Essentials of Pediatric Nursing - Chapter 20

The nurse is teaching the mother of an infant with a temporary ileostomy about stoma care. What is the most important instruction to emphasize to the mother to avoid an emergency situation?

"Call the doctor immediately if the stoma is not pink/red and moist." Explanation: A healthy stoma is pink and moist. If the stoma is dry or pale, the mother must notify the doctor immediately because it could indicate compromised circulation. Gathering supplies is important but would not be involved in avoiding an emergency situation.All of the other instructions are valid, but emphasizing the color of the healthy stoma is most important to avoid an emergency situation. Adhesive remover may be needed to ease pouch removal, but this action would not necessarily avoid an emergency situation. Meticulous skin care is important, but this action would not necessarily avoid an emergency situation.

The nurse is caring for a child following surgery due to a motor vehicle accident. The child suffered extensive damage to the small intestine resulting in short bowel syndrome. The parents voice concern to the nurse that their child will "never be the same." Which is the best response by the nurse?

"I cannot imagine what you are going through. We are here to support and educate you on your child's condition and treatments." Explanation: The nurse must always provide theraputic communication when speaking with clients and their caregivers. Being empathetic and reassuring the parents that the staff will be there to support them and educate them will provide some relief of anxiety since this is a chronic condition. Telling the parents there is nothing they could have done to prevent this from happening does not help the current situation. Giving hope is good, but giving possible false hope sets the family up for disappointment and a lack of trust with the health care team. Telling the family to be strong does not provide support at this time.

The nurse has performed client teaching to a 15-year-old boy with Crohn disease, and his parents, regarding the cobblestone lesions in his small intestine. Which comment by the family indicates learning occurred?

"I have to be careful because I am prone to not absorbing nutrients." Explanation: Crohn disease typically effects the small intestine more than the large intestine and it's onset is between the ages of 10 to 20 years. The cobblestone lesions in the small intestine prevents absorption of nutrients that normally occurs. The diarrhea is not directly related to the cobblestone lesions, and ulcerative colitis is characterized by the disease effecting the intestine(s) in a continuous pattern.

The mother of an infant tells the nurse during a routine visit to the clinic that she often notices a bulging mass in the lower abdominal and groin area when her baby cries. She asks the nurse if this is normal. How should the nurse respond?

"I understand your concern. I will be sure to document this in your child's medical record and report this information to your child's physician immediately." Explanation: The mother is describing common symptoms of an inguinal hernia. It may be possible to visualize the mass, but often the mass is seen only during crying or straining, making it difficult to actually identify in the clinic setting. It is important to notify the physician so treatment can be initiated.

The nurse is caring for an infant recently diagnosed with thrush and was prescribed nystatin. Which statement by the infant's mother would suggest a need for further education?

"I will add the nystatin to her bottle four times per day." Explanation: Administer nystatin suspension four times per day following feeding, not mixed in the bottle, to allow the medication to remain in contact with the lesions. In the younger infant, apply nystatin to the lesions with a cotton-tipped applicator. Infants and young children often mouth their toys, so it is important to clean them appropriately. Explain to parents of infants with thrush the importance of reporting diaper rash because fungal infections in the diaper area often occur concomitantly with thrush and also need to be treated.

The student nurse is caring for a child with the nursing diagnosis "Risk for fluid volume deficit related to inadequate oral intake". Which statement by the student would indicate a need for further education by the nursing instructor?

"I will make sure there is plenty of orange juice available. It's her favorite juice." Explanation: Proper interventions for children at risk for fluid volume deficit include maintaining IV line and administer IV fluid as ordered to maintain fluid volume. Offer small amounts of oral rehydration solution frequently to maintain fluid volume. Small amounts are usually well tolerated by children with diarrhea and vomiting. Avoid high-carbohydrate fluids such as Kool-Aid and fruit juice, as they are low in electrolytes, and increased simple carbohydrate consumption can decrease stool transit time. Daily weights are one of the best indicators of fluid volume status in children.

The client calls the health care provider's office stating that her preschooler drank laundry detergent from under the sink. Which statement by the parent needs further instruction?

"I will use syrup of ipecac to get it out of my child's system." Explanation: The CDC no longer recommends that the syrup of ipecac be used in the home for treatment of poisoning and, furthermore, recommends that it be disposed of safely. All the other statements are accurate. Depending on the amount of detergent ingested, the parent is instructed to first terminate any exposure and then possibly transport the child to a health care facility.

The mother of a young child, who has been treated for a bacterial urinary tract infection, tells the nurse her daughter has a white thick covering over her tongue. The mother states that she "has tried everything to get it off my child's tongue." How should the nurse respond?

"It's not unusual for a fungal infection to occur while taking an antibiotic for an infection. I will let your primary care provider know so we can get it treated." Explanation: Thrush is a fungal infection that can occur on the tongue while on an antibiotic for an unrelated bacterial infection. The antibiotic destroys normal flora, which allows the fungal infection to occur. Thrush requires an antifungal agent, such as nystatin liquid, to destroy the infection. Additional antibiotics will not help since it is a fungal infection.

The nurse is caring for a child with gastrointestinal concerns. What statement by the parent would indicate the nurse needs to further assess the child for constipation?

"My child has such large bowl movements that it clogs the toilet." Explanation: Constipation may be manifest by bowel movements that are large enough to clog the toilet, fewer bowel movements than normal, and bowel movements that are hard and pellet-like. Constipation is not likey if the child eats fruits and vegetables, even when beans are not incorporated in the child's diet. Passage of liquid stools can be a sign of constipation.

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." "The only treatment for celiac disease is a strict gluten-free diet." "Gluten is found in most wheat products, rye, barley and possibly oats."

A physician recommends a gastrostomy for a 4-year-old client with an obstruction. The parents ask the certified wound, ostomy, and continence nurse (CWOCN) what the surgery entails. What is the nurse's best response?

"The surgery creates an opening between the stomach and abdominal wall." Explanation: Ostomies can be created at various sites in the GI tract, depending on the child's clinical condition. A gastrostomy provides an opening between the stomach and the abdominal wall, and an esophagostomy communicates between the esophagus and an external site on the neck. Ostomies may be created at various sites in the small intestine (e.g., jejunostomy, ileostomy) or in the large intestine (e.g., colostomy).

The nurse is discussing the treatment of congenital aganglionic megacolon with the caregivers of a child diagnosed with this disorder. Which statement is the best explanation of the treatment for this diagnosis?

"The treatment for the disorder will be a surgical procedure." Explanation: Treatment of congenital aganglionic megacolon involves surgery with the ultimate resection of the aganglionic portion of the bowel. Chronic anemia may be present, but iron will not correct the disorder. Enemas may be given to initially achieve bowel elimination, but they will not treat the disorder. Differentiation must be made between this condition and psychogenic megacolon because of coercive toileting or other emotional problems. The child with aganglionic megacolon does not withhold stools or defecate in inappropriate places, and no soiling occurs.

The nurse is preparing a client for surgery and the client asks, "What does it mean when they say they are going to reduce my abdominal hernia?" Which response by the nurse is mostappropriate?

"This means the hernia contents will be manipulated back into your peritoneal cavity during surgery." Explanation: A hernia in the abdominal region is considered reducible when its contents are easily manipulated back through the inguinal ring into the peritoneal cavity. The nurse would reinforce this education, already provided by the primary health care provider when the surgery was explained, to the client. It is not necessary to cancel surgery when the nurse can provide education to the client. Reducing does not mean the intestines are twisted and edematous. Nor does it mean half of the contents will be removed.

The nurse is caring for a 13-year-old girl with suspected autoimmune hepatitis. The girl inquires about the testing required to evaluate the condition. How should the nurse respond?

"You will most likely have a blood test to check for certain antibodies." Explanation: Anti-nuclear antibodies are one of the diagnostic tests performed to diagnose autoimmune hepatitis. Ultrasound is to assess for liver or spleen abnormalities. Viral studies are performed to screen for viral causes of hepatitis. Ammonia levels may be ordered if hepatic encephalopathy is suspected.

The nurse is caring for a newborn following delivery who has been diagnosed with gastroschisis. Which actions by the nurse indicated knowledge of appropriate care for this disorder?

-The nurse assesses the color of the newborns abdominal organs -The nurse places the newborn in a radiant warmer to maintain the newborn's temperature -The nurse closely monitors the hydration status of the newborn for signs of dehydration Explanation: Gastroschisis is a herniation of the abdominal contents through an abdominal wall defect, usually to the left or right of the umbilicus.Gastroschisis differs from omphalocele in that there is no peritoneal sac protecting the herniated organs. The color of the protruding organs should be assessed to determine if perfusion is sufficient. The contents should be covered with a sterile, rather than a clean, dressing. Temperature regulation is compromised with the open abdominal wall so a radiant warmer is imperative. The parents should be encouraged to touch and spend time with the newborn to facilitate bonding. IV fluid will be ordered to prevent dehydration so close monitoring of the hydration status is imperative.

The nurse is caring for a child prescribed vancomycin 15 mg/kg IV every 6 hours for peritonitis. The child weights 45 lb (20.5 kg). How many milligrams will the nurse administer to this child in 24 hours?

1230

The nurse is providing care to a child who has had an appendectomy for a perforated appendix. The nurse would anticipate intravenous antibiotic therapy for how long?

7 to 14 days Explanation: The child with a perforated appendix requires 7 to 14 days of intravenous antibiotic therapy. If the child has a suppurative or gangrenous appendix that was not perforated, 2 to 3 days of antibiotics would be most likely ordered.

The nurse is conducting a physical examination of an 18-month-old with suspected intussusception. Which finding would the nurse identify as the hallmark of this condition?

A sausage-shaped mass in the upper midabdomen Explanation: A sausage-shaped mass in the upper midabdomen is the hallmark of intussusception. Perianal skin tags are highly suspicious of Crohn disease. Abdominal pain and guarding are also common with intussusception but are seen with many other conditions. Tenting would indicate dehydration.

The nurse is doing dietary teaching with the caregivers of a child diagnosed with idiopathic celiac disease. Of the following foods, which would most likely be appropriate in the child's diet?

Bananas Explanation: The young child should be started on a starch-free, low-fat diet. Bananas contain invert sugar and are usually well tolerated. Products that contain wheat, rye, or oats should be excluded.

A child is diagnosed with intussusception. The nurse anticipates that what action would be attempted first to reduce this condition?

Barium enema Explanation: A barium enema is successful in reducing a large percentage of intussusception cases. Other cases are reduced surgically. Upper endoscopy is used to visualize the upper gastrointestinal tract from the mouth to the upper jejunum. Endoscopic retrograde cholangiopancreatography is used to view the hepatobiliary system.

The nurse is administering an enteral feeding to a child with a gastrostomy tube (G-tube). Which action will the nurse take when administering a prescribed feeding through the client's G-tube?

Check for gastric residual before starting feeding Explanation: The nurse should check for gastric residual before starting feeding by gently aspirating from the tube with a syringe or positioning the tube below the level of the stomach with only the barrel of the syringe attached. The client should be positioned with his or her head elevated 30° to 45° and the formula should be allowed to flow with gravity, not plunged unless the tube is clogged. After feeding, the nurse should flush the tube with a small amount of water, unless contraindicated, and leave the G-tube open for 5 to 10 minutes after feeding to allow for escape of air.

A child is scheduled for a urea breath test. The nurse understands that this test is being performed for which reason?

Detect Helicobacter pylori Explanation: Urea breath test is used to detect the presence of H. pylori in the exhaled breath. This test does not evaluate gastric pH. Serum amylase and lipase levels are used to confirm pancreatitis. Esophageal manometry is used to evaluate esophageal contractile activity and effectiveness.

The labor and delivery nurse is caring for a mother who has demonstrated polyhydramnios upon delivery. The newborn displays copious, frothy bubbles of mucus in the mouth and nose, as well as drooling. The nurse is concerned that the infant has what disorder?

Esophageal atresia Explanation: Esophageal atresia refers to a congenitally interrupted esophagus where the proximal and distal ends do not communicate; the upper esophageal segment ends in a blind pouch and the lower segment ends a variable distance above the diaphragm. Polyhydramnios is often the first sign of esophageal atresia because the fetus cannot swallow and absorb amniotic fluid in utero, leading to accumulation. Omphalocele and gastroschisis are congenital anomalies of the anterior abdominal wall. Hiatal hernia involves a weakened diaphragm.

A nurse taking a health history of a newborn notes that there is a maternal history of polyhydramnios. What GI condition might this history precipitate?

Esophageal atresia (EA) Explanation: A maternal history of polyhydramnios is usually present in one-third of cases of EA and in some cases of tracheoesophageal fistula (TEF).

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?

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.

IV fluid administrationMonitor of intake and outputDaily 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.

The nurse is caring for a child with a diagnosis of pyloric stenosis during the preoperative phase of the child's treatment. What is the highest priority at this time?

Improving hydration Explanation: Preoperatively, the highest priority for the child with pyloric stenosis is to improve nutrition and hydration. Maintaining mouth and skin integrity, and relieving family anxiety are important, but these are not the priority. The child will not likely have intense pain. Preparing the family for home care would be a postoperative goal.

The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is mostaccurate related to the diagnosis of gastroesophageal reflux?

In this disorder the sphincter that leads into the stomach is relaxed. Explanation: Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus, which leads into the stomach, is relaxed and allows gastric contents to be regurgitated back into the esophagus. Congenital aganglionic megacolon is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Colic consists of recurrent paroxysmal bouts of abdominal pain. Pyloric stenosis is characterized by hypertrophy of the circular muscle fibers of the pylorus, which leads to an obstruction at the distal end of the stomach.

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 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 emergency department nurse is assessing a child who has presented with a 2-day history of nausea and vomiting with pain that is isolated to the right upper quadrant of the abdomen. Which action is most appropriate?

Prepare the child for admission to the hospital Explanation: The child's presentation is consistent with cholecystitis, which necessitates surgery in most cases. The child should be kept NPO and antacids are of no benefit. Genitourinary involvement is atypical.

A 12-year-old boy has just undergone a liver transplantation and is recovering. After performing a finger stick puncture and assessing the results, the nurse administers a 10% solution of dextrose IV. What is the correct rationale for this intervention?

Prevention of hypoglycemia Explanation: Hypoglycemia is a major danger following liver transplantation because glucose levels are regulated by the liver, and the transplanted organ may not function efficiently at first. Assess serum glucose levels hourly by finger stick puncture. A 10% solution of dextrose IV may be necessary to prevent hypoglycemia. Careful tissue matching before the transplantation is needed to reduce the possibility of stimulating T-cell rejection. Sodium, potassium, chloride, and calcium levels are evaluated approximately every 6 to 8 hours to be certain electrolyte balance is maintained, but potassium is rarely added to IV solutions because of the risk that renal failure has occurred. IV therapy with hypotensive agents such as hydralazine (Apresoline) and nitroprusside may be needed to reduce hypertension.

The nurse is assessing a 10-day-old infant for dehydration. Which finding indicates severe dehydration?

Tenting of skin Explanation: Tenting of skin is an indicator of severe dehydration. Soft and flat fontanels 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.

An adolescent is diagnosed with hepatitis A. Which problem should be considered when planning care?

The adolescent will become fatigued easily. Explanation: Hepatitis A is transmitted via the oral-fecal route; it is water borne and often occurs in areas of poor sanitation. The adolescent with hepatitis A will exhibit flu-like symptoms, a headache, anorexia and fatigue. The urine is not infectious and fever may be present as opposed to hypothermia. Irritability is not one of the symptoms of hepatitis A. The client is usually lethargic or listless.

The nurse is caring for a 6-month-old girl with diarrhea and dehydration. The mother is concerned because the girl has some patches on her tongue. Which feature indicates a geographic tongue rather than thrush?

The patches are light in color on the tongue. Explanation: A geographic tongue is a benign, noncontagious condition characterized by a reduction in the filiform papillae. 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 child might have by that age.

What occurs in the gastrointestinal system of the child with Hirschsprung disease?

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 intasussception. The relaxed sphincter in the lower portion of the esophagus is related to gastrointestinal reflux disorder.

A 6-week-old infant is diagnosed with pyloric stenosis. When taking a health history from the parent, which symptom would the expect to hear described?

Vomiting immediately after feeding Explanation: With pyeloric stenosis the circular muscle pyloris is hypertrophied. This thickness causes gastric outlet obstruction. The condition is seen in younger infants starting 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 eatling. 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.

An 18-month-old infant is brought to the emergency department with flu-like symptoms. The infant is diagnosed with pneumonia secondary to aspiration of stomach contents. The nurse explains to the parents that pneumonia is a condition that often occurs secondary to:

gastroesophageal reflux disease. Explanation: Gastroesophageal reflux (GER) is the passage of gastric contents into the esophagus. These refluxed contents may be aspirated into the lungs. The child with gastroesophageal reflux disease may present with the physical findings of pneumonia or GER-induced asthma. GER may cause apnea or an apparent life-threatening event in the younger infant. Pneumonia can occur in children with cystic fibrosis, but the child would need to have the cystic fibrosis diagnosis first. Hirschprung and inflammatory bowel diseases are diseases of the gastrointestinal tract that do not have respiratory symptoms as part of the diseases.

A child with severe vomiting for 3 days presents with hypopnea and hypokalemia. The nurse reports to the provider that this child is exhibiting signs of which condition?

metabolic alkalosis Explanation: With extended vomiting, there is a shift in Cl and K ions resulting in metabolic alkalosis. Metabolic acidosis is more commonly seen in severe diarrhea, and respiratory alkalosis and respiratory acidosis are caused by conditions that impact ventilation.

In caring for an infant diagnosed with pyloric stenosis the nurse would anticipate which intervention?

prepare the infant for surgery Explanation: In pyloric stenosis, the thickened muscle of the pyloris causes gastric outlet obstruction. The treatment is a surgical correction called a pyloromyotomy. The condition is not painful, so no analgesics would be needed until after surgical repair. The condition is not related to lactose in the diet, so changing to lactose-free formula would not correct the condition. A barium enema would be used to diagnose intussusception.

The nurse is caring for a 12-year-old child with Crohn disease. A primary assessment the nurse would want to make when caring for the child would be to note if:

the child has a temperature. Explanation: Crohn disease may affect any area of the digestive tract. It causes acute and chronic inflammation. It may also cause abscesses and fistulas. Inflammation and abscesses can cause increased temperatures. An increasing temperature could be the manifestation of the inflammation worsening or the development of an abscess and subsequent infection. A headache may accompany a fever and is a sign of generally not feeling well. It does not indicate progression of the disease. Clear lung sounds and no swollen joints are good signs but they are not associated with Crohn disease.