Chapter 41: Gastrointestinal Dysfunction

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

C Pressure on the bowel from obstruction leads to passage of "currant jelly" stools. Ribbon-like stools are characteristic of Hirschsprung's disease. With intussusception, passage of bloody mucus-coated stools occurs. Stools will not be hard. Loose, foul-smelling stools may indicate infectious gastroenteritis.

During the first few days after surgery for cleft lip, which intervention should the nurse do? a. Leave infant in crib at all times to prevent suture strain. b. Keep infant heavily sedated to prevent suture strain. c. Remove restraints periodically to cuddle infant. d. Alternate position from prone to side-lying to supine.

C The nurse should remove restraints periodically, while supervising the infant, to allow him or her to exercise arms and to provide cuddling and tactile stimulation. 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.

Caring for the newborn with a cleft lip and palate before surgical repair includes: a. Gastrostomy feedings. b. Keeping the infant in near-horizontal position during feedings. c. Allowing little or no sucking. d. Providing satisfaction of sucking needs.

D Using special or modified nipples for feeding techniques helps to meet the infant's sucking needs. 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.

An infant with short bowel syndrome will be discharged home on total parenteral nutrition (TPN) and gastrostomy feedings. Nursing care should include: a. Preparing the family for impending death. b. Teaching the family signs of central venous catheter infection. c. Teaching the family how to calculate caloric needs. d. Securing TPN and gastrostomy tubing under diaper to lessen risk of dislodgment.

B During TPN therapy, care must be taken to minimize the risk of complications related to the central venous access device, such as catheter infections, occlusions, or accidental removal. This is an important part of family teaching. The prognosis for patients with short bowel syndrome depends in part on the length of residual small intestine. It has improved with advances in TPN. Although parents need to be taught about nutritional needs, the caloric needs and prescribed TPN and rate are the responsibility of the health care team. The tubes should not be placed under the diapers because of risk of infection.

The nurse is caring for a boy with probable intussusception. He had diarrhea before admission but, while waiting for administration of air pressure to reduce the intussusception, he passes a normal brown stool. The most appropriate nursing action is to: a. Notify the practitioner. b. Measure abdominal girth. c. Auscultate for bowel sounds. d. Take vital signs, including blood pressure.

A Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic/therapeutic plan of care.

What food choice by the parent of a 2-year-old child with celiac disease indicates a need for further teaching? a. Oatmeal c. Corn muffin b. Rice cake d. Meat patty

A The child with celiac disease is unable to fully digest gluten, the protein found in wheat, barley, rye, and oats. Oatmeal contains gluten and is not an appropriate food selection. Rice is an appropriate choice because it does not contain gluten. Corn is digestible because it does not contain gluten. Meats do not contain gluten and can be included in the diet of a child with celiac disease.

An important nursing consideration in the care of a child with celiac disease is to: a. Refer to a nutritionist for detailed dietary instructions and education. b. Help the 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 The main consideration is helping the child adhere to dietary management. Considerable time is spent in explaining to the child and parents the disease process, the specific role of gluten in aggravating the condition, and those 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.

The nurse is caring for a neonate with a suspected tracheoesophageal fistula. Nursing care should include: a. Elevating the head but giving nothing by mouth. b. Elevating the head for feedings. c. Feeding glucose water only. d. Avoiding suctioning unless the infant is cyanotic.

A When a newborn is suspected of having tracheoesophageal fistula, the most desirable position is supine with the head elevated on an inclined plane of at least 30 degrees. It is imperative that any source of aspiration be removed at once; oral feedings are withheld. Feedings of fluids should not be given to infants suspected of having tracheoesophageal fistulas. The oral pharynx should be kept clear of secretion by oral suctioning. This is to avoid the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx.

For what clinical manifestation should a nurse be alert when suspecting a diagnosis of esophageal atresia? a. A radiograph in the prenatal period indicates abnormal development. b. It is visually identified at the time of delivery. c. A nasogastric tube fails to pass at birth. d. The infant has a low birth weight.

C Atresia is suspected when a nasogastric tube fails to pass 10 to 11 cm beyond the gum line. Abdominal radiographs will confirm the diagnosis. Prenatal radiographs do not provide a definitive diagnosis. The defect is not externally visible. Bronchoscopy and endoscopy can be used to identify this defect. Infants with esophageal atresia may have been born prematurely and with a low birth weight, but neither is suggestive of the presence of an esophageal atresia.

A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician explained the plan of therapy and its expected good results. However, the mother refuses to see or hold her baby. Initial therapeutic approach to the mother should be to: a. Restate what the physician has told her about plastic surgery. b. Encourage her to express her feelings. c. Emphasize the normalcy of her baby and the baby's need for mothering. d. Recognize that negative feelings toward the child continue throughout childhood.

B For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse must place emphasis not only on the infant's physical needs but also on the parents' emotional needs. The mother needs to be able to express her feelings before the acceptance of her child can occur. Although discussing plastic surgery will be addressed, 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 child's normalcy is emphasized, and the mother is assisted to recognize the child's uniqueness. A focus on abnormal maternal-infant attachment would be inappropriate at this time.

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

B Giving small frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal per ounce of formula has been recommended. Milk thickening agents have been shown to decrease the number of episodes of vomiting and increase the caloric density of the formula. This may benefit infants who are underweight as a result of GERD. Placing the child in Trendelenburg position would increase the reflux. Continuous nasogastric feedings are reserved for infants with severe reflux and failure to thrive. Smaller, more frequent feedings are recommended in reflux.

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

B The suture line should be cleansed gently after feeding. The child should be positioned on back or side or in an infant seat. Elbows are restrained to prevent the child from accessing the operative site. Postural drainage is not indicated. This would increase the pressure on the operative site when the child is placed in different positions. Mouth irrigations would not be indicated.

A mother who intended to breastfeed has given birth to an infant with a cleft palate. Nursing interventions should include (Select all that apply): a. Giving medication to suppress lactation. b. Encouraging and helping mother to breastfeed. c. Teaching mother to feed breast milk by gavage. d. Recommending use of a breast pump to maintain lactation until infant can suck.

B, D The mother who wishes to breastfeed may need encouragement and support because the defect does present some logistical issues. The nipple must be positioned and stabilized well back in the infant's oral cavity so that the tongue action facilitates milk expression. The suction required to stimulate milk, absent initially, may be useful before nursing to stimulate the let-down reflex. 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.

What is the most important information to be included in the discharge planning for an infant with gastroesophageal reflux? a. Teach parents to position the infant on the left side. b. Reinforce the parents' knowledge of the infant's developmental needs. c. Teach the parents how to do infant cardiopulmonary resuscitation (CPR). d. Have the parents keep an accurate record of intake and output.

C Risk of aspiration is a priority nursing diagnosis for the infant with gastroesophageal reflux. The parents must be taught infant CPR. Correct positioning minimizes the risk for aspiration. The correct position for the infant is on the right side after feeding and supine for sleeping. Knowledge of developmental needs should be included in discharge planning for all hospitalized infants, but it is not the most important in this case. Keeping a record of intake and output is not a priority and may not be necessary.

A 3-year-old child with Hirschsprung's disease is hospitalized for surgery. A temporary colostomy will be necessary. The nurse should recognize that preparing this child psychologically is: a. Not necessary because of child's age. b. Not necessary because the colostomy is temporary. c. Necessary because it will be an adjustment. d. Necessary because the child must deal with a negative body image.

C The child's age dictates the type and extent of psychologic 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 this age child for procedures. The preschooler is not yet concerned with body image.

The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis? a. Abdominal rigidity and pain on palpation b. Rounded abdomen and hypoactive bowel sounds c. Visible peristalsis and weight loss d. Distention of lower abdomen and constipation

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

An infant with pyloric stenosis experiences excessive vomiting that can result in: a. Hyperchloremia. c. Metabolic acidosis. b. Hypernatremia. d. Metabolic alkalosis.

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.

Therapeutic management of most children with Hirschsprung's disease is primarily: a. Daily enemas. b. Low-fiber diet. c. Permanent colostomy. d. Surgical removal of affected section of bowel.

D Most children with Hirschsprung's 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's disease is usually temporary.