Child with GI disorders-PEDs Success

29. Which foods should be offered to a child with hepatitis? 1. A tuna sandwich on whole wheat bread and a cup of skim milk. 2. Clear liquids, such as broth, and Jell-O. 3. A hamburger, French fries, and a diet soda. 4. A peanut butter sandwich and a milkshake.

1 1. A diet that is high in protein and carbohydrates helps maintain caloric intake and protein stores while preventing muscle wasting. A low-fat diet prevents abdominal distention. 2. The child should be encouraged to consume a diet higher in protein. 3. The child should be encouraged to consume a low-fat diet. 4. The child should be encouraged to consume a low-fat diet. TEST-TAKING HINT: The child with hepatitis is usually placed on a diet that is high in both protein and carbohydrates but low in fat.

23. Which is the best position for an 8-year-old who has just returned to the pediatric unit after an appendectomy for a ruptured appendix? 1. Semi-Fowler. 2. Prone. 3. Right side-lying. 4. Left side-lying.

3 1. The semi-Fowler position does not provide the most comfort to the post-operative appendectomy child. 2. The prone position does not allow the nurse to visualize the incision easily and would probably be uncomfortable for the child. 3. The right side-lying position promotes comfort and allows the peritoneal cavity to drain. 4. The left side-lying position may not provide as much comfort and will not allow the peritoneal cavity to drain as freely as the right side-lying position. TEST-TAKING HINT: The test taker should be led to answer 3 because lying on the same side as the abdominal incision is usually the most comfortable for the child.

12. Which discharge instruction for a child diagnosed with encopresis should the nurse question? 1. Limit the intake of milk. 2. Offer a diet high in protein. 3. Obtain a complete dietary log. 4. Follow up with a child psychologist.

2 . 1. Dairy products are limited as they can lead to constipation. 2. A diet high in protein will cause more constipation. 3. A complete dietary log should be kept to help correlate the foods that lead to constipation. 4. The child and family are encouraged to seek counseling, as there is often a psychological component to encopresis. TEST-TAKING HINT: Recall the developmental needs of children and successful approaches to meet their needs.

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

1, 2, 3, 4. 1. The lights in phototherapy increase insensible fluid loss, requiring the nurse to monitor fluid status closely. 2. The infant with pyloric stenosis is likely to be dehydrated due to persistent vomiting. 3. A 2-year-old with pneumonia may have increased insensible fluid loss due to tachypnea associated with respiratory illness. The nurse needs to monitor fluid status cautiously because fluid overload can result in increased respiratory distress. 4. The child with a burn experiences extensive extracellular fluid loss and is at great risk for dehydration. The younger child is at greater risk due to greater proportionate body surface area. 5. An adolescent starting her menses is not at risk for dehydration. TEST-TAKING HINT: The test taker needs to know that an infant needing phototherapy, an infant with persistent vomiting, a child with pneumonia, and a child with burns require more fluids because of the risk of dehydration.

50. The nurse is providing discharge instructions to the parents of an infant who has had surgery to open a low imperforate anus. The nurse knows that the discharge instructions have been understood when the child's parents say: 1. "We will use an oral thermometer because we cannot use a rectal one." 2. "We will call the physician if the stools change in consistency." 3. "Our infant will never be toilet-trained." 4. "We understand that it is not unusual for our infant's urine to contain stool."

2 1. Although a rectal thermometer should never be used in a child with an anorectal malformation, an oral thermometer should not be used in an infant or young child. 2. A change in stool consistency is important to report because it could indicate stenosis of the rectum. 3. The child with a low anorectal malformation should be capable of achieving bowel continence. 4. Any stool in the urine should be reported because it indicates a fistula is present. TEST-TAKING HINT: The test taker should eliminate answer 3 as it contains the word "never." There are very few circumstances in health care in which "never" is the case.

3. 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. 1. The information obtained from a urinalysis of an infant is not as helpful as serum electrolytes. The infant has limited ability to concentrate urine, so the specific gravity is not usually affected. 2. The information obtained from a urinalysis of an infant is not as helpful as serum electrolytes. The infant has limited ability to concentrate urine, so the specific gravity is not usually affected. A urinalysis does not need to be obtained by catheterization. 3. The analysis of serum electrolytes offers the most information and assists with the diagnosis of dehydration. 4. Although critical in diagnosing meningitis, a lumber puncture and analysis of cerebrospinal fluid are not done to confirm dehydration. TEST-TAKING HINT: Infants have limited ability to concentrate urine, so answers 1 and 2 can be eliminated immediately.

20. The nurse is administering Prilosec (omeprazole) to a 3-month-old with gastro - esophageal reflux (GER). The child's parents ask the nurse how the medication works. Select the nurse's best response. 1. "Prilosec is a proton pump inhibitor that is commonly used for reflux in infants." 2. "Prilosec decreases stomach acid, so it will not be as irritating when your child spits up." 3. "Prilosec helps food move through the stomach quicker, so there will be less chance for reflux." 4. "Prilosec relaxes the pressure of the lower esophageal sphincter."

2 . 1. Although this is an accurate description of the mechanism of action, it does not tell the parents how the medication functions. 2. This accurate description gives the parents information that is clear and concise. 3. Prilosec does not increase the rate of gastric emptying. 4. Prilosec does not relax the pressure of the lower esophageal sphincter. TEST-TAKING HINT: The test taker should eliminate answers 1 and 4 because they do not communicate information in a manner that will be clear to many parents.

57. The nurse is caring for a 1-month-old term infant who experienced an anoxic episode at birth. The health-care team suspects that the infant is developing necrotizing en - terocolitis (NEC). Which would the nurse expect to be included in the plan of care? 1. Immediately remove the feeding nasogastric tube (NGT) from the infant. 2. Obtain vital signs every 4 hours. 3. Prepare to administer antibiotics intravenously. 4. Change feedings to half-strength, administer slowly via a feeding pump.

3 . 1. The feedings should immediately be stopped, but the NGT should be placed to allow decompression of the stomach. 2. Vital signs should be obtained more frequently than every 4 hours because the infant is at high risk for peritonitis and sepsis. 3. Intravenous antibiotics are administered to prevent or treat sepsis. 4. Feedings are stopped immediately when a suspicion of NEC is present. TEST-TAKING HINT: The test taker needs to consider the plan of care for an infant with NEC. This child is at risk for becoming critically ill, so feedings are stopped and vital signs are monitored very closely.

10. The parents of a 4-year-old ask the nurse how to manage their child's constipation. Select the nurse's best response. 1. "Add 2 ounces of apple or pear juice to the child's diet." 2. "Be sure your child eats a lot of fresh fruit such as apples and bananas." 3. "Encourage your child to drink more fluids." 4. "Decrease bulky foods such as whole-grain breads and rice."

3 . 1. Two ounces of apple juice is most likely not a sufficient quantity to alter a 4-year-old child's bowel movements. 2. Although fresh fruits help decrease constipation, bananas tend to increase constipation. 3. Increasing fluid consumption helps to decrease the hardness of the stool. 4. Whole-grain bread is high in fiber and helps decrease constipation. TEST-TAKING HINT: Answer 1 decreases constipation in the infant but not in the preschooler.

58. More education about necrotizing enterocolitis (NEC) is needed in a nursing in-service when one of the participants states: 1. "Encouraging the mother to pump her milk for the feedings helps prevent NEC." 2. "Some sources state that the occurrence of NEC has increased because so many preterm infants are surviving." 3. "When signs of sepsis appear, the infant will likely deteriorate quickly." 4. "NEC occurs only in preemies and low-birth-weight infants."

4 . 1. It is thought that the breast milk contains macrophages that help fight infection, preventing NEC. 2. Because NEC is seen primarily in preterm and low-birth-weight infants, their increased survival rate has lead to an increase in the occurrence of NEC. 3. The infant's condition deteriorates rapidly when sepsis occurs, so early recognition and treatment are essential. 4. Although much more common in preterm and low-birth-weight infants, NEC is also seen in term infants as well. TEST-TAKING HINT: The test taker needs to be familiar with general concepts associated with NEC. Answer 4 contains the word "only," which is an absolute value that is rarely used in health care.

42. An expectant mother asks the nurse if her new baby will have an umbilical hernia. The nurse bases the response on the fact that it occurs: 1. More often in large infants. 2. In white infants more than in African American infants. 3. Twice as often in male infants. 4. More often in premature infants.

4 . 1. Umbilical hernias occur more often in low-birth-weight infants. 2. Umbilical hernias occur more often in African American infants than in white infants. 3. Umbilical hernias affect males and females equally. 4. Umbilical hernias occur more often in premature infants. TEST-TAKING HINT: The test taker needs to be familiar with the occurrence of umbilical hernias.

4. 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 D10W. 3. Administer a bolus of normal saline with 5% dextrose added to the solution. 4. Offer the child an oral rehydrating solution such as Pedialyte.

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

14. The nurse is caring for an infant newly diagnosed with Hirschsprung disease. What does the nurse understand about this infant's condition? 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.

1 1. In Hirschsprung disease, a portion of the large intestine has an area lacking in ganglion cells. This results in a lack of peristalsis as well as an accumulation of bowel contents and abdominal distention. 2. There is a lack of peristalsis at the aganglionic section of the bowel. 3. Hirschsprung disease does not include a small-bowel obstruction. 4. Hirschsprung disease does not present with inflammation throughout the large intestine. TEST-TAKING HINT: The test taker should be familiar with the pathophysiology of Hirschsprung disease in order to select answer 1.

28. Which manifestations should the nurse expect to find in a child in the early stages of acute hepatitis? 1. Nausea, vomiting, and generalized malaise. 2. Nausea, vomiting, and pain in the left upper quadrant. 3. Generalized malaise and yellowing of the skin and sclera. 4. Yellowing of the skin and sclera without any other generalized complaints.

1 1. The early stage of acute hepatitis is referred to as the anicteric phase, during which the child usually complains of nausea, vomiting, and generalized malaise. 2. A tender enlarged liver is noted in the right upper quadrant. 3. The child does not appear jaundiced until the icteric phase. 4. The child does not appear jaundiced until the icteric phase. The child usually does not feel well during the early stages of acute hepatitis. TEST-TAKING HINT: The test taker needs to be familiar with the manifestations of acute hepatitis. Knowing that the early stage is referred to as the anicteric phase, answers 3 and 4 can be eliminated.

53. The parent of a child being evaluated for celiac disease asks the nurse why it is important to make dietary changes. Select 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 1. The inability to digest protein leads to an accumulation of an amino acid that is toxic to the mucosal cells and villi, leading to absorption problems. 2. Extra villi cells are not created. Instead, villi become damaged, leading to absorption problems. 3. The intestine does not become more porous. There is difficulty with absorbing vitamins, leading to deficiencies, not toxicity. 4. The child experiences diarrhea, not constipation. TEST-TAKING HINT: The test taker needs to recall the pathophysiology of celiac disease in order to select answer 1. By recalling that the child with celiac usually appears malnourished and experiences diarrhea, the test taker can eliminate answers 3 and 4.

31. Which manifestation would the nurse expect to see in a 4-week-old infant with biliary atresia? 1. Abdominal distention, enlarged liver, enlarged spleen, clay-colored stool, and tea-colored urine. 2. Abdominal distention, multiple bruises, bloody stools, and hematuria. 3. Yellow sclera and skin tones, excessively oily skin, and prolonged bleeding times. 4. No manifestations until the disease has progressed to the advanced stage.

1 1. The infant with biliary atresia usually has an enlarged liver and spleen. The stools appear clay-colored due to the absence of bile pigments. The urine is tea-colored due to the excretion of bile salts. 2. The urine typically contains bile salts, not blood. There is usually no blood noted in the stool. 3. The skin is usually dry and itchy, not oily. 4. Manifestations of biliary atresia usually appear by 3 weeks of life. TEST-TAKING HINT: The test taker needs to be familiar with the manifestations of biliary atresia and should be led to select answer 1.

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. Select the nurse's best response. 1. "Genetics play a small role in Hirschsprung disease, so there is a chance the baby will develop it as well." 2. "There is no evidence to support a genetic link, so it is very unlikely the baby will also have it." 3. "It is rarely seen in boys, so it is not likely your new baby will have Hirschsprung disease." 4. "Hirschsprung disease is seen only in girls, so your new baby will not be at risk."

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

38. The nurse is caring for a newborn with esophageal atresia. When reviewing the mother's history, which would the nurse expect to find? 1. Maternal polyhydramnios. 2. Pregnancy lasting more than 38 weeks. 3. Poor nutrition during pregnancy. 4. Alcohol consumption during pregnancy.

1 . 1. Maternal polyhydramnios is present because the infant cannot swallow and absorb the amniotic fluid in utero. 2. Many mothers of infants with esophageal atresia deliver early due to the pressure of the unabsorbed amniotic fluid. 3. Although good nutrition is essential in every pregnancy, there is not a direct relationship between diet and esophageal atresia. 4. Although alcohol should not be consumed in any pregnancy, there is not a direct link between diet and esophageal atresia. TEST-TAKING HINT: The test taker should select answer 1 because esophageal atresia prevents the fetus from ingesting amniotic fluid, leading to increased amniotic fluid in utero.

33. Which is an accurate description of a Kasai procedure? 1. A palliative procedure in which the bile duct is attached to a loop of bowel to assist with bile drainage. 2. A curative procedure in which a connection is made between the bile duct and a loop of bowel to assist with bile drainage. 3. A curative procedure in which the bile duct is banded to prevent bile leakage. 4. A palliative procedure in which the bile duct is banded to prevent bile leakage.

1 . 1. The Kasai procedure is a palliative procedure in which the bile duct is attached to a loop of bowel to assist with bile drainage. 2. The procedure is palliative, not curative because most children require a liver transplant after a few years. 3. The Kasai procedure does not band the bile duct. 4. The Kasai procedure does not band the bile duct. TEST-TAKING HINT: The test taker can eliminate answers 2 and 3, as the majority of cases of biliary atresia require a liver transplant. The Kasai procedure is performed to give the child a few years to grow before requiring a transplant.

47. The nurse receives a call from the mother of a 6-month-old who describes her child as alternately sleepy and fussy. She states that her infant vomited once this morning and had two episodes of diarrhea. The last episode contained mucus and a small amount of blood. She asks the nurse what she should do. Select the nurse's best response. 1. "Your infant will need to have some tests in the emergency room to determine if anything serious is going on." 2. "Try feeding your infant in about 30 minutes; in the event of repeat vomiting, bring the infant to the emergency room for some tests and intravenous rehydration." 3. "Many infants display these symptoms when they develop an allergy to the formula they are receiving; try switching to a soy-based formula." 4. "Do not worry about the blood and mucus in the stool; it is not unusual for infants to have blood in their stools because their intestines are more sensitive."

1 1. The infant is displaying signs of intussusception. This is an emergency that needs to be evaluated to prevent ischemia and perforation. 2. The mother should be told not to give the infant anything by mouth and bring the infant immediately to the emergency room. 3. Although similar symptoms may be seen among infants with allergies, a more serious illness must first be ruled out. It is uncommon to see lethargy as a response to an allergy. 4. All bloody stools should be evaluated. TEST-TAKING HINT: The child is described as lethargic and is having diarrhea and vomiting. This child needs to be seen to rule out an intussusception. At the very least, the mother should be told to bring the child to the emergency room because the described signs could also be seen in severe dehydration. The test taker should be led to select answer 1.

62. The nurse is interviewing the parents of a 6-year-old who has been experiencing constipation. Which could be a causative factor? Select all that apply. 1. Hypothyroidism. 2. Muscular dystrophy. 3. Myelomeningocele. 4. Drinks a lot of milk. 5. Active in sports.

1, 2, 3, 4. 1. Hypothyroidism can be a causative factor in constipation. 2. Weakened abdominal muscles can be seen in muscular dystrophy and can lead to constipation. 3. Myelomeningocele affects the innervation of the rectum and can lead to constipation. 4. Excessive milk consumption can lead to constipation. 5. Activity tends to decrease constipation and increase regularity. TEST-TAKING HINT: The test taker has to know which of these conditions can cause constipation.

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, 3. 1. The child should not be allowed to use anything that creates suction in the mouth, such as pacifiers or straws. "Sippy" cups are acceptable. 2. The child should not have anything hard in the mouth, such as crackers, cookies, or a spoon. 3. Pain medication should be administered regularly to avoid crying, which places stress on the suture line. 4. A Yankauer suction should not be used in the mouth because it creates suction and is a hard instrument that could irritate the suture line. The child should be positioned to allow secretions to drain out of the child's mouth. Suction should be used only in the event of an emergency. 5. Elbow restraints are used until the repaired palate has healed. When at home, the parents need to monitor the child closely if restraints are removed to move the arms or for bathing. TEST-TAKING HINT: The child who has had a cleft palate repair should have nothing in the mouth that could irritate the suture line. Answers 2 and 4 can be eliminated.

32. The nurse is caring for an infant with biliary atresia. The parents ask why the child is receiving cholestyramine. Select the nurse's best response. 1. To lower your child's cholesterol. 2. To relieve your child's itching. 3. To help your child gain weight. 4. To help feedings be absorbed in a more efficient manner.

2 1. Although cholestyramine is used to lower cholesterol, its primary purpose in the child with biliary atresia is to relieve pruritus. 2. The primary reason cholestyramine is administered to the child with biliary atresia is to relieve pruritus. 3. Cholestyramine is not administered to help the child gain weight. 4. Cholestyramine does not assist with the absorption of feedings. TEST-TAKING HINT: The test taker needs to consider the manifestations of the disease process when considering why medications are administered. The liver is unable to eliminate bile, which leads to intense pruritus.

59. The nurse is caring for an infant who has been diagnosed with short bowel syndrome (SBS). The parent asks how the disease will affect the child. Select the nurse's best response. 1. "Because your child has a shorter intestine than most, your child will likely experience constipation and will need to be placed on a bowel regimen." 2. "Because your child has a shorter intestine than most, he will not be able to absorb all the nutrients and vitamins in food and will need to get nutrients in other ways." 3. "Unfortunately, most children with this diagnosis do not do very well." 4. "The prognosis and course of the disease have changed because hyperalimentation is available."

2 1. Children with SBS experience diarrhea, not constipation. 2. Because the intestine is used for absorption, children with SBS usually need alternative forms of nutrition such as hyperalimentation. 3. Without knowing how much intestine is involved, the nurse cannot make this assumption about prognosis and should not share this information with the infant's parents. 4. It is therapeutic to acknowledge the parents' concern. Without knowing the parents' knowledge base, this response may or may not be above the level of their comprehension. TEST-TAKING HINT: The test taker should eliminate answer 1 as it is false. Answer 3 can also be eliminated because it makes a generalization that should not be made without knowing the details of the child's diagnosis.

8. Which child can be discharged without further evaluation? 1. A 2-year-old who has had 24 hours of watery diarrhea that has changed to bloody diarrhea in the past 12 hours. 2. A 2-year-old who had a relapse of one diarrhea episode after restarting a normal diet. 3. A 6-year-old who has been having vomiting and diarrhea for 2 days and has decreased urine output. 4. A 10-year-old who has just returned from a Scout camping trip and has had several episodes of diarrhea.

2 1. Diarrhea containing blood needs further evaluation to determine the source of the blood and the child's blood counts and electrolyte balance. 2. It is common for children to have a relapse of diarrhea after resuming a regular diet. 3. Children who have had vomiting and diarrhea for more than 2 days require evaluation to determine if IV rehydration and hospital admission are necessary. 4. Diarrhea following a camping trip needs further evaluation because it may be due to bacteria or parasites. TEST-TAKING HINT: The test taker should eliminate answers 1 and 3 because they describe children who may have altered electrolytes and blood counts due to prolonged diarrhea.

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." Select 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 have the option of pumping your milk and then feeding 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 1. Encouraging parents to express their feelings is important, but it is more appropriate to give the parents information on breastfeeding. 2. Some mothers are able to breastfeed their infants who have a cleft lip and palate. The breast can help fill in the cleft and help the infant create suction. 3. Breastfeeding is sometimes an option. 4. Breastfeeding does not increase the risk of aspiration among infants with a cleft lip and palate. TEST-TAKING HINT: The test taker should be led to select answer 2 because the breast can sometimes act to fill in the cleft.

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

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 Tylenol (acetaminophen).

2 1. Many 3-year-olds have difficulty understanding how to use an incentive spirometer. 2. Blowing bubbles is a developmentally appropriate way to help the preschooler take deep breaths and cough. 3. In the early post-operative period, a fever is likely a respiratory issue and not a result of infection of the incision. 4. Although acetaminophen may be administered, encouraging the child to breathe deeply and cough will help prevent the fever from returning. TEST-TAKING HINT: The test taker should be aware that a fever in the first few days after surgery is generally due to pulmonary complications, so that answer 3 can be eliminated. Remembering the developmental needs of the child, the test taker should select answer 2.

43. The nurse is providing discharge teaching to the parents of an infant with an umbilical hernia. Which should be included in the plan of care? 1. If the hernia has not resolved on its own by the age of 12 months, surgery is generally recommended. 2. If the hernia appears to be more swollen or tender, seek medical care immediately. 3. To help the hernia resolve, place a pressure dressing over the area gently. 4. If the hernia is repaired surgically, there is a strong likelihood that it will return.

2 1. Most umbilical hernias resolve spontaneously by age 2 to 3 years. Surgery is not usually recommended until the age of 3 because the hernia may resolve before that. 2. If the hernia appears larger, swollen, or tender, the intestine may be trapped, which is a surgical emergency. 3. A pressure dressing should never be placed over the hernia because it can cause irritation and does not help the hernia resolve. 4. If the hernia is corrected surgically, the recurrence rate is low. TEST-TAKING HINT: The test taker should be led to select answer 2 because a change in the hernia indicates an incarcerated hernia, which is an emergency.

27. The nurse is providing discharge instructions to the parents of a child who had an appendectomy for a ruptured appendix 5 days ago. The nurse knows that further education is required when the parent states: 1. "We will wait a few days before allowing our child to return to school." 2. "We will wait 2 weeks before allowing our child to return to sports." 3. "We will call the pediatrician's office if we notice any drainage around the wound." 4. "We will encourage our child to go for walks every day."

2 1. The child should wait a few days before returning to school to avoid being easily fatigued. 2. The child should wait 6 weeks before returning to any strenuous activity. 3. Any signs of infection should be reported to the primary care provider. 4. The child should be encouraged to walk every day because it will help the bowels return to normal and help the child regain stamina. TEST-TAKING HINT: The test taker should note that the question is asking which of the answers indicate that more education is needed. Answer 2 should be selected because 2 weeks is too early to return to strenuous contact sports.

51. The nurse is caring for a neonate with an anorectal malformation. The nurse notes that the infant has not passed any stool per rectum but the infant's urine contains meconium. The nurse can make which assumption? 1. The child likely has a low anorectal malformation. 2. The child likely has a high anorectal malformation. 3. The child will not need a colostomy. 4. This malformation will be corrected with a nonoperative rectal pull-through.

2 1. The child who has stool in the urine has a fistula connecting the rectum to the urinary tract, and the anorectal malformation cannot be low. 2. The presence of stool in the urine indicates that the anorectal mal - formation is high. 3. This child probably needs a colostomy. 4. This malformation requires surgical correction. TEST-TAKING HINT: The test taker needs to consider that stool is present in the urine, indicating a fistula is present and a more complex anorectal malformation exists, so answers 1 and 4 can be eliminated.

56. Which manifestation suggests that an infant is developing necrotizing enterocolitis (NEC)? 1. Absorption of bolus orogastric feedings at a faster rate than previous feedings. 2. Bloody diarrhea. 3. Increased bowel sounds. 4. Appears hungry right before a scheduled feeding.

2 1. The feedings tend to take longer and often do not get absorbed before the next scheduled feeding. 2. Bloody diarrhea can indicate that the infant has NEC. 3. Bowel sounds tend to decrease, not increase. 4. The infant does not appear hungry but irritable. TEST-TAKING HINT: The test taker needs to be familiar with manifestations of NEC and be led to select answer 2.

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 reflux.

2 1. The fundus is wrapped around the inferior esophagus, not the inferior stomach. 2. The Nissen fundoplication involves wrapping the fundus of the stomach around the inferior esophagus, creating a lower esophageal sphincter or cardiac sphincter. 3. The fundus is not wrapped around the middle portion of the stomach. There is no benefit to decreasing the stomach's capacity. 4. The fundus of the stomach is not dilated. TEST-TAKING HINT: The test taker needs to be familiar with surgical options for GER disease.

40. The nurse is caring for a newborn who has just been diagnosed with tracheo - esophageal fistula and is scheduled for surgery. Which should the nurse expect to do in the pre-operative period? 1. Keep the child in a monitored crib, obtain frequent vital signs, and allow the parents to visit but not hold their infant. 2. Administer intravenous fluids and antibiotics. 3. Place the infant on 100% oxygen via a non-rebreather mask. 4. Have the mother feed the infant slowly in a monitored area, stopping all feedings 4 to 6 hours before surgery.

2 1. The infant should be monitored, and vital signs should be obtained frequently, but the parents should be encouraged to hold their baby. 2. Intravenous fluids are administered to prevent dehydration because the infant is NPO. Intravenous antibiotics are administered to prevent pneumonia because aspiration of secretions is likely. 3. The infant should receive only the amount of oxygen needed to keep saturations above 94%. 4. As soon as the diagnosis is made, the infant is made NPO because the risk for aspiration is extremely high. TEST-TAKING HINT: Infants with tracheo - esophageal fistula are at great risk for aspiration and subsequent pneumonia. With this knowledge, the test taker should eliminate answer 4 and select answer 2.

22. The parents of a child being evaluated for appendicitis tell the nurse the physician said their child has a positive Rovsing sign. They ask the nurse what this means. Select the nurse's best response. 1. "Your child's physician should answer that question." 2. "A positive Rovsing sign means the child feels pain in the right side of the abdomen when the left side is palpated." 3. "A positive Rovsing sign means pain is felt when the physician removes the hand from the abdomen." 4. "A positive Rovsing sign means pain is felt in the right lower quadrant when the child coughs."

2 . 1. This response is not helpful and dismisses the parent's concern. 2. A positive Rovsing sign occurs when the left lower quadrant is palpated and pain is felt in the right lower quadrant. 3. Pain that is felt when the hand is removed during palpation is called rebound tenderness. 4. Pain that is felt when the child coughs is called a positive cough sign. TEST-TAKING HINT: The test taker should immediately eliminate answer 1 because it is not therapeutic and is dismissive.

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 finding 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 1. All cases of bloody diarrhea need to be evaluated because this may be a sign of enterocolitis, which is a potentially fatal complication of Hirschsprung disease. 2. Although this is a potentially critical complication, calling a code is not necessary at this time as the infant is irritable and not unconscious. 3. All vital signs need to be evaluated because the child with enterocolitis can quickly progress to a state of shock. A quick head-to-toe assessment will allow the nurse to evaluate the child's circulatory system. 4. It is not a priority to test the stool for occult blood, as there is obvious blood in the sample. TEST-TAKING HINT: The test taker should select answer 3 because there is not enough information to determine the status of the child. Obtaining vital signs will help the nurse to assess the situation.

55. Which would the nurse expect to be included in the diagnostic workup of a child with suspected celiac disease? 1. Obtain complete blood count and serum electrolytes. 2. Obtain complete blood count and stool sample; keep child NPO. 3. Obtain stool sample and prepare child for jejunal biopsy. 4. Obtain complete blood count and serum electrolytes; monitor child's response to gluten-containing diet.

3 1. Although a blood count and serum electrolyte evaluation will likely be included in the child's evaluation, the diagnosis cannot be confirmed without a stool sample and jejuna biopsy. 2. The child is not usually kept NPO but is monitored to assess the response to the gluten-free diet. 3. A stool sample for analysis of fat and a jejunal biopsy can confirm the diagnosis. 4. The child's response to a gluten-free diet is monitored. TEST-TAKING HINT: The test taker should eliminate answers 1, 2, and 4 because they do not include preparing the child for a jejunal biopsy, which is the key to a definitive diagnosis of celiac disease.

5. 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 1. Fluid boluses of normal saline are administered according to the child's body weight. It is not unusual to have to repeat the bolus multiple times in order to see an improvement in the child's condition. 2. It is important to monitor serum electrolytes frequently in the dehydrated child. 3. Potassium is contraindicated because the child has not yet urinated. Potassium is not added to the maintenance fluid until kidney function has been verified. 4. The child with dehydration secondary to vomiting and diarrhea is placed on a clear liquid diet. TEST-TAKING HINT: Be aware of the usual ways in which dehydration is treated. Answer 3 should be selected because the description states that the child has not urinated.

7. 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 Imodium as needed. 2. Administer Kaopectate as needed. 3. Continue breastfeeding per routine. 4. The infant may return to day care 24 hours after antibiotics have been started.

3 1. Imodium slows intestinal motility and allows overgrowth of organisms and should therefore be avoided. 2. Kaopectate slows intestinal motility and allows overgrowth of organisms and should therefore be avoided. 3. Breastfeeding is usually well tolerated and helps prevent death of intestinal villi and malabsorption. 4. Antibiotics are not effective in viruses. Children should not return to day care while they are still having diarrhea. TEST-TAKING HINT: The test taker can eliminate answer 4 as antibiotics are not effective with viruses such as rotavirus. Answers 1 and 2 can be eliminated as antidiarrheal agents are not recommended in the pediatric population.

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 refeed." 4. "The baby is happy in spite of getting really upset after spitting up."

3 1. Infants with pyloric stenosis tend to be perpetually hungry because most of their feedings do not get absorbed. 2. Infants with pyloric stenosis vomit immediately after a feeding, especially as the pylorus becomes more hypertrophied. 3. Infants with pyloric stenosis are always hungry and often appear malnourished. 4. Most infants with pyloric stenosis are irritable because they are hungry. Parents do not usually describe the vomiting episodes as "spitting up" because infants tend to have projectile vomiting. TEST-TAKING HINT: Recall the dynamics of pyloric stenosis. Because feedings are not absorbed, the infant is irritable and hungry. The test taker can eliminate answers 1 and 4 and select answer 3.

25. The nurse is caring for a 5-year-old who has just returned from having an appendectomy. Which is the optimal way to manage pain? 1. Intravenous morphine as needed. 2. Liquid Tylenol (acetaminophen) with codeine as needed. 3. Morphine administered through a PCA pump. 4. Intramuscular morphine as needed.

3 1. Intravenous morphine given as needed may cause the child to have periods of pain when the medication has worn off. The child may also be hesitant to ask for pain medication, fearing an invasive procedure. 2. Liquid Tylenol with codeine may not offer sufficient pain control in the immediate post-operative period. 3. Morphine administered through a PCA pump offers the child control over managing pain. The PCA pump also has the benefit of offering a basal rate as well as an as-needed rate for optimal pain management. 4. The intramuscular route should be avoided if less invasive routes are available. A 5-year-old fears invasive procedures and may deny pain to avoid receiving an injection. TEST-TAKING HINT: The test taker recalls that PCA pumps are very effective, even in young children.

60. The nurse is caring for a 3-month-old infant who has short bowel syndrome (SBS) and has been receiving total parenteral nutrition (TPN). The parents ask if their child will ever be able to eat. Select the nurse's best response. 1. "Children with SBS are never able to eat and must receive all of their nutrition in intravenous form." 2. "You will have to start feeding your child because children cannot be on TPN longer than 6 months." 3. "We will start feeding your child soon so that the bowel continues to receive stimulation." 4. "Your child will start receiving tube feedings soon but will never be able to eat by mouth."

3 1. It is important for children with SBS to receive some feedings, either by tube or mouth, so that the intestine receives some stimulation. 2. Although TPN can cause long-term challenges, there is not an absolute time limit. 3. It is important to begin feedings as soon as the bowel is healed so that it receives stimulation and does not atrophy. 4. Feedings are provided by mouth or tube based on each child's needs. TEST-TAKING HINT: The test taker could eliminate answers 1 and 4 as they contain the word "never," which is rarely used in health-care scenarios.

41. The nurse is giving discharge instructions to the parent of a 1-month-old infant with tracheoesophageal fistula and a gastrostomy tube (GT). The nurse knows the mother understands the discharge teaching when she states: 1. "I will give my baby feedings through the GT but place liquid medications in the corner of the mouth to be absorbed." 2. "I will flush the GT with 2 ounces of water after each feeding to prevent the GT from clogging." 3. "I will clean the area around the GT with soap and water every day." 4. "I will place petroleum jelly around the GT if any redness develops."

3 1. Medications can be placed in the GT also. 2. Two ounces of water is too much water for an infant and could cause electrolyte imbalances. The tube can be flushed with 3 to 5 mL of water to prevent clogging. 3. The area around the GT should be cleaned with soap and water to prevent an infection. 4. If redness develops, the parents should call the physician because an infection could be present. TEST-TAKING HINT: The test taker should immediately eliminate answer 1 because medications and feedings can be placed in the GT. The test taker should recall that 2 ounces of water after each feeding is a large amount (recalling that infants are typically fed at least every 4 hours).

48. The nurse is caring for a 5-month-old infant with a diagnosis of intussusception. The infant has periods of irritability during which the knees are brought to chest and the infant cries, alternating with periods of lethargy. Vital signs are stable and within age-appropriate limits. The physician elects to give an enema. The parents ask the purpose of the enema. Select the nurse's most appropriate response. 1. "The enema will confirm the diagnosis. If the test result is positive, your child will need to have surgery to correct the intussusception." 2. "The enema will confirm the diagnosis. Although very unlikely, the enema may also help fix the intussusception so that your child will not immediately need surgery." 3. "The enema will help confirm the diagnosis and has a good chance of fixing the intussusception." 4. "The enema will help confirm the diagnosis and may temporarily fix the intussusception. If the bowel returns to normal, there is a strong likelihood that the intussusception will recur."

3 1. The enema is used for confirmation of diagnosis and reduction. In most cases of intussusception in young children, an enema is successful in reducing the intussusception. 2. In most cases of intussusception in young children, an enema is successful in reducing the intussusception. 3. In most cases of intussusception in young children, an enema is successful in reducing the intussusception. 4. There is not a high likelihood that the intussusception will recur. TEST-TAKING HINT: The test taker needs to be aware that intussusceptions in young children respond well to reduction by enema.

36. The nurse is caring for a 4-month-old who has just had an isolated cleft lip repaired. Select the best position for the child in the immediate post-operative period. 1. Right side-lying. 2. Left side-lying. 3. Supine. 4. Prone.

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

52. The nurse is caring for a newborn with an anorectal malformation and a colostomy. The nurse knows that more education is needed when the infant's parent states which of the following? 1. "I will make sure the stoma is red." 2. "There should not be any discharge or irritation around the outside of the stoma." 3. "I will keep a bag attached to avoid the contents of the small intestine coming in contact with the baby's skin." 4. "As my baby grows, a pattern will develop over time, and there should be predictable bowel movements."

3 1. The stoma should be red in color, indicating good perfusion. 2. Discharge or irritation around the stoma could indicate the presence of an infection. 3. The colostomy contains stool from the large intestine; an ileostomy contains the very irritating stool from the small intestine. 4. Babies usually develop a pattern to their bowel habits as they grow. TEST-TAKING HINT: Although it is important to keep a bag attached to the colostomy, the contents are not the irritating effluent of an ileostomy.

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

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

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. Select 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 fluids in medicine cups."

3 1. When Pedialyte is not tolerated, it is usually recommended that clear sodas and juices be diluted. Diet beverages are not recommended because the sugar is needed to help the sodium be reabsorbed. 2. Pedialyte is the best choice. If the child is not encouraged to drink Pedialyte, the child may become severely dehydrated. Other ways to encourage oral rehydration need to be considered. 3. Pedialyte is the first choice, as recommended by the American Academy of Pediatrics. Offering the child appropriate choices may allow the child to feel empowered and less likely to refuse the Pedialyte. Small, frequent amounts are usually better tolerated. 4. Offering small amounts of liquids is important. The type of beverage does matter because many fluids may increase vomiting and diarrhea. TEST-TAKING HINT: The test taker should eliminate answer 2 because it offers an ultimatum to a child. The child is likely to refuse the Pedialyte, worsening the state of dehydration.

19. The nurse is caring for a 4-month-old with gastroesophageal reflux (GER). The infant is due to receive Zantac (rantadine). Based on the medication's mechanism of action, when should this medication be administered? 1. Immediately before a feeding. 2. 30 minutes after the feeding. 3. 30 minutes before the feeding. 4. At bedtime.

3 . 1. If Zantac is administered immediately before a feeding, the medication will not have enough time to take effect. 2. This medication should be administered prior to a feeding to be effective. 3. Zantac decreases gastric acid secretion and should be administered 30 minutes before a feeding. 4. This medication should be administered prior to a feeding to be effective. TEST-TAKING HINT: The test taker needs to be familiar with the administration of Zantac.

11. A child is diagnosed with chronic constipation that has been unresponsive to dietary and activity changes. Which pharmacological measure is most appropriate? 1. Natural supplements and herbs. 2. Stimulant laxative. 3. Osmotic agent. 4. Pharmacological measures are not used in pediatric constipation.

3 . 1. Natural supplements and herbs are not recommended because the safety and efficacy are not standardized. 2. A stimulant laxative is not the drug of choice because it may increase abdominal discomfort and may lead to dependency. 3. A stool softener is the drug of choice because it will lead to easier evacuation. 4. Although diet and activity modification are tried first, medications are sometimes needed. TEST-TAKING HINT: The test taker should eliminate answer 4 as it implies that medications are never given to the constipated child. In health care, there are very few cases of "never" and "always."

2. The mother of a newborn asks the nurse why the infant has to nurse so frequently. Which is the best response? 1. Formula tends to be more calorically dense, and formula-fed babies require fewer feedings than breastfed babies. 2. The newborn's stomach capacity is small, and peristalsis is slow. 3. The newborn's stomach capacity is small, and peristalsis is more rapid than in older children. 4. Breastfed babies tend to take longer to complete a feeding than formula-fed babies.

3 . 1. The caloric content of breast milk and formula tends to be similar. 2. Peristalsis in infants is greater than in older children. 3. The small-stomach capacity and rapid movement of fluid through the digestive system account for the need for small frequent feedings. 4. Breastfed babies and formula-fed babies do not necessarily have a difference in feeding time. TEST-TAKING HINT: The test taker should eliminate answers 1 and 4 because they both form generalizations that are not supported by current literature.

9. 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 1. Free water should not be given as it does not contain any electrolytes and can lead to critical electrolyte imbalances. 2. Formula should be avoided, and clear liquids such as Pedialyte should be offered. 3. Twenty-four hours is too long for the infant to remain NPO. The infant needs to drink a rehydration solution such as Pedialyte in order to avoid severe dehydration. 4. Offering small amounts of clear liquids is usually well tolerated. If the child vomits, make NPO to allow the stomach to rest and then restart fluids. The child in this scenario is described as playful and therefore does not appear to be at risk for dehydration. TEST-TAKING HINT: The test taker should eliminate answers 1 and 3 because they could cause harm to the infant.

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 1. Rye toast contains gluten. 2. Unless otherwise indicated, pancakes are made of flour, which contains gluten. 3. Oat cereal contains gluten. 4. Cheese, banana slices, rice cakes, and whole milk do not contain gluten. TEST-TAKING HINT: The test taker needs to recall that children with celiac disease cannot tolerate gluten, which is found in wheat, barley, rye, and oats. Answers 1, 2, and 3 contain gluten.

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 confirm the diagnosis. 2. Prepare to accompany the infant to the radiology department for a reducing enema. 3. Prepare to start a second intravenous line to administer fluids and antibiotics. 4. Prepare to get the infant ready for immediate surgical correction.

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

30. Which would be an appropriate activity for the nurse to recommend to the parent of a toddler just diagnosed with acute hepatitis? 1. Climbing in a "playscape." 2. Kicking a ball. 3. Playing video games in bed. 4. Playing with puzzles in bed.

4 1. The child with acute hepatitis usually does not feel well, and activities should be limited to quiet, restful ones. 2. The child with acute hepatitis usually does not feel well, and activities should be limited to quiet, restful ones. 3. Video games are not developmentally appropriate for a 3-year-old. 4. Playing with puzzles is a developmentally appropriate activity for a 3-year-old on bedrest. TEST-TAKING HINT: The test taker should incorporate developmentally appropriate activities for the child in the early stages of acute hepatitis. Answers 1 and 2 can be eliminated as they are not activities that can be done while resting. Answer 4 should be selected because it is a better activity for a 3-year-old.

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 physician 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 1. The infant's feeding should be stopped immediately and oxygen administered. The nurse should call for help but should not leave the infant while in distress. 2. The mother should stop feeding the infant, but oxygen should be applied while the infant is cyanotic. The infant should be placed on a monitor, and vital signs should be obtained. 3. Although obtaining oxygen saturations is extremely important, the infant is visually cyanotic, so the nurse should administer oxygen as a priority. 4. The infant should be taken from the mother and placed in the crib where the nurse can assess the baby. Oxygen should be administered immediately, and vital signs should be obtained. TEST-TAKING HINT: The test taker should be led to answer 4 because the baby is cyanotic and needs oxygen.

34. The parents of a newborn diagnosed with a cleft lip and palate ask the nurse when their child's lip and palate will most likely be repaired. Select the nurse's best response. 1. "The palate and the lip are usually repaired in the first few weeks of life so that the baby can grow and gain weight." 2. "The palate and the lip are usually not repaired until the baby is approximately 6 months old so that the mouth has had enough time to grow." 3. "The lip is repaired in the first few months of life, but the palate is not usually repaired until the child is 3 years old." 4. "The lip is repaired in the first few weeks of life, but the palate is not usually repaired until the child is 18 months old."

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

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, finds 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 Zofran (ondansetron). 2. Cancel the ultrasound, and prepare to administer an intravenous bolus. 3. Prepare for the probable discharge of the patient. 4. Immediately notify the physician of the child's status.

4 1. The ultrasound should not be canceled but obtained emergently because the child probably has a perforated appendix. The child should be NPO because surgery is imminent. 2. The ultrasound should not be canceled but obtained emergently because the child probably has a perforated appendix. 3. The child will not be discharged due to most likely having a perforated appendix. 4. The physician should be notified immediately, as a sudden change or loss of pain often indicates a perforated appendix. TEST-TAKING HINT: The test taker should eliminate answers 1 and 2 because there is no reason to cancel the ultrasound. The physician should always be notified of any changes in a patient's condition.

24. The nurse is to receive a 4-year-old from the recovery room after an appendectomy. The parents have not seen the child since surgery and ask what to expect. Select the nurse's best response. 1. "Your child will be very sleepy, have an intravenous line in the hand, and have a nasal tube to help drain the stomach. If your child needs pain medication, it will be given intravenously." 2. "Your child will be very sleepy, have an intravenous line in the hand, and have white stockings to help prevent blood clots. If your child needs pain medication, we will give it intravenously or provide a liquid to swallow." 3. "Your child will be wide awake and will have an intravenous line in the hand. If your child needs pain medication, we will give it intravenously or provide a liquid to swallow." 4. "Your child will be very sleepy and have an intravenous line in the hand. If your child needs pain medication, we will give it intravenously."

4 . 1. An NGT is not needed when an appendix has not ruptured. 2. Antiembolic stockings are not used in children this young, who will likely be moving the lower extremities and ambulating. 3. The child in the immediate post-operative period is usually not wide awake. 4. In the immediate post-operative period, the child is usually sleepy but can be roused. The child usually has an intravenous line for hydration and pain medication. TEST-TAKING HINT: The test taker should eliminate answer 1 because NGTs are not used unless the appendix has ruptured. Answer 2 can also be eliminated because a 4-year-old who is post appendectomy is not at risk for blood clots.

16. The nurse is caring for an 8-week-old male who has just been diagnosed with Hirschsprung disease. The parents ask what they should expect. Select the nurse's best response. 1. "It is really an easy disease to manage. Most children are placed on stool softeners to help with constipation until 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 . 1. The constipation will not resolve with stool softeners. The affected bowel needs to be removed. 2. Most colostomies are not permanent. The large intestine is usually reattached, and the colostomy is taken down. 3. The child with Hirschsprung disease requires surgery to remove the aganglionic portion of the large intestine. 4. The aganglionic portion needs to be removed. Although most children have a temporary colostomy placed, many infants are able to bypass the colostomy and have the bowel immediately reattached. TEST-TAKING HINT: The test taker should be led to answer 4 as it is the least restrictive of all answers and is the only one that states that the child will require surgery. Children with Hirschsprung disease are managed surgically.

1. The parent of a newborn asks, "Will my baby spit out the formula if it is too hot or too cold?" Select the nurse's best response. 1. "Babies have a tendency to reject hot fluids but not cold fluids, which could result in abdominal discomfort." 2. "Babies have a tendency to reject cold fluids but not hot fluids, which could result in esophageal burns." 3. "Your baby would most likely spit out formula that was too hot, but your baby could swallow some of it, which could result in a burn." 4. "Your baby is too young to be physically capable of spitting out fluids and will automatically swallow anything."

4 1. Swallowing is a reflex in neonates; infants younger than 6 weeks cannot voluntarily control swallowing. 2. Swallowing is a reflex in neonates; infants younger than 6 weeks cannot voluntarily control swallowing. 3. The infant is not capable of selectively rejecting fluid because swallowing is a reflex until 6 weeks. 4. Swallowing is a reflex in infants younger than 6 weeks. TEST-TAKING HINT: Swallowing is a reflex that is present until the age of 6 weeks. The test taker should eliminate answers 1, 2, and 3 as they suggest that the infant is capable of selectively rejecting fluids.

17. Which should the nurse include in the plan of care to decrease symptoms of gastroesophageal reflux (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 first 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, 5. 1. Placing the infant in an infant seat increases intra-abdominal pressure, placing the infant at increased risk for GER. 2. The prone position is not recommended as it may lead to sudden infant death syndrome (SIDS). 3. Although most infants outgrow GER, providing the parents with this education will not help decrease the symptoms. 4. Keeping the infant in an upright position is the best way to decrease the symptoms of GER. The infant can also be placed in the supine position with the head of the crib elevated. A harness can be used to keep the child from sliding down. 5. Burping the infant frequently may help decrease spitting up by expelling air from the stomach more often. TEST-TAKING HINT: The test taker may be led to answer 3. However, the question is looking for ways to decrease reflux. Although decreasing parental anxiety may help decrease reflux, the better answers are 4 and 5 as they are more likely to be part of an effective management plan.