chapter 20 peds final
A 4-month-old has had a fever, vomiting, and loose watery stools every few hours for 2 days. The mother calls the physician's office and asks the nurse what she should do. Which response by the nurse is most appropriate? "Do not give the child anything to drink for 4 hours. If the fever goes down and the loose stools stop, you can resume breastfeeding." "Continue breastfeeding as you have been doing. The fluid from the breast milk is important to maintain fluid balance." "Give a clear pediatric electrolyte replacement for the next few hours, then call back to report on how your child is doing." "Bring the child to the office today so we can evaluate her fluid balance and determine the best treatment."
"Bring the child to the office today so we can evaluate her fluid balance and determine the best treatment." Explanation: An infant's body comprises a high percentage of fluid that can be lost very quickly when vomiting, fever, and diarrhea are all present. This infant needs to be seen by the physician based on her age and symptoms; hospitalization may be necessary for intravenous rehydration depending upon her status when assessed.
A nurse caring for an infant born with a cleft palate notices that the parents rarely interact with their child. The nurse overhears the mother telling her spouse that she "feels like crying" every time she looks at their infant. What would be the best response from the nurse? "I sense you could use more information on caring for a cleft palate. Would you be interested in meeting with other parents who have dealt with this?" "Your infant needs you right now. You should put your negative feelings about the condition aside for your infant's sake." "Many infants are born with this condition. Your infant's palate is not nearly as bad as some cases." "Keep in mind that your infant's condition is not life-threatening and can be corrected eventually."
"I sense you could use more information on caring for a cleft palate. Would you be interested in meeting with other parents who have dealt with this?" Explanation: For many parents, having their infant born with a cleft lip or palate is overwhelming and to some even appalling. The nurse can support the parents by acknowledging their normal feelings of guilt, anger, and sadness. The nurse should support the family's adjustment to an infant's condition by demonstrating an accepting, caring attitude toward the child and family and providing the parents with opportunities and support for normal infant-parent interactions. Many parents need additional support outside the hospital or during surgical repairs. Parent-to-parent support groups are available and parents should be given information about to how to contact a local group. It may be difficult for a parent to bond with an infant who the parent feels is not perfect and those feeling cannot be easily dismissed. It does not matter if the defect is not life-threatening; it is still important to the parents and requires much skill to repair and heal. Stating this is being judgmental.
The nurse is providing discharge teaching regarding oral fluid rehydration to a mother who brought her child to the clinic because of vomiting over the past 2 days. The child is mildly dehydrated. Which comments by the mother indicated learning occurred? "I should not give my child any fluids for 1 to 2 hours after an episode of vomiting." "My child can drink milk if he feels like it to help in rehydration." "Oral rehydration solutions (ORS) are good sources of fluids for rehydration." "I should be sure my child receives 50 to 100 ml/kg of oral rehydration solution (ORS) over 4 hours." "Solutions like Pedialyte are not necessary for mild dehydration."
"I should not give my child any fluids for 1 to 2 hours after an episode of vomiting." "Oral rehydration solutions (ORS) are good sources of fluids for rehydration." "I should be sure my child receives 50 to 100 ml/kg of oral rehydration solution (ORS) over 4 hours." Explanation: In the child with mild to moderate dehydration resulting from vomiting, withhold oral feeding for 1 to 2 hours after emesis, after which time oral rehydration can begin. Tap water, milk, undiluted fruit juice, soup, and broth are not appropriate for oral rehydration. Oral rehydration solutions include Pedialyte, Infalyte, and Ricelyte. The recommendation for children with mild to moderate dehydration is 50 to 100 ml/kg of ORS over 4 hours.
A nurse is caring for a 6-year-old girl recently diagnosed with celiac disease and is discussing dietary restrictions with the girl's mother. Which response indicates a need for further teaching? "My daughter is eating more vegetables." "There is gluten hidden in unexpected foods." "There are many types of flour besides wheat." "My daughter can eat any kind of fruit."
"My daughter can eat any kind of fruit." Explanation: While most fruits and fruit juices are allowed, the nurse needs to make sure the mother knows that some fruit pie fillings and dried fruit may contain gluten.
The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac disease. The caregivers make the following statements. Which statement indicates a need for further teaching regarding the dietary restrictions for the child with celiac disease? "The soup we eat at our house is all made from scratch." "She loves hot dogs, and we always cut hers up into small pieces." "I have learned to make my own bread with no gluten." "Even though milk and pudding are good for her, we don't give her those foods."
"She loves hot dogs, and we always cut hers up into small pieces." Explanation: Commercially canned creamed soups, cold cuts, frankfurters, and pudding mixes generally contain wheat products and should not be included in the diet of the child with celiac syndrome. This caregiver needs further teaching regarding giving her child hot dogs, even if they are cut into small pieces. The other choices show an understanding of the dietary restrictions.
The student nurse is preparing a presentation on celiac disease. What information should be included? Select all apply. "Symptoms of celiac disease include diarrhea, steatorrhea, anemia, and dental disorders." "Most children with celiac disease are diagnosed within the first year of life." "The only treatment for celiac disease is a strict gluten-free diet." "Gluten is found in most wheat products, rye, barley and possibly oats." "The entire family will need to eat a gluten-free diet."
"Symptoms of celiac disease include diarrhea, steatorrhea, anemia, and dental disorders." "The only treatment for celiac disease is a strict gluten-free diet." "Gluten is found in most wheat products, rye, barley and possibly oats." Explanation: Celiac disease is an immunologic disorder in which gluten causes damage to the small intestine. The only treatment currently is consuming a gluten-free diet. While the child needs to have a gluten-free diet, the rest of the family does not. Most children present by the age of 2 for evaluation. Symptoms of celiac disease include diarrhea, constipation, steatorrhea, weight loss, poor muscle tone, anemia and dental disorders. Gluten is found in most grains, like wheat, rye, barley and possibly oats.
The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac syndrome. Which foods would be permitted in the diet of the child with celiac syndrome? Select all that apply. Applesauce Bananas Skim milk Rye bread Wheat bread
Applesauce Bananas Skim milk Explanation: The child is usually started on a gluten-free, low-fat diet. Skim milk and bananas are usually well tolerated. Lean meats, puréed vegetables, and fruits are gradually added to the diet. Wheat, rye, and oats (unless specifically gluten free) are not included in the diet.
The nurse observes the interactions of parents with their infant who was born with a cleft lip. The mother is attempting to feed the baby, but does not make eye contact. The father is watching television with his back turned to the mother and baby. What psychosocial nursing intervention would be most helpful to this family? Ask the parents if they have any questions regarding the care of their child. Explain to the parents that surgical intervention will fix the defect in the baby's lip. Teach the mother the appropriate technique for breastfeeding an infant with cleft lip. Refer the family to a social worker or mental health practitioner.
Ask the parents if they have any questions regarding the care of their child. Explanation: The family's emotional response to the birth of a child with cleft lip, palate, or both may range from grief to anger to denial. The nurse should encourage the parents to express their feelings and provide the parents with opportunities and support for normal infant-parent interactions.
The nurse observes the interactions of parents with their infant who was born with a cleft lip. The mother is attempting to feed the baby, but does not make eye contact. The father is watching television with his back turned to the mother and baby. What psychosocial nursing intervention would be most helpful to this family? Ask the parents if they have any questions regarding the care of their child. Explain to the parents that surgical intervention will fix the defect in the baby's lip. Teach the mother the appropriate technique for breastfeeding an infant with cleft lip. Refer the family to a social worker or mental health practitioner.
Ask the parents if they have any questions regarding the care of their child. Explanation: The family's emotional response to the birth of a child with cleft lip, palate, or both may range from grief to anger to denial. The nurse should encourage the parents to express their feelings and provide the parents with opportunities and support for normal infant-parent interactions.
The nurse is taking a health history of a 2-year-old girl presenting with a sudden onset of severe vomiting. Which description would suggest an obstruction? Bilious vomiting Projectile vomiting Effortless vomiting Bloody vomiting
Bilious vomiting Explanation: The contents and character of the vomitus may give clues to the cause of vomiting. Bilious vomiting is never considered normal and suggests an obstruction. Projectile vomiting is associated with pyloric stenosis. The gender and the age of the child are not consistent with pyloric stenosis. Effortless vomiting is often seen in gastroesophageal reflux. Bloody emesis can signify esophageal or gastrointestinal bleeding.
A child presents with intermittent abdominal pain, severe anorexia, and diarrhea. The child's height and weight are significantly behind standards for age. There is skin breakdown in the anal region. The nurse explains that this presentation is consistent with which diagnosis? Crohn disease ulcerative colitis food poisoning Hirschsprung disease
Crohn disease Explanation: Intermittent abdominal pain, anorexia, diarrhea, growth delays, and perianal lesions are characteristic of Crohn disease. In ulcerative colitis, the pain is continuous with bloody diarrhea, but anorexia, weight loss, and growth delay are mild. Food poisoning is an acute condition and may result in weight loss but not growth delays. In Hirschsprung disease the bowel lacks nerve innervation, so it lacks motility and fecal output.
The nurse is caring for a child admitted with gastroesophageal reflux (GER). Which clinical manifestation would likely be seen in this child? Effortless vomiting just after the child has eaten Forceful vomiting followed by the child being eager to eat again Severe constipation with occasional ribbon-like stools Bouts of diarrhea with failure to gain weight
Effortless vomiting just after the child has eaten Explanation: The child with GER usually gains weight and feeds well. It must be determined if there are underlying symptoms or complications that might suggest GERD. In the child with GERD, almost immediately after feeding, the child vomits the contents of the stomach. The vomiting is effortless, not projectile in nature. The child with GERD is irritable and hungry, but may refuse to eat. Aspiration after vomiting may lead to respiratory concerns, such as apnea, wheezing, cough, and pneumonia. Failure to thrive and lack of normal weight gain occurs. Symptoms seen in the older child may include heartburn, nausea, epigastric pain, and difficulty swallowing. Forceful vomiting with the child wanting to eat shortly after vomiting is associated with pyloric stenosis. Severe constipation with ribbon-like stools would be indicative of Hirschsprung disease. Bouts of diarrhea with failure to gain weight is associated with Crohn disease.
The mother of a newborn with a cleft lip reports she is having a hard time looking her baby. What is the best action by the nurse? Explain that surgery will make this better in the future. Encourage the mother to provide care for her infant. Encourage the child's mother to hold her infant against her shoulder to provide closeness while not looking at the defect. Tell the mother that while this is difficult it will get easier.
Encourage the mother to provide care for her infant. Explanation: Providing care to the infant is the best means for the mother to begin bonding with her baby. Activities such as feeding, diapering and bathing will be helpful. Encouraging the mother to avoid looking at the cleft lip will not assist her in the process of accepting it. While surgery will be performed it will not take place for a few months. making it vital that she begin bonding with her infant. Telling the parent she will get used to it minimizes her concerns and is not the most therapeutic response by the nurse.
A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease? Gastroenteritis Ulcerative colitis (UC) Hirschsprung disease Short bowel syndrome (SBS)
Hirschsprung disease Explanation: The nurse should suspect Hirschsprung disease when the newborn does not pass meconium in the first 24 hours after birth, and has bilious vomiting or abdominal distention and feeding intolerance with bilious aspirates and vomiting. Typical signs and symptoms of gastroenteritis include diarrhea, nausea, vomiting, and abdominal pain. The characteristic GI manifestation of UC is bloody diarrhea accompanied by crampy, typically left-sided lower abdominal pain. Clinical manifestations of untreated SBS include profuse watery diarrhea, malabsorption, and failure to
A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease? Gastroenteritis Ulcerative colitis (UC) Hirschsprung disease Short bowel syndrome (SBS)
Hirschsprung disease Explanation: The nurse should suspect Hirschsprung disease when the newborn does not pass meconium in the first 24 hours after birth, and has bilious vomiting or abdominal distention and feeding intolerance with bilious aspirates and vomiting. Typical signs and symptoms of gastroenteritis include diarrhea, nausea, vomiting, and abdominal pain. The characteristic GI manifestation of UC is bloody diarrhea accompanied by crampy, typically left-sided lower abdominal pain. Clinical manifestations of untreated SBS include profuse watery diarrhea, malabsorption, and failure to thrive.
A child is hospitalized with dehydration as a result of rotavirus. When reviewing the plan of treatment, what can the nurse anticipate will be included? Select all that apply. antidiarrheal agents antibiotic therapy IV fluid administration monitor of intake and output daily weight assessment
IV fluid administration monitor of intake and output daily weight assessment Explanation: Rotavirus is viral in nature. Antibiotic therapy is not used in the care and treatment of a viral infection. Antidiarrhea medications are not utilized as they are not effective. Intake and output will be observed. Daily weight will aid in the determination of hydration status. IV fluids may be indicated in the rehydration process.
An infant brought to the emergency department has been vomiting for 2 days. The nurse assesses the infant and finds sunken fontanels (fontanelles), tenting skin, dry mucus membranes and no urine output for 12 hours. Which intervention(s) will the nurse complete as first-line care for this infant? Select all that apply. Insert a peripheral IV. Begin maintenance IV fluids. Start oral rehydration. Administer a prescribed IV fluid bolus. Administer an antiemetic.
Insert a peripheral IV. Administer a prescribed IV fluid bolus. Administer an antiemetic. Explanation: This infant is showing signs of severe dehydration. These symptoms include sunken fontanels (fontanelles), tenting of the skin, dry mucus membranes, delayed capillary refill, an increased heart rate and a urine output of less than 1ml/kg/hr. The nurse will need to insert a peripheral IV and begin the prescribed bolus IV infusion. After the bolus has been completed, the infant would need to be reassessed for urine output and symptom improvement. The health care provider would then prescribe another IV bolus or begin maintenance IV fluids. Antiemetics can be prescribed if necessary. Oral rehydration is used for mild or moderate dehydration.
A 9-month-old girl is brought to the emergency room with what appears to be bouts of intense abdominal pain 15 minutes apart in which she draws up her legs and cries, often accompanied by vomiting. In between the bouts, the child recovers and appears to be without symptoms. Blood is found in the stool. What condition should the nurse suspect in this case? Intussusception Volvulus with malrotation Necrotizing enterocolitis Short-bowel/short-gut syndrome
Intussusception Explanation: Intussusception, the invagination of one portion of the intestine into another, usually occurs in the second half of the first year of life. Children with this disorder suddenly draw up their legs and cry as if they are in severe pain; they may vomit. After the peristaltic wave that caused the discomfort passes, they are symptom-free and play happily. In approximately 15 minutes, however, the same phenomenon of intense abdominal pain strikes again. After approximately 12 hours, blood appears in the stool and possibly in vomitus, described as a "currant jelly" appearance. Volvulus with malrotation and necrotizing enterocolitis typically occur in the first 6 months of life and do not match the symptoms described above. Short-bowel/short-gut syndrome typically occurs when a large portion of the intestine has been removed due to a previous disease or trauma.
A mother calls the doctor's office and tells the nurse that she is concerned because her 4-month-old keeps "spitting up" with every feeding. What would indicate that the child is regurgitating as opposed to vomiting? Only occurs with feeding Is projected 1 ft away from infant Is curdled and extremely sour smelling Continues until stomach is empty
Only occurs with feeding Explanation: Regurgitation typically occurs only with feeding, runs out of the mouth with little force, smells barely sour and is only slightly curdled, appears to cause no pain or distress, occurs only once per feeding, and amounts to only about 1 to 2 tsp. Vomiting may occur at times other than feeding, is forceful and is typically projected 1 ft or more away from infant, is extremely sour smelling and curdled, is typically accompanied by crying, continues until the stomach is empty, and amounts to the full stomach contents.
A mother is alarmed because her 6-week-old boy has begun vomiting almost immediately after every feeding. In the past week, the vomiting has grown more forceful, with the vomit projecting several feet from his mouth. He is always hungry again just after vomiting. At the physician's office, the nurse holds the child and offers him a bottle. While he drinks, the nurse notes an olive-size lump in his right abdomen. Which condition should the nurse suspect in this child? Pyloric stenosis Peptic ulcer disease Gastroesophageal reflux Appendicitis
Pyloric stenosis Explanation: With pyloric stenosis, at 4 to 6 weeks of age, infants typically begin to vomit almost immediately after each feeding. The vomiting grows increasingly forceful until it is projectile, possibly projecting as much as 3 to 4 feet. Infants are usually hungry immediately after vomiting because they are not nauseated. A definitive diagnosis can be made by watching the infant drink. If a pyloric stenosis is present, the sphincter feels round and firm, approximately the size of an olive in the right abdomen. Peptic ulcer disease in neonates usually presents with hematemesis (blood in vomitus) or melena (blood in the stool). Gastroesophageal reflux involves a small (1-2 tsp) volume and is not forceful. Appendicitis typically begins with anorexia for 12 to 24 hours; children do not eat and do not act like their usual selves. Nausea and vomiting may then occur, followed by diffuse abdominal pain.
The nurse is caring for a 6-month-old infant with diarrhea and dehydration. The parent is concerned because the infant has some patches on the tongue. Which feature indicates a geographic tongue? Some patches are light in color and other patches are dark in color. The patches are thick, white plaques on the tongue. There are also plaques on the buccal mucosa. There are also white patches on the erupted teeth.
Some patches are light in color and other patches are dark in color. Explanation: A geographic tongue is a benign, noncontagious condition characterized by a reduction in the filiform papillae. Oral candidiasis (thrush) is characterized by thick, white plaques that form on the tongue. With thrush, plaques also appear on the buccal mucosa and often occur concomitantly in the diaper area. There would not be any patches on the few teeth the infant may have by that age.
The nurse is caring for a 6-month-old infant who was admitted to the emergency room 24 hours ago with signs of severe diarrhea. The infant's rectal temperature is 104°F (40°C), with weak and rapid pulse and respirations. The skin is pale and cool. The child is on IV rehydration therapy, but the diarrhea is persisting. The infant has not voided since being admitted. Which is the priority nursing intervention? Take a stool culture Administer antibiotic therapy Administer IV potassium Feed the child a cracker
Take a stool culture Explanation: Treatment of severe diarrhea focuses on regulating electrolyte and fluid balance by initiating a temporary rest for the gastrointestinal tract, oral or IV rehydration therapy, and discovering the organism responsible for the diarrhea. All children with severe diarrhea or diarrhea that persists longer than 24 hours should have a stool culture taken to determine if bacteria are causing the diarrhea; if so, a definite antibiotic therapy can be prescribed. Because a side effect of many antibiotics is diarrhea, antibiotics should not routinely be used to treat diarrhea without an identifiable bacterial cause. Before the initial IV fluid is changed to a potassium solution, be certain the infant or child has voided—proof that the kidneys are functioning; in this case, the child is not voiding yet. The child should not be fed a cracker, as the gastrointestinal tract should be rested until the diarrhea stops.
The nurse is assessing a 10-day-old infant for dehydration. Which finding indicates severe dehydration? Pale and slightly dry mucosa Blood pressure of 80/42 mm Hg Tenting of skin Soft and flat fontanels (fontanelles)
Tenting of skin Explanation: Tenting of skin is an indicator of severe dehydration. Soft and flat fontanels (fontanelles) indicate mild dehydration. Pale and slightly dry mucosa indicates mild or moderate dehydration. Blood pressure of 80/42 mm Hg is a normal finding for an infant.
The nurse is reviewing the blood urea nitrogen (BUN) results of an assigned client. The test is elevated. What factors may be associated with this result? Select all that apply. The child may be dehydrated. The child may be experiencing water intoxication. The child's diet contains high levels of protein. The child has type 1 diabetes. There may be an infectious process in the child.
The child may be dehydrated. The child's diet contains high levels of protein. There may be an infectious process in the child. Explanation: Blood urea nitrogen may be elevated with a high-protein diet or dehydration, and may be decreased with overhydration or water intoxication. There is no direct link between this test and the presence of diabetes. BUN levels may be increased with an infectious process such as glomerulonephritis.
What occurs in the gastrointestinal system of the child with Hirschsprung disease? There is a partial or complete mechanical obstruction in the intestine. There is a severe narrowing of the lumen of the pylorus. There is an invagination or telescoping of one portion of the bowel into a distal portion. There is a relaxed sphincter in the lower portion of the esophagus.
There is a partial or complete mechanical obstruction in the intestine. Explanation: Congenital aganglionic megacolon, also called Hirschsprung disease, is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. A narrowing of the lumen of the pylorus is associated with pyloric stenosis in young infants. The telescoping of the bowel is intussusception. The relaxed sphincter in the lower portion of the esophagus is related to gastrointestinal reflux disorder.
The nurse is talking with a pregnant client about cleft lips and palates. The client has asked if these can be tested for. What information should be included in the nurse's response? Select all that apply. The quadruple marker test can be used to detect these conditions. There are no ways to determine the presence of cleft lips or palates prior to delivery. Ultrasounds can be used to assess for these conditions. Most cleft lips and palates are found at delivery. The nuchal translucency test can be used to screen for cleft lips and palates.
Ultrasounds can be used to assess for these conditions. Most cleft lips and palates are found at delivery. Explanation: Ultrasounds can be used to identify the presence of cleft lips or palates. Most, however, are found after birth. The quadruple screening test assesses for potential down syndrome and neuro tube defects. Nuchal translucency testing is used to assess for Down syndrome.
A 6-week-old infant is diagnosed with pyloric stenosis. When taking a health history from the parent, which symptom would the nurse expect to hear described? Refusal to eat Vomiting about 2 hours after feeding Chronic diarrhea Vomiting immediately after feeding
Vomiting immediately after feeding Explanation: With pyloric stenosis the circular muscle pylorus is hypertrophied. This thickness causes gastric outlet obstruction. The condition is seen in younger infants starting at 3 to 6 weeks of age. The infant has projectile nonbilious vomiting. It occurs directly after eating and is not related to the feeding position. The infant is hungry shortly after eating. There is weight loss and/or dehydration. The treatment is a pyloromyotomy to reduce the increased size and increase the opening. Diarrhea is not associated with the disorder.
The health care provider prescribes an abdominal radiograph for a newborn to check for Hirschsprung disease. The nurse examines the newborn and finds which symptoms that are indicative of this disease? Select all that apply. abdominal distention absence of stool in the rectum enterocolitis bilious vomiting displaced anus presence of a fistula
abdominal distention absence of stool in the rectum enterocolitis bilious vomiting Explanation: Hirschsprung disease is a movement disorder of the intestinal tract. The ganglion are missing, which causes inadequate motility. The nurse should suspect Hirschsprung disease when the newborn does not pass meconium in the first 24 hours after birth and has bilious vomiting or has abdominal distention, feeding intolerance with bilious aspirates, and vomiting. In anorectal malformations, the anus is absent or displaced and the presence of a fistula may be noted when gas or stool is expelled from the urethra or vagina.
A mother brings her 3-year-old son to the ER and tells the triage nurse that he has been vomiting blood. A medical history determines that the 3-year-old has no history of GI disturbances and his only symptoms are a slightly elevated fever and vomiting bright red blood. Based on these symptoms, what condition might the nurse suspect? GI tract obstruction intussusception gastroesophageal reflux acute upper GI bleeding
acute upper GI bleeding Explanation: Vomiting bright red blood indicates acute upper GI bleeding. Emesis containing brown, foul-smelling stool indicates GI obstruction. Stool with red blood and mucus is associated with intussusception. Bleeding is not generally indicative of gastroesophageal reflux.
The nurse is caring for a 2-year-old child with a gastrointestinal infection resulting in 4 to 5 liquid stools per day over the past 3 days. Based on this information, which important concern(s) will the nurse address in the child's care? Select all that apply. fluid deficiency risk: dehydration diarrhea and loss of electrolytes the risk for skin maceration in the perineum undernourishment risk: malnutrition availability of parents to care for the child
fluid deficiency risk: dehydration diarrhea and loss of electrolytes the risk for skin maceration in the perineum Explanation: Four to five loose stools per day are considered diarrhea. The child is at risk for fluid and electrolyte deficiency given the length of time and number of stools per day. The risk for skin maceration can occur in the perianal area because of the prolonged skin exposure to liquid stools. The child does not have malnutrition. Malnutrition is defined as a condition that results from a nutrient deficiency or overconsumption. Parental presence to care for the child can be addressed after the immediate needs of the child are addressed.
A child has been admitted to the acute care facility for the management of dehydration. The nurse is preparing to administer intravenous fluid replacement to the child. Which fluids are suitable for use? Select all that apply. lactated Ringer's normal saline 5% dextrose in water 0.45% saline 10% dextrose in water
lactated Ringer's normal saline Explanation: Intravenous fluids can be used to treat dehydration. The fluids used need to be isotonic. Examples of isotonic fluids include normal saline and Ringer's lactate solution.
The nurse is caring for a newborn with a cleft palate. Which findings in the maternal medical record are considered to be contributing factors? Select all that apply. maternal tobacco use moderate maternal alcohol use prior to pregnancy maternal age less than 18 years anticonvulsant therapy used to manage a seizure disorder reports of marijuana use in early pregnancy
maternal tobacco use anticonvulsant therapy used to manage a seizure disorder Explanation: Certain risk factors from the mother may have contributed to the infant being born with a cleft palate. These include maternal smoking, prenatal infection, advanced maternal age, and use of anticonvulsants or steroids.
The nurse is reviewing the medical record of a child with a cleft lip and palate. When reviewing the child's history, what would the nurse identify as a risk factor for this condition? mother age 42 with pregnancy maternal use of acetaminophen in third trimester preterm birth history of hypoxia at birth
mother age 42 with pregnancy Explanation: Advanced maternal age is a risk factor for cleft lip and palate. Drugs such as anticonvulsants, steroids, and other medications during early pregnancy are considered risk factors. Acetaminophen is not associated with an increased risk for cleft lip and palate. Preterm birth is not a risk factor for the development of cleft lip and palate. Hypoxia or anoxia is a risk factor for the development of necrotizing enterocolitis.
The nurse teaches a parent to differentiate between regurgitation and vomiting in the infant. The parent correctly states which characteristic of regurgitation? Select all that apply. occurs with feeding no appearance of distress followed by dry retching forceful expulsion of stomach contents timing unrelated to feeding
occurs with feeding no appearance of distress Explanation: Regurgitation occurs with feeding; the infant does not exhibit signs of distress. Forceful expulsion of stomach contents that is followed by dry retching unrelated to feeding are characteristics of vomiting.
A toddler is being seen in the clinic. The parents describe a 2-day history of vomiting and diarrhea. The nurse's assessment finds the toddler is listless, has pale and slightly dry mucus membranes and has decreased skin turgor. Based on this assessment, what intervention would the nurse implement first? oral rehydration therapy bolus IV fluids administer an antiemetic administer an antidiarrheal
oral rehydration therapy Explanation: This toddler is exhibiting signs of moderate dehydration. In addition to a dry mucus membrane, being listless and having decreased skin turgor, the nurse may also assess a higher heart rate than expected, mildly sunken eye orbits, delayed capillary refill and the urine output of less than 1ml/kg/hr. The treatment for moderate dehydration is oral rehydration therapy (ORT). The toddler should receive 50 to 100 ml/kg over a 4-hour period. The initial intake should be very small, about 0.5 to 2 ounces every 15 minutes. This can be progressed as the toddler tolerates. If the toddler vomits, the ORT should be held for 1 hour before restarting. A bolus IV is used to treat severe dehydration. Administering an antiemetic or antidiarrheal may or may not be needed, so these cannot be the first choice for treatment.
A toddler is being seen in the clinic. The parents describe a 2-day history of vomiting and diarrhea. The nurse's assessment finds the toddler is listless, has pale and slightly dry mucus membranes and has decreased skin turgor. Based on this assessment, what intervention would the nurse implement first? oral rehydration therapy bolus IV fluids administer an antiemetic administer an antidiarrheal
oral rehydration therapy Explanation: This toddler is exhibiting signs of moderate dehydration. In addition to a dry mucus membrane, being listless and having decreased skin turgor, the nurse may also assess a higher heart rate than expected, mildly sunken eye orbits, delayed capillary refill and the urine output of less than 1ml/kg/hr. The treatment for moderate dehydration is oral rehydration therapy (ORT). The toddler should receive 50 to 100 ml/kg over a 4-hour period. The initial intake should be very small, about 0.5 to 2 ounces every 15 minutes. This can be progressed as the toddler tolerates. If the toddler vomits, the ORT should be held for 1 hour before restarting. A bolus IV is used to treat severe dehydration. Administering an antiemetic or antidiarrheal may or may not be needed, so these cannot be the first choice for treatment.
The nurse is obtaining the history of an infant with a suspected intestinal obstruction. Which response regarding newborn stool patterns would indicate a need for further evaluation for Hirschsprung disease? passed a meconium stool in the first 24 to 48 hours of life has had diarrhea for 3 days constipated and passing gas for 2 days passed a meconium plug
passed a meconium plug Explanation: If the parent reports that the child passed a meconium plug, the infant should be evaluated for Hirschsprung disease. Constipation, not diarrhea, is associated with this condition; however, constipation alone would not necessarily warrant further evaluation for Hirschsprung disease. Passing a meconium stool in the first 24 to 48 hours of life is normal.
The nurse is positioning an infant who has just had his left-sided cleft lip repaired. What positions are acceptable for this infant? Select all that apply. left side-lying right side-lying supine prone high Fowler
right side-lying supine Explanation: It is critical to prevent injury to the facial suture line or to the palatal operative sites. Do not allow the infant to rub the facial suture line. To prevent this, position the infant in a supine or side-lying position (opposite side of the cleft lip).
A 3-month-old is admitted with severe diarrhea. Yesterday, the infant weighed 11 pounds (5 kg). Today, this infant weighs 9 pounds, 8 ounces (4.3 kg). Based on this information the nurse documents that the infant has: severe dehydration. failure to thrive. malabsorption syndrome. risk for fluid volume deficit.
severe dehydration. Explanation: A loss of more than 10% of body weight in a day is a sign of severe dehydration. Failure to thrive and malabsorption syndrome are long-term conditions, not objectively defined by a 24-hour weight change. This child is no longer at risk for a fluid volume deficit but is showing signs of dehydration.
A group of nursing students are reviewing information about celiac disease. The students demonstrate understanding of this disorder when they identify which classic symptoms? Select all that apply. steatorrhea constipation diarrhea failure to thrive sunken abdomen polycythemia
steatorrhea constipation diarrhea failure to thrive Explanation: Classic symptoms of celiac disease include steatorrhea, constipation, diarrhea, failure to thrive, weight loss, abdominal distention or bloating (not a sunken abdomen), and anemia (not polycythemia).
The caregiver of a child diagnosed with celiac disease tells the nurse that the child has large amounts of bulky stools and what looks like fat in the stools. The clinical manifestation this caregiver is describing is: steatorrhea. severe diarrhea. currant jelly stools. projectile stools.
steatorrhea. Explanation: Celiac disease is an immunologic response to gluten, which causes damage to the small intestine. Steatorrhea (fatty stools) is a classic symptom of celiac disease. Symptoms also include abdominal distention or bloating, constipation, and nutritional deficiencies. Currant jelly stools are a sign of intussusception. Projectile vomiting is a sign of pyloric stenosis. Severe diarrhea could be caused by a bacteria or virus. Projectile stools represent severe diarrhea.
The parents of a 4-week-old report that their infant has forceful vomiting but seems very hungry immediately after vomiting. Upon further questioning, the nurse notifies the physician of the findings and pyloric stenosis is suspected. The nurse prepares the parents for the possibility of which diagnostic procedures and treatment? upper GI series pyloric ultrasound physical examination of the abdomen surgical repair CT scan
upper GI series pyloric ultrasound physical examination of the abdomen surgical repair Explanation: Frequently, a diagnosis is made with the client history and palpation of a hard, moveable "olive" mass in the right upper quadrant. If no mass is palpated, the most common diagnostic procedure is a pyloric ultrasound. An upper GI series is sometimes performed, but this test is much more invasive than an ultrasound. Surgical repair is necessary. A CT scan is not warranted.
A child weighing 10 kg is admitted with severe vomiting for the past 3 days. The nurse writes a nursing diagnosis of Risk for deficient fluid volume related to vomiting. When the nurse reassesses the child, which outcomes would indicate the effectiveness of the treatment plan? Select all that apply. urine specific gravity of 1.008 urine output of 15 mL/hour tolerating sips of clear fluids poor skin turgor on abdomen drinks 16 ounces of milk per nursing shift
urine specific gravity of 1.008 urine output of 15 mL/hour tolerating sips of clear fluids Explanation: Outcome criteria include: skin turgor remains good; specific gravity of urine is 1.003 to 1.030, and urine output is more than 1 ml/kg/hr; and tolerating sips of clear fluids. Drinking large volumes of whole milk can increase the vomiting.
