old with a cleft lip and palate. The mother of the child demonstrates understanding of the disorder with which statements? Select all that apply. A) "My smoking during pregnancy didn't have anything to do with this disorder. Smoking primarily causes low birth weight." B) "I know my baby takes a lot longer to feed than most children this age." C) "It really worries me that my baby may have some other disorders that haven't been detected yet." D) "I wonder if my baby will develop speech problems when language development begins?" E) "Thankfully there are healthcare providers that specialize in correcting this type of disorder."

Ans: B, C, D, E Feedback: Feeding and speech are especially difficult for the child with cleft lip and palate until the defect is repaired. Cleft lip and palate occurs frequently in association with other anomalies and has been identified in more than 350 syndromes. Plastic surgeons or craniofacial specialists, oral surgeons, dentists or orthodontists, and prosthodontists are some of the healthcare providers that specialize in repair of this disorder. The mother is incorrect in stating that smoking is not associated with cleft lip or palate. Maternal smoking during pregnancy is a major risk factor for the disorder.

25. After teaching the parents of a child diagnosed with celiac disease about nutrition, the nurse determines that the teaching was effective when the parents identify which foods as appropriate for their child? Select all that apply. A) Wheat germ B) Peanut butter C) Carbonated drinks D) Shellfish E) Jelly F) Flavored yogurt

Ans: B, C, D, E Feedback: Foods allowed in a gluten-free diet include peanut butter, carbonated drinks, shellfish, and jelly. Wheat germ and flavored yogurt should be avoided.

12. Which finding would lead the nurse to suspect that a child is experiencing moderate dehydration? A) Dusky extremities B) Tenting of skin C) Sunken fontanels D) Hypotension

Ans: C Feedback: A child with moderate dehydration would exhibit sunken fontanels. Severe dehydration would be characterized by dusky extremities, skin tenting, and hypotension.

15. The nurse is providing care to a child with an intussusception. The child has a bowel movement and the nurse inspects the stool. The nurse would most likely document the stool's appearance as having what quality? A) Greasy B) Clay-colored C) Currant jelly-like D) Bloody

Ans: C Feedback: The child with intussusception often exhibits currant jelly-like stools that may or may not be positive for blood. Greasy stools are associated with celiac disease. Cay-colored stools are observed with biliary atresia. Bloody stools can be seen with several gastrointestinal disorders, such as inflammatory bowel disease.

6. The nurse is caring for a 4-year-old boy who has undergone an appendectomy. The child is unwilling to use the incentive spirometer. Which approach would be most appropriate to elicit the child's cooperation? A) "Can you cough for me please?" B) "You must blow in this or you might get pneumonia." C) "If you don't try, I will have to get the healthcare provider." D) "Can you blow this cotton ball across the tray?"

Ans: D Feedback: Children are more likely to cooperate with interventions if play is involved. Encourage deep breathing by playing games. Asking the boy to cough is less likely to engage him. Telling the child he might get pneumonia is not age appropriate and is unhelpful. Threatening to call the healthcare provider is unhelpful and inappropriate. Remember, however, that the incentive spirometer works on the principle of the amount of air inhaled, not exhaled. Having the child take a deep breath prior to blowing the cotton ball is a beginning step.

14. 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? A) Frozen yogurt B) Rye bread C) Creamed spinach D) Fruit juice

Ans: D Feedback: 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.

8. The nurse has developed a plan of care for a 12-month-old hospitalized with dehydration as a result of rotavirus. Which intervention would the nurse include in the plan of care? A) Encouraging consumption of fruit juice B) Offering Kool-Aid or popsicles as tolerated C) Encouraging milk products to boost caloric intake D) Maintaining the intravenous (IV) fluid rate as ordered

Ans: D Feedback: The nurse should maintain an IV line and administer the IV fluid as ordered to maintain fluid volume. High-carbohydrate fluids like fruit juice, Kool-Aid, and popsicles should be avoided as they are low in electrolytes, increase simple carbohydrate consumption, and can decrease stool transit time. Milk products should be avoided during the acute phase of illness as they may worsen diarrhea.