GI/dehydration

61. Which child may need extra fluids to prevent dehydration? Select all that apply. 1. A 7-day-old receiving phototherapy. 2. A 6-month-old with newly diagnosed pyloric stenosis. 3. A 2-year-old with pneumonia. 4. A 2-year-old with full-thickness burns to the chest, back, and abdomen. 5. A 13-year-old who has just started her menses.

1. A 7-day-old receiving phototherapy. 2. A 6-month-old with newly diagnosed pyloric stenosis. 3. A 2-year-old with pneumonia. 4. A 2-year-old with full-thickness burns to the chest, back, and abdomen.

14. The nurse is caring for an infant newly diagnosed with Hirschsprung disease. What does the nurse understand about this infant ' s condition? Select all that apply. 1. There is a lack of peristalsis in the large intestine and an accumulation of bowel contents, leading to abdominal distention. 2. There is excessive peristalsis throughout the intestine, resulting in abdominal distention. 3. There is a small-bowel obstruction, leading to ribbon-like stools. 4. There is inflammation throughout the large intestine, leading to accumulation of intestinal contents and abdominal distention. 5. There is an accumulation of bowel contents, leading to non-passage of stools.

1. There is a lack of peristalsis in the large intestine and an accumulation of bowel contents, leading to abdominal distention. 5. There is an accumulation of bowel contents, leading to non-passage of stools.

35. The nurse is caring for a newborn with a cleft lip and palate. The mother states, "I will not be able to breastfeed my baby." Which is the nurse ' s best response? 1. "It sounds like you are feeling discouraged. Would you like to talk about it?" 2. "Sometimes breastfeeding is still an option for babies with a cleft lip and palate. Would you like more information?" 3. "Although breastfeeding is not an option, you can pump your milk and then feed it to your baby with a special nipple." 4. "We usually discourage breastfeeding babies with cleft lip and palate as it puts them at an increased risk for aspiration."

2. "Sometimes breastfeeding is still an option for babies with a cleft lip and palate. Would you like more information?"

46. The nurse is caring for a 7-week-old scheduled for a pyloromyotomy in 24 hours. Which 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 nasogastric tube (NGT) to low wall suction. 3. Obtain serum electrolytes; keep infant NPO; do not attempt to pass NGT due to obstruction. 4. Offer infant small frequent feedings; keep NPO 6 to 8 hours before surgery.

2. Keep infant NPO; begin intravenous fl uids at maintenance; place nasogastric tube (NGT) to low wall suction. In addition to giving fl uids intravenously and keeping the infant NPO, an NGT is placed to decompress the stomach.

18. The nurse knows that Nissen fundoplication involves which of the following? 1. The fundus of the stomach is wrapped around the inferior stomach, mimicking a lower esophageal sphincter. 2. The fundus of the stomach is wrapped around the inferior esophagus, mimicking a cardiac sphincter. 3. The fundus of the stomach is wrapped around the middle portion of the stomach, decreasing the capacity of the stomach. 4. The fundus of the stomach is dilated, decreasing the likelihood of refl ux.

2. The fundus of the stomach is wrapped around the inferior esophagus, mimicking a cardiac sphincter. 2. The Nissen fundoplication involves wrapping the fundus of the stomach around the inferior esophagus, creating a lower esophageal, or cardiac, sphincter.

6. The parent of a 5-year-old states that the child has been having diarrhea for 24 hours, vomited twice 2 hours ago, and now claims to be thirsty. The parent asks what to offer the child because the child is refusing Pedialyte. Which is the nurse ' s most appropriate response? 1. "You can offer clear diet soda such as Sprite and ginger ale." 2. "Pedialyte is really the best thing for your child, who, if thirsty enough, will eventually drink it." 3. "Pedialyte is really the best thing for your child. Allow your child some choice in the way to take it by offering small amounts in a spoon, medicine cup, or syringe." 4. "It really does not matter what your child drinks as long as it is kept down. Try offering small amounts of fl uids in medicine cups."

3. "Pedialyte is really the best thing for your child. Allow your child some choice in the way to take it by offering small amounts in a spoon, medicine cup, or syringe."

44. The nurse is caring for an infant with pyloric stenosis. The parent asks if any future children will likely have pyloric stenosis. Which is 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."

3. "Pyloric stenosis can run in families. It is more common among males."

45. 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 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 about 30 minutes after most feedings." 3. "The baby is always hungry after vomiting, so I feed her again." 4. "The baby is happy in spite of getting really upset after spitting up."

3. "The baby is always hungry after vomiting, so I feed her again."

The nurse is caring for a 2-year-old child who was admitted to the pediatric unit for moderate dehydration due to vomiting and diarrhea. The child is restless with periods of irritability. The child is afebrile with a heart rate of 148 and a blood pressure of 90/42. Baseline laboratory tests reveal the following: Na 152, Cl 119, and glucose 115. The parents state that the child has not urinated in 12 hours. After establishing a saline lock, the nurse reviews the physician ' s orders. Which order should the nurse question? 1. Administer a saline bolus of 10 mL/kg, which may be repeated if the child does not urinate. 2. Recheck serum electrolytes in 12 hours. 3. After the saline bolus, begin maintenance fluids of D5 1⁄4 NS with 10 mEq KCl/L. 4. Give clear liquid diet as tolerated.

3. After the saline bolus, begin maintenance fluids of D5 1⁄4 NS with 10 mEq KCl/L. 3. Potassium is contraindicated because the child has not yet urinated. Potassium is not added to the maintenance fl uid until kidney function has been verifi ed.

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 does not produce tears when crying. Which task will help confirm the diagnosis of dehydration? 1. Urinalysis obtained by bagged specimen. 2. Urinalysis obtained by sterile catheterization. 3. Analysis of serum electrolytes. 4. Analysis of cerebrospinal fluid.

3. Analysis of serum electrolytes. 3. The analysis of serum electrolytes offers the most information and assists with the diagnosis of dehydration.

39. Which should be the nurse ' s immediate action when a newborn begins to cough and choke and becomes cyanotic while feeding? 1. Inform the health-care provider of the situation. 2. Have the mother stop feeding the infant, and observe to see if the choking episode resolves on its own. 3. Immediately determine the infant ' s oxygen saturation and have the mother stop feeding the infant. 4. Take the infant from the mother and administer blow-by oxygen while obtaining the infant ' s oxygen saturation.

4. Take the infant from the mother and administer blow-by oxygen while obtaining the infant ' s oxygen saturation.

Rotavirus is a pathogen implicated in acute gastroenteritis in children under the age of 2. A priority nursing problem list for a child with acute diarrhea caused by rotavirus would be: A. Fluid volume B. Chronic pain C. Sleep pattern D. Overnutrition

A. Fluid volume

An infant has been admitted with the diagnosis of dehydration. The physician has ordered a fluid bolus of 300 mL to be administered over 5 hours. What is the hourly rate the pump will be set at? A. 62.5 mL B. 60 mL/hr C. 150 mL/hr D. 30 mL/hr

B. 60 mL/hr

When performing a pediatric abdominal assessment, what would be the first action by the nurse? A. Palpation of the abdomen for a mass B. Auscultation for bowel sounds C. Inspecting for abdominal distention D. Percussion for hollow sounds due to gas in the bowel

C. Inspecting for abdominal distention

The nurse is discussing nutrition with an adolescent with Celiac disease. The nurse would recommend which of the following diets? A. A high carb diet B. A high protein diet C. No rye, wheat, or barley D. Diet rich in healthy grains

C. No rye, wheat, or barley

The problem list for a child with severe diarrhea includes Fluid Volume Deficit. Which outcome is the most appropriate for this child? A. The parents will seek prompt attention for the child's worsening condition preventing the development of severe dehydration. B. Parents will be able to successfully treat the child's diarrhea at home with oral rehydration fluids. C. The child will exhibit signs of normal hydration. D. Child will engage in normal activities.

C. The child will exhibit signs of normal hydration.

40. What is the best description of pyloric stenosis? a. Dilation of the pylorus b. Hypertrophy of the pyloric muscle c. Hypotonicity of the pyloric muscle d. Reduction of tone in the pyloric muscle

b. Hypertrophy of the pyloric muscle ANS: B Hypertrophic pyloric stenosis occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric channel. Dilation of the pylorus, hypotonicity of the pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis. DIF: Cognitive Level: Understand REF: p. 728 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

10. Which therapeutic management should the nurse prepare to initiate first for a child with acute diarrhea and moderate dehydration? a. Clear liquids b. Adsorbents, such as kaolin and pectin c. Oral rehydration solution (ORS) d. Antidiarrheal medications such as paregoric

c. Oral rehydration solution (ORS) ANS: C ORS is the first treatment for acute diarrhea. Clear liquids are not recommended because they contain too much sugar, which may contribute to diarrhea. Adsorbents are not recommended. Antidiarrheals are not recommended because they do not get rid of pathogens. DIF: Cognitive Level: Apply REF: p. 700 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

43. What are the results of excessive vomiting in an infant with pyloric stenosis? a. Hyperchloremia b. Hypernatremia c. Metabolic acidosis d. Metabolic alkalosis

d. Metabolic alkalosis ANS: D Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Chloride ions and sodium are lost with vomiting. Metabolic alkalosis, not acidosis, is likely. DIF: Cognitive Level: Understand REF: p. 728 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

16. Which therapeutic management treatment is implemented for children with Hirschsprung disease? a. Daily enemas b. Low-fiber diet c. Permanent colostomy d. Surgical removal of affected section of bowel

d. Surgical removal of affected section of 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 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. DIF: Cognitive Level: Understand REF: p. 703 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

41. Which observation made of the exposed abdomen is most indicative of pyloric stenosis? a. Abdominal rigidity b. Substernal retraction c. Palpable olive-like mass d. Marked distention of lower abdomen

c. Palpable olive-like mass ANS: C The diagnosis of pyloric stenosis is often made after the history and physical examination. The olive-like mass is easily palpated when the stomach is empty, the infant is quiet, and the abdominal muscles are relaxed. Abdominal rigidity and substernal retraction are usually not present. The upper abdomen, not lower abdomen, is distended. DIF: Cognitive Level: Understand REF: p. 728 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

26. The nurse is caring for a 3-year-old who had an appendectomy 2 days ago. The child has a fever of 101.8°F (38.8°C) and breath sounds are slightly diminished in the right lower lobe. Which action is most appropriate? 1. Teach the child how to use an incentive spirometer. 2. Encourage the child to blow bubbles. 3. Obtain an order for intravenous antibiotics. 4. Obtain an order for acetaminophen (Tylenol).

2. Encourage the child to blow bubbles. Blowing bubbles is a developmentally appropriate way to help the preschooler take deep breaths and cough.

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. Which is the nurse ' s best response? 1. "The palate and the lip are usually repaired in the fi rst 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 fi rst 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 fi rst few weeks of life, but the palate is not usually repaired until the child is 18 months old."

4. "The lip is repaired in the fi rst few weeks of life, but the palate is not usually repaired until the child is 18 months old."

54. The nurse is caring for a 14-year-old with celiac disease. The nurse knows that the patient understands the diet instructions by ordering which of the following meals? 1. Eggs, bacon, rye toast, and lactose-free milk. 2. Pancakes, orange juice, and sausage links. 3. Oat cereal, breakfast pastry, and nonfat skim milk. 4. Cheese, banana slices, rice cakes, and whole milk.

4. Cheese, banana slices, rice cakes, and whole milk. Rye toast contains gluten. Unless otherwise indicated, pancakes are made of wheat flour, which contains gluten. Oat cereal and breakfast pastry contain gluten. Cheese, banana slices, rice cakes, and whole milk do not contain gluten.

17. Which should the nurse include in the plan of care to decrease symptoms of gastroesophageal refl ux (GER) in a 2-month-old? Select all that apply. 1. Place the infant in an infant seat immediately after feedings. 2. Place the infant in the prone position immediately after feeding to decrease the risk of aspiration. 3. Encourage the parents not to worry because most infants outgrow GER within the fi rst year of life. 4. Encourage the parents to hold the infant in an upright position for 30 minutes following a feeding. 5. Suggest that the parents burp the infant after every 1-2 ounces consumed.

4. Encourage the parents to hold the infant in an upright position for 30 minutes following a feeding. 5. Suggest that the parents burp the infant after every 1-2 ounces consumed.

21. A 10-year-old is being evaluated for possible appendicitis and complains of nausea and sharp abdominal pain in the right lower quadrant. An abdominal ultrasound is scheduled, and a blood count has been obtained. The child vomits, fi nds the pain relieved, and calls the nurse. Which should be the nurse ' s next action? 1. Cancel the ultrasound and obtain an order for oral ondansetron (Zofran). 2. Cancel the ultrasound and prepare to administer an intravenous bolus. 3. Prepare for the probable discharge of the patient. 4. Immediately notify the health-care provider of the child ' s status.

4. Immediately notify the health-care provider of the child ' s status. the health-care provider should be notifi ed immediately, because a sudden change or loss of pain often indicates a perforated appendix.

49. The nurse will soon receive a 4-month-old who has been diagnosed with 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 is the most appropriate action for the receiving nurse? 1. Prepare to accompany the infant to a computed tomography scan to confi rm 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 fl uids and antibiotics. 4. Prepare to get the infant ready for immediate surgical correction.

4. Prepare to get the infant ready for immediate surgical correction. Intussusception with peritonitis is a surgical emergency, so preparing the infant for surgery is the nurse ' s top priority.

1. Which condition in a child should alert a nurse for increased fluid requirements? a. Fever b. Mechanical ventilation c. Congestive heart failure d. Increased intracranial pressure (ICP)

a. Fever ANS: A Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. Respiratory rate influences insensible fluid loss and should be monitored in the mechanically ventilated child. Congestive heart failure is a case of fluid overload in children. Increased ICP does not lead to increased fluid requirements in children. DIF: Cognitive Level: Understand REF: p. 689 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

12. A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. What should therapeutic management of this child begin with? a. Intravenous (IV) fluids b. ORS c. Clear liquids, 1 to 2 ounces at a time d. Administration of antidiarrheal medication

a. Intravenous (IV) fluids ANS: A In children with severe dehydration, IV fluids are initiated. ORS is acceptable therapy if the dehydration is not severe. Diarrhea is not managed by using clear liquids by mouth. These fluids have a high carbohydrate content, low electrolyte content, and high osmolality. Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea. DIF: Cognitive Level: Apply REF: p. 706 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

24. The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis. Which is appropriate to relieve the abdominal discomfort? a. Place in Trendelenburg position. b. Allow to assume position of comfort. c. Apply moist heat to the abdomen. d. Administer a saline enema to cleanse bowel.

b. Allow to assume position of comfort. ANS: B The child should be allowed to take a position of comfort, usually with the legs flexed. The Trendelenburg position will not help with the discomfort. In any instance in which appendicitis is a possibility, there is a danger in administering a laxative or enemas or applying heat to the area. Such measures stimulate bowel motility and increase the risk of perforation. DIF: Cognitive Level: Apply REF: p. 709 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

6. Parents call the clinic and report that their toddler has had acute diarrhea for 24 hours. The nurse should further ask the parents if the toddler has which associated factor that is causing the acute diarrhea? a. Celiac disease b. Antibiotic therapy c. Immunodeficiency d. Protein malnutrition

b. Antibiotic therapy ANS: B Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be associated with antibiotic therapy. Celiac disease is a problem with gluten intolerance and may cause chronic diarrhea if not identified and managed appropriately. Immunodeficiency would occur with chronic diarrhea. Protein malnutrition or kwashiorkor causes chronic diarrhea from lowered resistance to infection. DIF: Cognitive Level: Apply REF: p. 691 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

36. The nurse is caring for an infant whose cleft lip was repaired. What important aspects of this infant's postoperative care should be included? a. Arm restraints, postural drainage, mouth irrigations b. Cleansing the suture line, supine and side-lying positions, arm restraints c. Mouth irrigations, prone position, cleansing the suture line d. Supine and side-lying positions, postural drainage, arm restraints

b. Cleansing the suture line, supine and side-lying positions, arm restraints ANS: B The suture line should be cleansed gently after feeding. The child should be positioned on the back, on the side, or in an infant seat. Elbows are restrained to prevent the child from accessing the operative site. Postural drainage is not indicated. This would increase the pressure on the operative site when the child is placed in different positions. There is no reason to perform mouth irrigations, and the child should not be placed in the prone position where injury to the suture site can occur. DIF: Cognitive Level: Apply REF: p. 725 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

35. A mother who intended to breastfeed has given birth to an infant with a cleft palate. What nursing interventions should be included? 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. Encouraging and helping mother to breastfeed. ANS: B The mother who wishes to breastfeed may need encouragement and support because the defect does present some logistical issues. The nipple must be positioned and stabilized well back in the infant's oral cavity so that the tongue action facilitates milk expression. Because breastfeeding is an option, if the mother wishes to breastfeed, medications should not be given to suppress lactation. Because breastfeeding can usually be accomplished, gavage feedings are not indicated. The suction required to stimulate milk, absent initially, may be useful before nursing to stimulate the let-down reflex. DIF: Cognitive Level: Apply REF: p. 724 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

33. 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. What is the initial therapeutic approach for the mother? a. Restating what the physician has told her about plastic surgery. b. Encouraging her to express her feelings. c. Emphasizing the normalcy of her baby and the baby's need for mothering. d. Recognizing that negative feelings toward the child continue throughout childhood.

b. Encouraging her to express her feelings. ANS: B For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse must emphasize not only the infant's physical needs but also the parents' emotional needs. The mother needs to be able to express her feelings before she can accept her child. Although the nurse will restate what the physician has told the mother about plastic surgery, it is not part of the initial therapeutic approach. As the mother expresses her feelings, the nurse's actions should convey to the parents that the infant is a precious human being. The nurse emphasizes the child's normalcy and helps the mother recognize the child's uniqueness. DIF: Cognitive Level: Apply REF: p. 723 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Psychosocial Integrity

22. Which clinical manifestation would be the most suggestive of acute appendicitis? a. Rebound tenderness b. Bright red or dark red rectal bleeding c. Abdominal pain that is relieved by eating d. Abdominal pain that is most intense at McBurney point

ANS: D Pain is the cardinal feature. It is initially generalized, usually periumbilical. The pain localizes to the right lower quadrant at McBurney point. Rebound tenderness is not a reliable sign and is extremely painful to the child. Bright red or dark red rectal bleeding and abdominal pain that is relieved by eating are not signs of acute appendicitis. DIF: Cognitive Level: Understand REF: p. 709 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

17. Enemas are ordered to empty the bowel preoperatively for a child with Hirschsprung disease. What enema solution should be used? a. Tap water b. Normal saline c. Oil retention d. Phosphate preparation

b. Normal saline ANS: B Isotonic solutions should be used in children. Saline is the solution of choice. Plain water is not used. This is a hypotonic solution and can cause rapid fluid shift, resulting in fluid overload. Oil-retention enemas will not achieve the "until clear" result. Phosphate enemas are not advised for children because of the harsh action of the ingredients. The osmotic effects of the phosphate enema can result in diarrhea, which can lead to metabolic acidosis. DIF: Cognitive Level: Apply REF: p. 703 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

13. The nurse is caring for an infant diagnosed with Hirschsprung disease. The mother states she is pregnant with a boy and wants to know if her new baby will likely have the disorder. Which is 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."

1. "Genetics play a small role in Hirschsprung disease, so there is a chance the baby will develop it as well."

53. The parent of a child being evaluated for celiac disease asks the nurse why it is important to make dietary changes. Which is the nurse ' s best response? 1. "The body ' s response to gluten causes damage to the mucosal cells in the intestine, leading to absorption problems." 2. "The body ' s response to consumption of anything containing gluten is to create special cells called villi, which leads to more diarrhea." 3. "The body ' s response to gluten causes the intestine to become more porous and hang on to more of the fat-soluble vitamins, leading to vitamin toxicity." 4. "The body ' s response to gluten causes damage to the mucosal cells, leading to malabsorption of water and hard, constipated stools."

1. "The body ' s response to gluten causes damage to the mucosal cells in the intestine, leading to absorption problems."

A 4-month-old is brought to the emergency department with severe dehydration. The 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 would the nurse expect to do immediately? 1. Administer a bolus of normal saline. 2. Administer a bolus of D 10W. 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.

1. Administer a bolus of normal saline. 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.

37. 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. 1. Allow the infant to have familiar items of comfort such as a favorite stuffed animal and a "sippy" cup. 2. Once liquids have been tolerated, encourage a bland diet such as soup, Jell-O, and saltine crackers. 3. Administer pain medication on a regular schedule, as opposed to an as-needed schedule. 4. Use a Yankauer suction catheter on the infant ' s mouth to decrease the risk of aspiration of oral secretions. 5. When discharged, remove elbow restraints.

1. Allow the infant to have familiar items of comfort such as a favorite stuffed animal and a "sippy" cup. 3. Administer pain medication on a regular schedule, as opposed to an as-needed schedule.

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 the chest and the infant cries, alternating with periods of lethargy. Vital signs are stable and within age-appropriate limits. The health-care provider elects to give an enema. The parents ask the purpose of the enema. Which is 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 fi x the intussusception so that your child will not immediately need surgery." 3. "The enema will help confirm the diagnosis and has a good chance of fixing the intussusception." 4. "The enema will help confirm the diagnosis and may temporarily fi x the intussusception. If the bowel returns to normal, there is a strong likelihood that the intussusception will recur."

3. "The enema will help confirm the diagnosis and has a good chance of fixing the intussusception."

15. 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? 1. Reassure the parents that this is an expected fi nding and not uncommon. 2. Call a code for a potential cardiac arrest and stay with the infant. 3. Immediately obtain all vital signs with a quick head-to-toe assessment. 4. Obtain a stool sample for occult blood.

3. Immediately obtain all vital signs with a quick head-to-toe assessment.

The nurse is caring for a 9-month-old with diarrhea secondary to rotavirus. The child has not vomited and is mildly dehydrated. Which is likely to be included in the discharge teaching? 1. Administer loperamide (Imodium) as needed. 2. Administer bismuth subsalicylate (Kaopectate) as needed. 3. continue breastfeeding per routine 4. The infant may return to day care 24 hours after antibiotics have been started.

3. continue breastfeeding per routine

The nurse receives a call from the parent of a 10-month-old who has vomited three times in the past 8 hours. The parent describes the baby as playful and wanting to drink. The parent asks the nurse what to give the child. Select the nurse ' s best response. 1. "Replace the next feeding with regular water, and see if that is better tolerated." 2. "Do not allow your baby to eat any solids; give half the normal formula feeding, and see if that is better tolerated." 3. "Do not let your baby eat or drink anything for 24 hours to give the stomach a chance to rest." 4. "Give your child 1⁄2 ounce of Pedialyte every 10 minutes. If vomiting continues, wait an hour, and then repeat what you previously gave."

4. "Give your child 1⁄2 ounce of Pedialyte every 10 minutes. If vomiting continues, wait an hour, and then repeat what you previously gave."

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. Which is 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 it 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 bowel is involved."

4. "Although your child will require surgery, there are different ways to manage the disease, depending on how much bowel is involved."

A child is admitted with dehydration. Weight is 56 lbs. After a fluid bolus is given, maintenance IV fluids ordered. What rate does the nurse set the IV pump at? (round to the whole number)

67 mL/hour 56 lb => 25.5 kg 1,500ml + (20 x 5.5) = 1610 ml 1610ml/day => 67 ml per hour

Which pediatric patient should the nurse assess first? A. A 14-month-old with a 2-day history of acute gastroenteritis, low grade fever of 100.4 degrees F, sleeping in his stroller, holding a bottle of apple juice. The child's vital signs are HR 152, RR 26. B. A 2-month-old exclusively breast-fed infant with a chief complaint of vomiting after each feeding and then wanting to feed again. The infant was born 3 weeks prematurely. She is awake and alert but crying in her father's arms. Her vital signs indicate tachycardia.

B. A 2-month-old exclusively breast-fed infant with a chief complaint of vomiting after each feeding and then wanting to feed again. The infant was born 3 weeks prematurely. She is awake and alert but crying in her father's arms. Her vital signs indicate tachycardia. This infant may have pyloric stenosis and could possibly need surgery. Also due to her age and body mass she is at higher risk of becoming dehydrated faster than an older child with gastroenteritis. Pg 665-666

The nurse is assessing a child with the medical diagnosis of pyloric stenosis; the nurse is likely to note which of the following? A. "Currant jelly" stools B. Regurgitation C. Steatorrhea D. Projectile vomiting

D. Projectile vomiting

The healthcare provider is caring for a 3-month-old infant diagnosed with infectious gastroenteritis. The infant is lethargic and the mucous membranes are dry. Which additional finding would support a diagnosis of moderate dehydration? A. Increased capillary refill B. Increased thirst C. Anuria D. Sunken fontanel

D. Sunken fontanel

3. Which type of dehydration is defined as "dehydration that occurs in conditions in which electrolyte and water deficits are present in approximately balanced proportion"? a. Isotonic dehydration b. Hypotonic dehydration c. Hypertonic dehydration d. All types of dehydration in infants and small children

a. Isotonic dehydration ANS: A Isotonic dehydration is the correct term for this definition and is the most frequent form of dehydration in children. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic. Hypertonic dehydration results from water loss in excess of electrolyte loss and is usually caused by a proportionately larger loss of water or a larger intake of electrolytes. This definition is specific to isotonic dehydration. DIF: Cognitive Level: Understand REF: p. 694 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

45. 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. Which nursing action is the most appropriate? a. Notify practitioner b. Measure abdominal girth c. Auscultate for bowel sounds d. Take vital signs, including blood pressure

a. Notify practitioner ANS: A Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic-therapeutic care plan. The first action would be to report the normal stool to the practitioner. DIF: Cognitive Level: Apply REF: p. 728 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

46. Which is an important nursing consideration in the care of a child with celiac disease? 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 with stress to minimize symptoms.

a. Refer to a nutritionist for detailed dietary instructions and education. ANS: A The main consideration is helping the child adhere to dietary management. Considerable time is spent explaining to the child and parents about the disease process, the specific role of gluten in aggravating the condition, and foods that must be restricted. Referral to a nutritionist would help in this process. The most severe symptoms usually occur in early childhood and adult life. Dietary avoidance of gluten should be lifelong. Celiac disease is not transmissible or stress related. DIF: Cognitive Level: Apply REF: p. 732 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort

20. A 4-month-old infant has gastroesophageal reflux (GER) but is thriving without other complications. Which should the nurse suggest to minimize reflux? a. Place in Trendelenburg position after eating. b. Thicken formula with rice cereal. c. Give continuous nasogastric tube feedings. d. Give larger, less frequent feedings.

b. Thicken formula with rice cereal. ANS: B Small, frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal per ounce of formula have been recommended. Milk-thickening agents have been shown to decrease the number of episodes of vomiting and to increase the caloric density of the formula. This may benefit infants who are underweight as a result of GER disease. Placing the child in a Trendelenburg position would increase the reflux. Continuous nasogastric feedings are reserved for infants with severe reflux and failure to thrive. DIF: Cognitive Level: Apply REF: p. 726 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

5. An infant is brought to the emergency department with dehydration. Which physical assessment finding does the nurse expect? a. Weight gain b. Bradycardia c. Poor skin turgor d. Brisk capillary refill

c. Poor skin turgor ANS: C Clinical manifestations of dehydration include poor skin turgor, weight loss, lethargy, and tachycardia. The infant would have prolonged capillary refill, not brisk. DIF: Cognitive Level: Understand REF: p. 691 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

21. A histamine-receptor antagonist such as cimetidine (Tagamet) or ranitidine (Zantac) is ordered for an infant with GER. What is the purpose of this medication? a. Prevent reflux b. Prevent hematemesis c. Reduce gastric acid production d. Increase gastric acid production

c. Reduce gastric acid production ANS: C The mechanism of action of histamine-receptor antagonists is to reduce the amount of acid present in gastric contents and perhaps prevent esophagitis. Preventing reflux or hematemesis and increasing gastric acid production are not the modes of action of histamine-receptor antagonists. DIF: Cognitive Level: Understand REF: p. 707 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

37. 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. Remove restraints periodically to cuddle infant. ANS: C Remove restraints periodically, while supervising the infant, to allow him or her to exercise arms and to provide cuddling and tactile stimulation. The infant should not be left in the crib, but should be removed for appropriate holding and stimulation. Analgesia and sedation are administered for pain. Heavy sedation is not indicated. The child should not be placed in the prone position. DIF: Cognitive Level: Apply REF: p. 725 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

7. Which pathogen is the viral pathogen that frequently causes acute diarrhea in young children? a. Giardia organisms b. Shigella organisms c. Rotavirus d. Salmonella organisms

c. Rotavirus ANS: C Rotavirus is the most frequent viral pathogen that causes diarrhea in young children. Giardia (parasite) and Salmonella are bacterial pathogens that cause diarrhea. Shigella is a bacterial pathogen that is uncommon in the United States. DIF: Cognitive Level: Understand REF: p. 697 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

23. When caring for a child with probable appendicitis, the nurse should be alert to recognize that which condition or symptom is a sign of perforation? a. Bradycardia b. Anorexia c. Sudden relief from pain d. Decreased abdominal distention

c. Sudden relief from pain ANS: C Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Tachycardia, not bradycardia, is a manifestation of peritonitis. Anorexia is already a clinical manifestation of appendicitis. Abdominal distention usually increases. DIF: Cognitive Level: Understand REF: p. 709 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

42. 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 peristalsis and weight loss pg 728 ANS: C Visible gastric peristaltic waves that move from left to right across the epigastrium and weight loss are observed in pyloric stenosis. Abdominal rigidity and pain on palpation or a rounded abdomen and hypoactive bowel sounds are usually not present. The upper abdomen, not lower abdomen, is distended.

18. A 3-year-old child with Hirschsprung 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 colostomy is temporary. c. necessary because it will be an adjustment. d. necessary because the child must deal with a negative body image.

c. necessary because it will be an adjustment. ANS: C The child's age dictates the type and extent of psychological preparation. When a colostomy is performed, the child who is at least preschool age is told about the procedure and what to expect in concrete terms, with the use of visual aids. It is necessary to prepare a 3-year-old child for procedures. The preschooler is not yet concerned with body image. DIF: Cognitive Level: Understand REF: p. 705 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Psychosocial Integrity: Coping and Adaptation

11. A school-age child with diarrhea has been rehydrated. The nurse is discussing the child's diet with the family. Which statement by the parent would indicate a correct understanding of the teaching? a. "I will keep my child on a clear liquid diet for the next 24 hours." b. "I should encourage my child to drink carbonated drinks but avoid food for the next 24 hours." c. "I will offer my child bananas, rice, applesauce, and toast for the next 48 hours." d. "I should have my child eat a normal diet with easily digested foods for the next 48 hours."

d. "I should have my child eat a normal diet with easily digested foods for the next 48 hours." ANS: D Easily digested foods such as cereals, cooked vegetables, and meats should be provided for the child. Early reintroduction of nutrients is desirable. Continued feeding or reintroduction of a regular diet has no adverse effects and actually lessens the severity and duration of the illness. Clear liquids and carbonated drinks have high carbohydrate content and few electrolytes. Caffeinated beverages should be avoided because caffeine is a mild diuretic. The BRAT diet has little nutritional value and is high in carbohydrates.

4. A nurse is admitting an infant with dehydration caused from water loss in excess of electrolyte loss. Which type of dehydration is this infant experiencing? a. Isotonic b. Isosmotic c. Hypotonic d. Hypertonic

d. Hypertonic ANS: D Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion and is another term for isomotic dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic. DIF: Cognitive Level: Understand REF: p. 694 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

44. What is invagination of one segment of bowel within another called? a. Atresia b. Stenosis c. Herniation d. Intussusception

d. Intussusception ANS: D Intussusception occurs when a proximal section of the bowel telescopes into a more distal segment, pulling the mesentery with it. The mesentery is compressed and angled, resulting in lymphatic and venous obstruction. Invagination of one segment of bowel within another is the definition of intussusception, not atresia, stenosis, or herniation. DIF: Cognitive Level: Understand REF: p. 728 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

34. What should be included in caring for the newborn with a cleft lip and palate before surgical repair? a. Gastrostomy feedings b. Keeping infant in near-horizontal position during feedings c. Allowing little or no sucking d. Providing satisfaction of sucking needs

d. Providing satisfaction of sucking needs ANS: D Using special or modified nipples for feeding techniques helps meet the infant's sucking needs. Gastrostomy feedings are usually not indicated. Feeding is best accomplished with the infant's head in an upright position. The child requires both nutritive and nonnutritive sucking. DIF: Cognitive Level: Apply REF: p. 723 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential