GI

22. Which description of a stool is characteristic of intussusception? a. Ribbon-like stools b. Hard stools positive for guaiac c. "Currant jelly" stools d. Loose, foul-smelling stools

ANS: C The characteristic stool of intussusception is described as "currant jelly." Ribbon-like stools are characteristic of Hirschsprung disease. With intussusception, passage of bloody mucous stools occurs. Stools will not be hard. Loose, foul-smelling stools may indicate infectious gastroenteritis.

40. Therapeutic management of most children with Hirschsprung disease is primarily a. daily enemas. b. low-fiber diet. c. permanent colostomy. d. surgical removal of the affected section of the bowel.

ANS: D Most children with Hirschsprung 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. Preoperative management may include enemas and a low-fiber, high-calorie, high-protein diet, until the child is physically ready for surgery. The colostomy that is created in Hirschsprung disease is usually temporary.

20. What is an appropriate statement for the nurse to make to parents of a child who has had a barium enema to correct an intussusception? a. "I will call the physician when the baby passes his first stool." b. "I am going to dilate the anal sphincter with a gloved finger to help the baby pass the barium." c. "Your baby can't have anything to eat or drink until bowel function returns." d. "Add cereal to the baby's formula to help him pass the barium."

ANS: C Post procedure, the child is kept NPO until bowel function returns. The physician does not need to be notified when the infant passes the first stool. Dilating the anal sphincter is not appropriate for the child after a barium enema.

3. A nursing is caring for an infant who is postoperative following cleft lip and palate repair. Which of the following is an appropriate action for the nurse to take? A. Remove the packing in the mouth. B. Place the infant in an upright position. C. Offer a pacifier with sucrose. D. Assess mouth with a tongue blade.

A. INCORRECT: The packing in the mouth should stay in place for 2 to 3 days. B. CORRECT: Placing the infant in an upright position will facilitate drainage and prevent aspiration. This is an appropriate action for the nurse to take. C. INCORRECT: Objects in the mouth could injure the surgical site and should be avoided. D. INCORRECT: Objects in the mouth could injure the surgical site and should be avoided.

49. A nurse working in an emergency room of a large pediatric hospital receives a transfer call from a reporting nurse at a local community hospital. The nurse will soon receive a 4-month-old who has been diagnosed with an intussusception. The infant is described as very lethargic with the following vital signs, T 101.8°F (38.7°C), HR 181, BP 68/38. The reporting nurse states the infant's abdomen is very rigid. Which of the following is the most appropriate action for the receiving nurse? 1. Prepare to accompany the infant to a computed tomography scan to confirm the diagnosis. 2. Prepare to accompany the infant to the radiology department for a reducing enema. 3. Prepare to start a second intravenous line to administer fluids and antibiotics. 4. Prepare to get the infant ready for immediate surgical correction.

1. The child has already been diagnosed and appears to have developed peritonitis, which is a surgical emergency. 2. Although reducing enemas have a high success rate among infants with intussusception, they are contraindicated in the presence of peritonitis. 3. Although a second intravenous line may be needed, the nurse's first priority is getting the child to the operating room. 4. Intussusception with peritonitis is a surgical emergency, so preparing the infant for surgery is the nurse's top priority. TEST-TAKING HINT: The child has already been diagnosed and is displaying signs of shock and peritonitis. The nurse must act quickly and get the child the surgical attention needed to avoid disastrous consequences.

16. The nurse is caring for an 8-week-old male who has just been diagnosed with Hirschsprung disease. The parents ask what they should expect. Select the nurse's best response. 1. "It is really an easy disease to manage. Most children are placed on stool softeners to help with constipation until the constipation resolves." 2. "A permanent stool diversion, called a colostomy, will be placed by the surgeon to bypass the narrowed area." 3. "Daily bowel irrigations will help your child maintain regular bowel habits." 4. "Although your child will require surgery, there are different ways to manage the disease, depending on how much of your child's bowel is involved."

1. The constipation will not resolve with stool softeners. The affected bowel needs to be removed. 2. Most colostomies are not permanent. The large intestine is usually reattached, and the colostomy is taken down. 3. The child with Hirschsprung disease requires surgery to remove the aganglionic portion of the large intestine. 4. 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. TEST-TAKING HINT: The test taker should be led to answer 4 as it is the least restrictive of all answers and is the only one that states that the child will require surgery. All children with Hirschsprung disease are managed surgically.

4. A 4-month-old female is brought to the emergency department with severe dehydration. Her heart rate is 198, and her blood pressure is 68/38. The infant's anterior fontanel is sunken. The nurse notes that the infant does not cry when the intravenous line is inserted. The child's parents state that she has not "held anything down" in 18 hours. The nurse obtains a finger-stick blood sugar of 94. Which of the following would the nurse expect to do immediately? 1. Administer a bolus of normal saline. 2. Administer a bolus of D10W. 3. Administer a bolus of normal saline with 5% dextrose added to the solution. 4. Offer the child an oral rehydrating solution such as Pedialyte.

4. 1. Dehydration is corrected with the administration of an isotonic solution, such as normal saline or lactated Ringer solution. 2. Solutions containing dextrose should never be administered in bolus form because they may result in cerebral edema. 3. Solutions containing dextrose should never be administered in bolus form because they may result in cerebral edema. 4. Severe dehydration is not usually corrected with oral solutions; children with altered levels of consciousness should be kept NPO. TEST-TAKING HINT: The test taker should immediately eliminate answers 2 and 3 as they both suggest administering glucose in bolus form, which is always contraindicated in the pediatric population. Answer 4 should be eliminated as the infant is severely dehydrated and not responding to painful stimulation, which is suggested by the lack of a cry on intravenous insertion.

45. The nurse is caring for an 8-week-old infant being evaluated for pyloric stenosis. Which of the following statements made by the parents would be typical of a child with this diagnosis? 1. "The baby is a very fussy eater and just does not want to eat." 2. "The baby tends to have a very forceful vomiting episode approximately 30 minutes after most feedings." 3. "The baby is always hungry." 4. "The baby is happy in spite of getting really upset on spitting up."

45. 1. Infants with pyloric stenosis tend to be perpetually hungry because most of their feedings do not get absorbed. 2. Infants with pyloric stenosis vomit immediately after a feeding, especially as the pylorus becomes more hypertrophied. 3. Infants with pyloric stenosis are always hungry and often appear malnourished. 4. Most infants with pyloric stenosis are irritable because they are hungry. Parents do not usually describe the vomiting episodes as "spitting up" because infants tend to have projectile vomiting.

46. The nurse is caring for a 7-week-old scheduled for a pyloromyotomy in 24 hours. Which of the following would the nurse expect to find in the plan of care? 1. Keep infant NPO; begin intravenous fluids at maintenance. 2. Keep infant NPO; begin intravenous fluids at maintenance; place NGT to low wall suction. 3. Obtain serum electrolytes; keep infant NPO; do not attempt to pass NGT due to obstruction from pylorus. 4. Offer infant small frequent feedings; keep NPO 6 to 8 hours before surgery.

1. In addition to giving fluids intravenously and keeping the infant NPO, an NGT is placed to decompress the stomach. 2. In addition to giving fluids intravenously and keeping the infant NPO, an NGT is placed to decompress the stomach. 3. The pylorus is distal to the stomach, so an NGT is placed above the obstruction. 4. The infant is made NPO as soon as diagnosis is confirmed. Allowing the infant to feed perpetuates the vomiting and continued hypertrophy of the pylorus. TEST-TAKING HINT: The test taker should consider the pathophysiology of pyloric stenosis and eliminate answers 1, 3, and 4.

36. 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 postoperative period. 1. Right side-lying. 2. Left side-lying. 3. Supine. 4. Prone.

1. The infant may rub the face on the bedding if positioned on the side. 2. The infant may rub the face on the bedding if positioned on the side. 3. The supine position is preferred because there is decreased risk of the infant rubbing the suture line. 4. The infant may rub the face on the bedding if positioned on the abdomen. TEST-TAKING HINT: The test taker should be led to answer 3 because it is the only option in which the suture line is not at increased risk for injury.

2. A nurse is caring for a child who has Hirschsprung disease. Which of the following is an appropriate action for the nurse to take? A. Encourage a high-fiber, low-protein, low-calorie diet. B. Prepare the family for surgery. C. Place an NG for decompression. D. Initiate bedrest.

2. A. INCORRECT: A client who has Hirschsprung disease is encouraged to eat a low-fiber, high-protein, high-calorie diet.B. CORRECT: A client who has Hirschsprung disease requires surgery to remove the affected segment of the intestine. Preparing the family for surgery is an appropriate action for the nurse to take.C. INCORRECT: A client who has Hirschsprung disease is managed nutritionally. Placing an NG for decompression is not an appropriate action for the nurse to take.D. INCORRECT: A client who has Meckel's diverticulum is placed on bedrest to prevent further bleeding. NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures

386. A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem? 1. Diarrhea 2. Metabolic acidosis 3. Metabolic alkalosis 4. Hyperactive bowel sounds

386. 3 Rationale: Vomiting causes the loss of hydrochloric acid and subsequent metabolic alkalosis.Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate. Diarrhea might ormight not accompanyvomiting.Hyperactive bowel sounds are not associated with vomiting. Test-Taking Strategy: Focus on the subject, complications related to vomiting. Recalling that gastric fluids are acidic and that the loss of these fluids leads to alkalosis will assist you in answering the question. No data in the question support options 1 and 4. Review: Fluid and electrolyte balance and vomiting Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Pediatrics—Gastrointestinal Priority Concepts: Acid-Base Balance; Fluid and Electrolyte Balance Reference: Hockenberry, Wilson (2015), p. 1132.

34. The parents of a newborn diagnosed with a cleft lip and palate ask the nurse when their child's lip and palate will most likely be repaired. Select the nurse's best response. 1. "The palate and the lip are usually repaired in the first few weeks of life so that the baby can grow and gain weight." 2. "The palate and the lip are usually not repaired until the baby is approximately 6 months old so that the mouth has had enough time to grow." 3. "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." 4. "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."

1. The palate is not repaired until the child is approximately 18 months old to allow for growth. Waiting beyond 18 months may interfere with speech. 2. The lip is usually repaired in the first few weeks of life, and the palate is usually repaired at approximately 18 months. 3. The palate is repaired earlier than 3 years so that speech development is not impaired. 4. 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. TEST-TAKING HINT: The test taker should consider the palate's involvement in the development of speech and therefore eliminate answer 3. The palate is usually given at least a year to grow sufficiently.

44. The nurse is caring for an infant with pyloric stenosis. The parents ask if any future children will likely have pyloric stenosis. Select the nurse's best response. 1. "You seem worried; would you like to discuss your concerns?" 2. "It is very rare for a family to have more than one child with pyloric stenosis." 3. "Pyloric stenosis can run in families. It is more common among males." 4. "Although there can be a genetic link, it is very unusual for girls to have pyloric stenosis."

1. This approach sounds like the nurse is avoiding the mother's question. It would be better to offer the information and then ask about her concerns. 2. It is not at all uncommon for a family to have multiple children with pyloric stenosis. 3. Pyloric stenosis can run in families, and it is more common in males. 4. Although pyloric stenosis occurs more often in males, it can occur in females, especially in siblings of a child with pyloric stenosis. TEST-TAKING HINT: The test taker needs to be familiar with pyloric stenosis.

48. The nurse is caring for a 5-month-old infant with a diagnosis of intussusception. The infant has periods of irritability during which the knees are brought to chest and the infant cries, alternating with periods of lethargy. Vital signs are stable and within age-appropriate limits. The physician elects to give an enema. The parents ask the purpose of is the enema. Select the nurse's most appropriate response. 1. "The enema will confirm the diagnosis. If the test result is positive, your child will need to have surgery to correct the intussusception." 2. "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." 3. "The enema will help confirm diagnosis and has a good chance of fixing the intussusception." 4. "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."

1. This approach sounds like the nurse is avoiding the mother's question. It would be better to offer the information and then ask about her concerns. 2. It is not at all uncommon for a family to have multiple children with pyloric stenosis. 3. Pyloric stenosis can run in families, and it is more common in males. 4. Although pyloric stenosis occurs more often in males, it can occur in females, especially in siblings of a child with pyloric stenosis. TEST-TAKING HINT: The test taker needs to be familiar with pyloric stenosis.

13. The nurse is caring for an infant diagnosed with Hirschsprung disease. The mother states she is pregnant with a male and wants to know if her new baby will likely have the disorder. Select the nurse's best response. 1. "Genetics play a small role in Hirschsprung disease, so there is a chance the baby will develop it as well." 2. "There is no evidence to support a genetic link, so it is very unlikely the baby will also have it." 3. "It is rarely seen in boys, so it is not likely your new baby will have Hirschsprung disease." 4. "Hirschsprung disease is seen only in girls, so your new baby will not be at risk."

13. 1. There is a genetic component to Hirschsprung disease, so any future siblings are also at risk. 2. There is a genetic component to Hirschsprung disease. 3. Hirschsprung disease is seen more commonly in males than females. 4. Hirschsprung disease is seen in both males and females but is more common in males. TEST-TAKING HINT: The test taker can eliminate answers 3 and 4 as they are similar and therefore would not likely be the correct answer.

382. The clinic nurse reviews the record of an infant and notes that the health care provider 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? 1. Diarrhea 2. Projectile vomiting 3. Regurgitation of feedings 4. Foul-smelling ribbon-like stools

382. 4 Rationale: Hirschsprung's disease is a congenital anomaly also known as congenital aganglionosis or aganglionic megacolon. It occurs as the result of an absence of ganglion cells in the rectum and other areas of the affected intestine. 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. Delayed passage or absence of meconium stool in the neonatal period is also a sign. Bowel obstruction, especially in the neonatal period; abdominal pain and distention; and failure to thrive are also clinical manifestations. Options 1, 2, and 3 are not associated specifically with this disorder. Test-Taking Strategy: Note the strategicwords, most likely. Use knowledge regarding the pathophysiology associated with Hirschsprung's disease to direct you to the correct option. Remember that chronic constipation beginning in the first month of life and resulting in pellet-like or ribbon-like, foulsmelling stools is a clinical manifestation of this disorder. Review: Hirschsprung's disease Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Pediatrics—Gastrointestinal Priority Concepts: Clinical Judgment; Elimination Reference: Hockenberry, Wilson (2015), p. 1074.

388. 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 parent about the child's symptoms? 1. Watery diarrhea 2. Projectile vomiting 3. Increased urine output 4. Vomiting large amounts of bile

388. 2 Rationale: In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. Clinical manifestations of pyloric stenosis include projectile vomiting, irritability, hunger and crying, constipation, and signs of dehydration, including a decrease in urine output. Test-Taking Strategy: Focus on the subject, themanifestations of pyloric stenosis. Considering the anatomical location of this disorder and its potential effects will assist in eliminating options 1 and 3. Thinking about the pathophysiology of the disorder and recalling that a major clinical manifestation is projectile vomiting will assist in directing you to the correct option from those remaining. Review: Pyloric stenosis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity

390. The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented? 1. Watery diarrhea 2. Ribbon-like stools 3. Profuse projectile vomiting 4. Bright red blood and mucus in the stools

390. 4 Rationale: Intussusception is a telescoping of 1 portion of the bowel into another. The condition results in an obstruction to the passage of intestinal contents. A child with intussusception typically has severe abdominal pain that is crampy and intermittent, causing the child to draw in the knees to the chest. Vomitingmay be present, but is not projectile. Bright red blood and mucus are passed through the rectum and commonly are described as currant jelly-like stools. Watery diarrhea and ribbon-like stools are not manifestations of this disorder. Test-Taking Strategy: Focus on the subject, themanifestationsof intussusception.Think about the pathophysiologyassociated with this condition. Recalling that a classic manifestation is currant jelly-like stools will assist in directing you to the correct option. Review: Intussusception

1. What is the best response by the nurse to a mother asking about the cause of her infant's bilateral cleft lip? a. "Did you use alcohol during your pregnancy?" b. "Does anyone in your family have a cleft lip or palate?" c. "This defect is associated with intrauterine infection during the second trimester." d. "The prevalent of cleft lip is higher in Caucasians."

ANS: B Cleft lip and palate result from embryonic failure resulting from multiple genetic and environmental factors. A genetic pattern or familial risk seems to exist. Tobacco during pregnancy (not drinking) has been associated with bilateral cleft lip. The defect occurred at approximately 6 to 8 weeks of gestation. Second-trimester intrauterine infection is not a known cause of bilateral cleft lip. The prevalence of cleft lip and palate is higher in Asian and Native American populations.

4. The nurse is providing home care instructions to the parents of an infant being discharged after repair of a bilateral cleft lip. Which instructions should the nurse include? (Select all that apply.) a. Acetaminophen (Tylenol) should not be given to your infant. b. Feed your infant in an upright position. c. Place your infant prone for a period of time each day. d. Burp your child frequently during feedings. e. Apply antibiotic ointment to the lip as prescribed.

ANS: B, D, E After cleft lip surgery the parents are taught to feed the infant in an upright position to decrease the chance of choking. The parents are taught to burp the infant frequently during feedings because excess air is often swallowed. Parents are taught to cleanse the suture line area with a cotton swab using a rolling motion and apply antibiotic ointment with the same technique. Tylenol is used for pain, and the child should never be placed prone as this position can damage the suture line.

The postoperative care plan for an infant with surgical repair of a cleft lip includes a. a clear liquid diet for 72 hours. b. nasogastric feedings until the sutures are removed. c. elbow restraints to keep the infant's fingers away from the mouth. d. rinsing the mouth after every feeding.

ANS: C Keeping the infant's hands away from the incision reduces potential complications at the surgical site. The infant's diet is advanced from clear liquid to soft foods within 48 hours of surgery. After surgery, the infant can resume preoperative feeding techniques. Rinsing the mouth after feeding is an inappropriate intervention. Feeding a small amount of water after feedings will help keep the mouth clean. A cleft lip repair site should be cleansed with a wet sterile cotton swab after feedings.

8. What information should the nurse include when teaching the parents of a 5-week-old infant about pyloromyotomy? a. The infant will be in the hospital for a week. b. The surgical procedure is routine and "no big deal." c. The prognosis for complete correction with surgery is good. d. They will need to ask the physician about home care nursing.

ANS: C Pyloromyotomy is the definitive treatment for pyloric stenosis. Prognosis is good with few complications. These comments reassure parents. The infant will remain in the hospital for a day or two postoperatively. Although the prognosis for surgical correction is good, telling the parents that surgery is "no big deal" minimizes the infant's condition. Home care nursing is not necessary after a pyloromyotomy.