NUR 307 - Chapter 42: Nursing Care of the Child With an Alteration in Bowel Elimination/Gastrointestinal Disorder

A child is admitted with a temperature, 101.2°F (38.4°C); pulse rate 100 beats/min; respirations 24 breaths/min. On admission the pain is localized in right lower quadrant. Legs are drawn up against the abdomen. Bowel sounds are sluggish. Rebound tenderness is present. White blood cell count of 17,000/mm3. Ultrasound confirms appendicitis. Which instruction would the nurse give to the child and the parent?

Do not rub or put pressure on the abdomen. The nurse would instruct the child/parent to not rub or put pressure on the abdomen as palpating an inflamed appendix may cause it to rupture. A child with appendicitis will be NPO for surgery and therefore not instructed to drink. Heat to the abdomen may also cause the inflamed appendix to rupture. Ice is not an effective intervention.

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

Inguinal hernia usually occurs in girls.

False Inguinal hernia is a protrusion of a section of the bowel into the inguinal ring. It occurs usually in boys (9:1) because, as the testes descend from the abdominal cavity into the scrotum late in fetal life, a fold of parietal peritoneum also descends, forming a tube from the abdomen to the scrotum.

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 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.

The nurse is talking with a woman who is in her 2nd trimester of pregnancy who has been diagnosed with polyhdyramnios. The physician has ordered an ultrasound be performed to check for the presence of esophageal atresia. Which statement by the woman indicates an understanding of the relationship between these conditions?

"Babies with esophageal atresia have an inability to swallow amniotic fluid causing the excess buildup." Review the maternal history for polyhydramnios. Often this is the first sign of esophageal atresia because the fetus cannot swallow and absorb amniotic fluid in utero, leading to accumulation. Esophageal atresia is an underlying cause of polyhydramnios.

The nurse is preparing an 18-month-old for discharge following treatment for dehydration secondary to diarrhea. What instruction would the nurse most likely include in the discharge teaching?

"Encourage a bland diet." After rehydration is achieved, it is important to encourage the child to consume a bland diet in order to maintain energy and growth. The solid foods presented are easily digested and age appropriate. The parents should avoid prolonged used of clear liquids in the child with diarrhea because "starvation stools" might result. Fluids high in glucose such as fruit juice, gelatin, and soda may worsen diarrhea. Gelatin is high in glucose and may worsen diarrhea.

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." 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 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." 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 reinforcing dietary teaching with the caregiver of a child diagnosed with celiac syndrome. The caregivers make the following statements. Which statement indicates a need for further teaching regarding the dietary restrictions for the child with celiac syndrome?

"She loves hot dogs, and we always cut hers up into small pieces." Commercially canned creamed soups, cold cuts, frankfurters, and pudding mixes generally contain wheat products and should not be included in the diet of the child with celiac syndrome. This caregiver needs further teaching regarding giving her child hot dogs, even if they are cut into small pieces. The other choices show an understanding of the dietary restrictions.

The novice nurse is discussing the diagnosis of intussusception with a group of peers. What statement demonstrates the nurse's appropriate understanding regarding this disorder?

"The stools of the infant are called currant jelly stools and consist of blood and mucus." In the child with intussusception, the stools consist of blood and mucus, thereby earning the name currant jelly stools. There is a telescoping of the upper portion of the bowel slipping over the lower portion. The condition occurs more often in boys than in girls and the highest incidence occurs in infants between the ages of 4 and 10 months. The infant who previously appeared healthy and happy suddenly becomes pale, cries out sharply, and draws up the legs in a severe colicky spasm of pain. This spasm may last for several minutes, after which the infant relaxes and appears well until the next episode, which may occur 5, 10, or 20 minutes later.

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." 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 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." 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.

A child is diagnosed with short bowel syndrome. What would the nurse expect to be included in the child's plan of care? Select all that apply.

- Antibiotics - Vitamin supplements - Total parenteral nutrition For the child with short bowel syndrome, typically, antibiotics, vitamin and mineral supplements, antidiarrheal agents, and total parenteral nutrition are prescribed. Laxatives and immunosuppressants are not used.

The nurse teaches a parent to differentiate between regurgitation and vomiting in the infant. The parent correctly states which characteristic of regurgitation? Select all that apply.

- occurs with feeding - no appearance of distress Regurgitation occurs with feeding; the infant does not exhibit signs of distress. Forceful expulsion of stomach contents that is followed by dry retching unrelated to feeding are characteristics of vomiting.

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 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 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.

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

Detect Helicobacter pylori 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.

A nurse examining a neonate is unable to identify the fetal stomach. The nurse knows that this sign strongly indicates which condition?

Esophageal atresia (EA) Inability to identify the fetal stomach strongly suggests EA. The upper abdomen is typically distended in pyloric stenosis and duodenal atresia. Hernias typically present as a bulge in the groin area.

A father brings Jacob, age 2, to the health clinic with complaints of diarrhea, vomiting, and abdominal pain. The father tells the nurse that he is a single parent and Jacob is enrolled in a local daycare center. Based on this information, what gastrointestinal condition might the nurse suspect?

Gastroenteritis Outbreaks of gastroenteritis routinely occur in day care centers, schools, institutions for the handicapped, and other places where overcrowding is prevalent and hygiene is inadequate. Typical signs and symptoms include diarrhea, nausea, vomiting, and abdominal pain.

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

He will become fatigued easily. Most children with hepatitis are exhausted. Urine is not infectious.

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 most accurate related to the diagnosis of gastroesophageal reflux?

In this disorder the sphincter that leads into the stomach is relaxed. 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 digestive process begins in which organ of the gastrointestinal system?

Mouth Food enters the mouth, and the digestive process begins. Digestion takes place by mechanical and chemical mechanisms. As the food continues through the stomach and intestines, digestion continues.

A mother calls the doctor's office and tells the nurse that she is concerned because her 4-month-old keeps "spitting up" with every feeding. What would indicate that the child is regurgitating as opposed to vomiting?

Only occurs with feeding Regurgitation typically occurs only with feeding, runs out of the mouth with little force, smells barely sour and is only slightly curdled, appears to cause no pain or distress, occurs only once per feeding, and amounts to only about 1 to 2 tsp. Vomiting may occur at times other than feeding, is forceful and is typically projected 1 ft or more away from infant, is extremely sour smelling and curdled, is typically accompanied by crying, continues until the stomach is empty, and amounts to the full stomach contents.

The nurse is caring for a teenager diagnosed with acute pancreatitis. Which order would the nurse question?

PO pain management Maintain NPO status and nasogastric tube suction and patency. Administer intravenous fluids to keep the child hydrated and correct any alterations in fluid and electrolyte balance. Pain management is crucial in children with pancreatitis, due to NPO status, medications are typically prescribed intravenously. Serial monitoring of serum amylase levels will determine when oral feeding may be restarted.

The nurse caring for an 18-month-old infant with Meckel diverticulum knows that the most common clinical manifestation of this condition is:

Painless rectal bleeding With Meckel diverticulum, most symptomatic children present younger than age 2 years. Intermittent, painless rectal bleeding is the most common clinical manifestation of Meckel diverticulum. The blood is most often bright red or maroon and may be passed independent of stool due to ulceration at the junction of the ectopic tissue and the normal ileal mucosa.

If an adolescent has hepatitis B, what would be an important nursing action?

Strict enforcement of standard precautions Hepatitis B is spread through contaminated blood. Standard precautions help prevent contact with this.

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

Tenting of skin 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.

A nurse explains to the family of an infant with an inguinal hernia that the surgeon will attempt manual reduction prior to surgical repair. Which statement describes this technique?

The client is sedated and the incarcerated contents of the hernia are manipulated back into the peritoneal cavity. Manual reduction of an incarcerated hernia of any type is attempted before surgical repair. The child is sedated, the lower torso is elevated, and the incarcerated contents of the hernia are gently manipulated back into the peritoneal cavity. If the reduction is successful, elective surgical repair is scheduled 24 to 48 hours later.

Constipation may be initially caused by psychological problems.

True Some children begin holding stool for psychological reasons. Once the process begins, however, the hardened stool, the anal fissures, and the pain on defecation soon occur, and what began for an emotional reason becomes a physical ailment. This is important to understand, because with these children, therapy involves both counseling to correct the initial problem and treatment of the physical symptoms.

A child with inflammatory bowel disease is started on an anti-inflammatory medication. Which item would the nurse teach the child/parent about being on this type of medication? Select all that apply.

Use sunscreen and protective clothing while outside. Anti-inflammatory medications increase sensitivity to sunlight and may crystalize in the urine. These medications are irritating to the gastric lining and are taken with food to avoid irritation. These drugs decrease folic acid absorption; therefore, parents should anticipate a concurrent prescription for folic acid.

Which assessment finding would suggest that a child's postoperative feeding schedule following pyloric stenosis surgery should be slowed?

Vomiting Vomiting after a feeding suggests the pyloric valve is not yet able to accommodate feedings well, possibly from edema.

A 3-year-old child has been brought to the clinic for assessment because of frequent episodes of constipation. After ruling an out an organic cause, the child's plan of care should prioritize:

administering over the counter stool softeners on a temporary basis. Once any organic process is ruled out as a cause, constipation may initially be managed with dietary manipulation such as increasing fiber and fluids. However, behavior modification is necessary for most children. Children need to relearn to allow bowel evacuation when stool is present. Medications are used when other measures have failed. Frequent toileting may or may not be beneficial.

Noah is an 18-month-old who is brought to the ER with flu-like symptoms. He 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. The child with gastroesophageal reflux disease may present with the physical findings of pneumonia secondary to aspiration of refluxed stomach contents.

The nurse recommends rotavirus vaccine for which group of clients?

neonates Rotavirus vaccine is given to infants. It is not appropriate for neonates, toddlers, or preschoolers.

Which body system is most sensitive to lead ingestion?

nervous system The system most affected from lead ingestion is the nervous system. The onset of chronic lead poisoning is insidious. Symptoms of irritability, hyperactivity, aggression, impulsiveness, or disinterest in play may be noted. Short attention span, lethargy, learning difficulties, and distractibility are signs of lead poisoning. The other systems are impacted by lead but not to the same degree.

In caring for an infant diagnosed with pyloric stenosis, the nurse would anticipate that she would:

prepare the infant for surgery. A surgical procedure called a pyloromyotomy (also known as a Fredet-Ramstedt operation) is the treatment of choice for pyloric stenosis.

The nurse is assessing a child who was admitted with a fever, chills, nausea and vomiting, and reports of abdominal pain. The physician suspects appendicitis. During the nursing assessment the nurse notes maximal tenderness upon palpation over the McBurney point. Place an X on McBurney's point.

McBurney's point is the area in the right lower quadrant of the abdomen where the most pressure tends to be felt upon palpation when the client has appendicitis. It lies between the naval and the right anterior superior iliac spine.

The nurse is caring for an infant recently diagnoses 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." 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." 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.

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." 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).

A child is experiencing an acute exacerbation of Crohn disease for which she is prescribed prednisone. The nurse teaches the parents and child about this medication. Which statement by the parents indicates that the teaching was successful?

"We should not stop this medication abruptly." Prednisone is a corticosteroid. Stopping the medication abruptly could lead to adrenal insufficiency. Weight gain would be associated with corticosteroid use. Weight loss is associated with the disease. Corticosteroids help to reduce inflammation and suppress the normal immune response. Typically, anti-inflammatory agents such as mesalamine may appear in the stool. This indicates poor absorption.

The nurse is reviewing the history of a child who has chronic oral lesions. What risk factors does the nurse expect to find when reviewing the child's history? Select all that apply.

- Recently finished the last chemotherapy treatment for leukemia - Severe malabsorption from a GI disorder Common risk factors for oral lesion include immune deficiency, cancer chemotherapy treatment, exposure to infectious agents, trauma, stress, or celiac or Crohn disease.

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

she has a temperature. Because Crohn disease leads to patches of inflammation in the bowel, the temperature increases if more patches become involved.

The nurse is caring for a toddler whose blood study came back with an above normal level of lead. The parent is upset and states, "I don't know how this is happening; we live in a newer house." Which are areas where a toddler can find exposure to lead? Select all that apply.

- older toys that are painted - drinking water - storage of beverages from earthenware - lead contained in the soil Lead is present in older toys, possibly from previous generations. There is national attention on lead pipes introducing lead into drinking water at schools and public facilities. Lead can also be in the soil. Earthenware pottery is a porous material and painted in various colors. Through drinking, lead from the pottery or paint can be ingested.

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." 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 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." 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 nurse is working with the mother of a toddler experiencing constipation. What information regarding childhood constipation should the nurse share with the mother? Select all that apply.

- "Have your son sit on the toilet twice a day, after breakfast and dinner, for 5 to 15 minutes." - "If your child has a fecal impaction, you can give him an enema." - "Reward your child for sitting on the toilet as asked, not just when they have a bowel movement." Proper education for constipation in children includes educating the families about the importance of compliance with medication use. Many children present to their physician or nurse practitioner with fecal impaction or partial impaction. Teach parents how to disimpact their children at home; this often requires an enema or stimulation therapy. To facilitate daily bowel evacuation, the child should sit on the toilet twice a day (after breakfast and dinner) for 5 to 15 minutes. Instruct the family to keep a "star" or reward chart to encourage compliance. Parents should award the star for compliance with time sitting on the toilet and should not reserve rewards for successful bowel movements only.

A 9-year-old child has undergone a temporary colostomy in the ascending colon several days ago. The nurse has just completed discharge teaching to the child and the parents. Which statements by the child or parents warrants additional instruction from the nurse?

- "It is important to change the pouch and skin appliance every other day to decrease the risk of problems with the skin." - "We will need to use an antimicrobial soap to cleanse the area around the stoma in order to prevent any skin infection." Appliances and pouches can be left in place for 4 days as long as the appliance is intact; changing more frequently can lead to skin impairment. Regular soap, not antimicrobial soap, and water is all that is needed to clean around the stoma site. Antimicrobial and perfumed soaps may be irritating to the skin. An ascending colostomy will produce unformed, thick liquid stool so emptying the pouch more frequently will be necessary; this will likely be a challenge for the child at school initially. A pale stoma indicates poor perfusion; this should be reported to the physician immediately.

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." Celiac disease is an immunologic disorder in which gluten causes damage to the small intestine. The only treatment currently is a gluten-free diet. While the child needs to have a gluten-free diet, the rest of the family does not. Most children present by the age of 2 for evaluation. Symptoms of celiac disease include diarrhea, constipation, steatorrhea, weight loss, poor muscle tone, anemia and dental disorders. Gluten is found in most grains, like wheat, rye, barley and possibly oats.

A group of nursing students are reviewing information about celiac disease. The students demonstrate understanding of this disorder when they identify which classic symptoms? Select all that apply.

- Steatorrhea - Constipation - Diarrhea - Failure to thrive Classic symptoms of celiac disease include steatorrhea, constipation, diarrhea, failure to thrive, weight loss, abdominal distention or bloating (not a sunken abdomen), and anemia (not polycythemia).

The parents of a 4-week-old report that their infant has forceful vomiting but seems very hungry immediately after vomiting. Upon further questioning, the nurse notifies the physician of the findings and pyloric stenosis is suspected. The nurse prepares the parents for the possibility of which diagnostic procedures and treatment?

- Upper GI series - Pyloric ultrasound - Physical examination of the abdomen - Surgical repair Frequently a diagnosis is made with the client history and palpation of a hard, moveable "olive" mass in the right upper quadrant. If no mass is palpated the most common diagnostic procedure is a pyloric ultrasound. An upper GI series is sometimes performed, but this test is much more invasive than an ultrasound. Surgical repair is necessary. A CT scan is not warranted.

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 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.

A 9-month-old girl is brought to the emergency room with what appears to be bouts of intense abdominal pain 15 minutes apart in which she draws up her legs and cries, often accompanied by vomiting. In between the bouts, the child recovers and appears to be without symptoms. Blood is found in the stool. What condition should the nurse suspect in this case?

Intussusception Intussusception, the invagination of one portion of the intestine into another, usually occurs in the second half of the first year of life. Children with this disorder suddenly draw up their legs and cry as if they are in severe pain; they may vomit. After the peristaltic wave that caused the discomfort passes, they are symptom-free and play happily. In approximately 15 minutes, however, the same phenomenon of intense abdominal pain strikes again. After approximately 12 hours, blood appears in the stool and possibly in vomitus, described as a "currant jelly" appearance. Volvulus with malrotation and necrotizing entercolitis typically occur in the first 6 months of life and do not match the symptoms described above. Short-bowel/short-gut syndrome typically occurs when a large portion of the intestine has been removed due to a previous disease or trauma.

A 10-year-old male presents with low-grade fever, nausea, and abdominal pain. The nurse examining him suspects appendicitis and checks for rebound tenderness in what quadrant?

Lower right With appendicitis, percussion reveals irritation and pain in the right lower quadrant. Rebound tenderness present with palpation in the right lower quadrant, is referred to as the McBurney point, an area of tenderness 1.5 to 2 in. (3.8 to 5 cm) in from the right anterior superior iliac spine along a line extending to the umbilicus.

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 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.

A mother is alarmed because her 6-week-old boy has begun vomiting almost immediately after every feeding. In the past week, the vomiting has grown more forceful, with the vomit projecting several feet from his mouth. He is always hungry again just after vomiting. At the physician's office, the nurse holds the child and gives him a bottle of water. While he drinks, she notes an olive-size lump in his right abdomen. Which condition should the nurse suspect in this child?

Pyloric stenosis With pyloric stenosis, at 4 to 6 weeks of age, infants typically begin to vomit almost immediately after each feeding. The vomiting grows increasingly forceful until it is projectile, possibly projecting as much as 3 to 4 feet. Infants are usually hungry immediately after vomiting because they are not nauseated. A definitive diagnosis can be made by watching the infant drink. If a pyloric stenosis is present, the sphincter feels round and firm, approximately the size of an olive in the right abdomen. Peptic ulcer disease in neonates usually presents with hematemesis (blood in vomitus) or melena (blood in the stool). Gastroesophageal reflux involves a small (1-2 tsp) volume and is not forceful. Appendicitis typically begins with anorexia for 12 to 24 hours; children do not eat and do not act like their usual selves. Nausea and vomiting may then occur, followed by diffuse abdominal pain.