PEDs Chapt 20 Nursing Care of the Child with a Gastrointestinal Disorder(nclex)
The nurse is teaching the mother of an infant with a temporary ileostomy about stoma care. Which of the following is the most important instruction to emphasize to the mother to avoid an emergency situation? a) "Gather all of your supplies before you begin." b) "Call the doctor immediately if the stoma is not pink/red and moist." c) "You may need adhesive remover to ease pouch removal." d) "You must be meticulous in caring for the surrounding skin."
"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 2-year-old boy with an umbilical hernia and is teaching the mother about this condition. Which of the following responses from the mother indicates a need for further teaching? a) "My son could have some appearance-related self-esteem issues." b) "Incarceration is rare, but it can occur." c) "I need to watch for pain, tenderness, or redness." d) "I can tape a quarter over the hernia to reduce it."
"I can tape a quarter over the hernia to reduce it." Correct Explanation: The use of home remedies to reduce an umbilical hernia should be discouraged because of the risk of bowel strangulation. The mother needs to be aware that strangulation can occur, but it is rare with an umbilical hernia. Pain, tenderness, or redness indicates incarceration, which although rare with umbilical hernias, can occur. She needs to understand the signs of strangulation and understand that some children have self-esteem issues related to the large protrusion of the unrepaired umbilical hernia. Physical needs of the child have priority over any types of potential psychosocial issues. Self-esteem issues may arise due to a large protrusion of an unrepaired umbilical hernia.
A nurse caring for Paulo, an infant born with a cleft palate, notices that the parents rarely interact with their child. The nurse overhears the mother telling her husband that she "feels like crying" every time she looks at their son. Which of the following would be the best response from the nurse? a) "I sense you could use more information on caring for a cleft palate. Would you be interested in meeting with other parents who have dealt with this?" b) "Keep in mind that your son's condition is not life-threatening and can be corrected eventually." c) "Many infants are born with this condition. Your son's palate is not nearly as bad as some cases." d) "Your son needs you right now. You should put your negative feelings about his condition aside for his sake."
"I sense you could use more information on caring for a cleft palate. Would you be interested in meeting with other parents who have dealt with this?" Correct Explanation: The nurse should support the family's adjustment to a child's condition by demonstrating an accepting, caring attitude toward the child and family and providing the parents with opportunities and support for normal infant-parent interactions.
The nurse is caring for a 4-year-old with oral vesicles and ulcers from herpangina. The child is refusing fluids due to the pain and the mother is concerned about his hydration status. Which of the suggestions would be most appropriate? a) "Offer 'magic mouthwash' followed by a popsicle." b) "Encourage him to have some soda." c) "Try some Anbesol or Kank-A." d) "Offer him some orange juice."
"Offer 'magic mouthwash' followed by a popsicle." Correct Explanation: Children are more likely to cooperate with interventions if play is involved. "Magic" analgesic mouthwash followed by a popsicle is most likely to alleviate some pain and then provide hydration. Soda should be avoided because it can cause stinging and burning. Orange juice should be avoided because it can cause stinging and burning. Anbesol might be helpful but it will likely be difficult to apply. Additionally, oral analgesics are often necessary.
The nurse is collecting data on a 2 ½ year-old child admitted with a diagnosis of gastroenteritis. When interviewing the caregivers, which of the following questions would be most important for the nurse to ask? a) "How many times a day does your child urinate?" b) "What foods has your child eaten during the last few days." c) "Tell me about the types of stools you child has been having." d) "How long has your child been toilet trained?"
"Tell me about the types of stools you child has been having." Correct Explanation: For the child with gastroenteritis, the interview with the family caregiver must include specific information about the history of bowel patterns and the onset of diarrheal stools, with details on number and type of stools per day. Recent eating patterns, if the child is toilet trained, and how many times a day the child urinates are important questions, but the highest priority is gathering data regarding the stools and stool pattern. (less)
A physician recommends a gastrostomy for a 4-year-old patient 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? a) "The surgery is performed to create an opening between the esophagus and the neck." b) "The surgery creates an opening between the stomach and abdominal wall." c) "The surgery will create an opening to the large intestine." d) "The surgery will create an opening to the small intestine."
"The surgery creates an opening between the stomach and abdominal wall." Correct 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 of the following statements is the best explanation of the treatment for this diagnosis? a) "Your child will be treated with oral iron preparations to correct the anemia." b) "The treatment for the disorder will be a surgical procedure." c) "We will give enemas until clear and then teach you how to do these at home." d) "Your child will receive counseling so the underlying concerns will be addressed."
"The treatment for the disorder will be a surgical procedure." Correct 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.
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? a) "We should not stop this medication abruptly." b) "She might lose some weight initially." c) "We might notice some of the medication in her stool" d) "This drug helps to control the abdominal cramping."
"We should not stop this medication abruptly." Correct Explanation: 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 child has been diagnosed with severe dehydration. The physician has ordered the nurse to administer a bolus of 20 mL/kg of normal saline over a 2-hour period. The child weighs 63.5 pounds. How should the nurse set the child's intravenous administration pump? (mL/hour) Round to the nearest whole number. _____ mL/hour
289 Correct Explanation: The child weighs 63.5 pounds. 63.5 pounds x 1 kg/2.2 pounds = 577.2727 mL 577.2727 mL of normal saline/2 hours = 288.6364 mL Rounded to the nearest whole number = 289 mL/hour
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 which time frame? a) 1 to 3 days b) 3 to 5 days c) 5 to 7 days d) 7 to 14 days
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 infant is listless with sunken fontanels and has been diagnosed with dehydration. The infant is still producing at least 1 mL/kg each hour of urine. The infant weighs 13.2 pounds. At the minimum, how many milliliters of urine will the infant produce during the next 8-hour shift? _____ mL
48 Correct Explanation: 13.2 pounds x 1 kg/2.2 pounds = 6 kg 6 kg x 1 mL/kg = 6 mL/hour 6 mL x 8 hours = 48 mL/8-hour shift
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 congenital aganglionic megacolon? a) In this disorder the sphincter that leads into the stomach is relaxed. b) There are recurrent paroxysmal bouts of abdominal pain. c) A partial or complete intestinal obstruction occurs. d) A thickened, elongated muscle causes an obstruction at the end of the stomach.
A partial or complete intestinal obstruction occurs. Correct Explanation: Congenital aganglionic megacolon, also called Hirschsprung disease, is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. 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. Colic consists of recurrent paroxysmal bouts of abdominal pain. Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus is relaxed and allows gastric contents to be regurgitated back into the esophagus.
The nurse is conducting a physical examination of an 18-month-old with suspected intussusception. Which of the following findings would the nurse identify as the hallmark of this condition? a) A sausage-shaped mass in the upper midabdomen b) Skin tenting c) Perianal skin tags d) Abdominal pain and guarding
A sausage-shaped mass in the upper midabdomen Correct 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 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 pyloric stenosis? a) There are recurrent paroxysmal bouts of abdominal pain. b) In this disorder the sphincter that leads into the stomach is relaxed. c) A thickened, elongated muscle causes an obstruction at the end of the stomach. d) A partial or complete intestinal obstruction occurs.
A thickened, elongated muscle causes an obstruction at the end of the stomach. Correct Explanation: Pyloric stenosis is characterized by hypertrophy of the circular muscle fibers of the pylorus, with a severe narrowing of its lumen. The pylorus is thickened to as much as twice its size, is elongated, and has a consistency resembling cartilage. As a result of this obstruction at the distal end of the stomach, the stomach becomes dilated. 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. Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus is relaxed and allows gastric contents to be regurgitated back into the esophagus.
A mother brings her 3-year-old son to the ER and tells the triage nurse that he has been vomiting blood. A medical history determines that the 3-year-old has no history of GI disturbances and his only symptoms are a slightly elevated fever and vomiting bright red blood. Based on these symptoms, what condition might the nurse suspect? a) GI tract obstruction b) Acute upper GI bleeding c) Intussusception d) Gastroesophageal reflux
Acute upper GI bleeding Correct Explanation: Vomiting bright red blood indicates acute upper GI bleeding. Emesis containing brown, foul-smelling stool indicates GI obstruction. Stool with red blood and mucus is associated with intussusception. Bleeding is not generally indicative of gastroesophageal reflux.
The nurse observes the interactions of parents with their infant who was born with a cleft lip. The mother is attempting to feed the baby, but does not make eye contact. The father is watching television with his back turned to the mother and baby. What psychosocial nursing intervention would be most helpful to this family? a) Teach the mother the appropriate technique for breast-feeding an infant with cleft lip. b) Ask the parents if they have any questions regarding the care of their child. c) Explain to the parents that surgical intervention will fix the defect in the baby's lip. d) Refer the family to a social worker or mental health practitioner.
Ask the parents if they have any questions regarding the care of their child. Explanation: The family's emotional response to the birth of a child with cleft lip, palate, or both may range from grief to anger to denial. The nurse should encourage the parents to express their feelings and provide the parents with opportunities and support for normal infant-parent interactions.
The nurse is 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? a) Bananas b) Oatmeal c) Toast d) Potatoes
Bananas Correct 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 which of the following would be attempted first to reduce this condition? a) Upper endoscopy b) Endoscopic retrograde cholangiopancreatography c) Surgery d) Barium enema
Barium enema Correct 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 taking a health history of a 2-year-old girl presenting with a sudden onset of severe vomiting. Which of the following descriptions would suggest an obstruction distal to the ampulla of Vater? a) Bloody vomiting b) Effortless vomiting c) Bilious vomiting d) Projectile vomiting
Bilious vomiting Correct Explanation: The contents and character of the vomitus may give clues to the cause of vomiting. Bilious vomiting is never considered normal and suggests an obstruction distal to the ampulla of Vater. Projectile vomiting is associated with pyloric stenosis. The gender and the age of the child are not consistent with pyloric stenosis. Effortless vomiting is often seen in gastroesophageal reflux. Bloody emesis can signify esophageal or gastrointestinal bleeding.
A child is scheduled for a urea breath test. The nurse understands that this test is being performed for which reason? a) Determine esophageal contractility b) Detect Helicobacter pylori c) Confirm pancreatitis d) Evaluate gastric pH
Detect Helicobacter pylori Correct 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 nurse is caring for a child admitted with gastroesophageal reflux (GER). Which of the following clinical manifestations would likely be seen in this child? a) Bouts of diarrhea with failure to gain weight b) Severe constipation with occasional ribbon-like stools c) Forceful vomiting followed by the child being eager to eat again. d) Effortless vomiting just after the child has eaten.
Effortless vomiting just after the child has eaten. Correct Explanation: Almost immediately after feeding, the child with gastroesophageal reflux vomits the contents of the stomach. The vomiting is effortless, not projectile in nature.
A preschooler has celiac disease. Her mother is preparing a gluten-free diet. By preparing which breakfast foods would you believe she understands the diet? a) Cheerios (oat cereal) and skim milk b) Wheat toast and grape jelly c) Eggs and orange juice d) Rye toast and peanut butter
Eggs and orange juice Correct Explanation: Children with celiac disease cannot digest the protein in common grains, such as wheat, rye, and oats.
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? a) Cleft palate b) Hernia c) Pyloric stenosis d) Esophageal atresia (EA)
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 nurse examining a neonate is unable to identify the fetal stomach. The nurse knows that this sign strongly indicates which of the following conditions? a) Pyloric stenosis b) Duodenal atresia c) Esophageal atresia (EA) d) Hernia
Esophageal atresia (EA) Explanation: 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.
The pH of blood is normally slightly acidic, ranging from 6.85 to 6.95. a) False b) True
False Correct Explanation: The pH of blood is normally slightly alkaline, ranging from 7.35 to 7.45.
The nurse has admitted a child with a diagnosis of severe gastroenteritis. To help prevent the risk of transmitting infection to other patients, the nurse should a) Follow standard precautions b) Sterilize thermometers between patients c) Discourage anyone from visiting d) Wear a mask when handling articles contaminated with feces
Follow standard precautions Explanation: To prevent the spread of possibly infectious organisms to other pediatric patients, follow standard precautions issued by the Centers for Disease Control. Gloves should be worn when handling items contaminated with feces, but masks are not necessary. Visitor should be limited to family only. Take the temperature with a thermometer that is used only for that child.
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? a) Appendicitis b) Pancreatitis c) Gastroenteritis d) Hirschsprung disease
Gastroenteritis Correct Explanation: Outbreaks of gastroenteritis routinely occur in daycare 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.
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: a) Inflammatory bowel disease b) Cystic fibrosis c) Gastroesophageal reflux disease d) Hirschsprung disease
Gastroesophageal reflux disease Correct Explanation: The child with gastroesophageal reflux disease may present with the physical findings of pneumonia secondary to aspiration of refluxed stomach contents.
A 2-month-old boy is admitted to the emergency room with severe diarrhea. Intravenous fluid is prescribed for him. Before adding potassium to this solution, which assessment would you record? a) He "attunes" to a music box. b) His hands are restrained. c) He has voided. d) He cries with tears.
He has voided. Explanation: With severe diarrhea, kidney function may fail. It is important to document that kidney function is intact before adding potassium to prevent hyperkalemia.
An adolescent boy is diagnosed with hepatitis A. Which problem should be considered when planning care? a) His urine will be dark and infectious. b) He will be very irritable and perhaps require sedation. c) Hypothermia is common. d) He will become fatigued easily.
He will become fatigued easily. Correct Explanation: Most children with hepatitis are exhausted. Urine is not infectious.
A nurse prepares a menu for a patient with Crohn Disease. What is the focus of dietary management for this disease? a) Low fiber, low calorie b) Low calorie, high carbohydrate c) High calorie, high protein d) High calorie, high fiber
High calorie, high protein Correct Explanation: The goal of nutritional intervention is to provide adequate nutrient intake to optimize normal growth and development—including pubertal development, which is frequently delayed—and to prevent and correct nutrient deficiencies. Dietary management focuses on enhancing protein and calorie intake. Generally, a high-protein, high-calorie diet is recommended.
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? a) Ulcerative colitis (UC) b) Gastroenteritis c) Short bowel syndrome (SBS) d) Hirschsprung disease
Hirschsprung disease Correct 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.
The nurse is caring for a child with a diagnosis of pyloric stenosis during the preoperative phase of the child's treatment. Which of the following goal has the highest priority at this time? a) Maintaining skin integrity b) Improving hydration c) Promoting comfort d) Preparing family for home care
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 most accurate related to the diagnosis of gastroesophageal reflux? a) A thickened, elongated muscle causes an obstruction at the end of the stomach. b) In this disorder the sphincter that leads into the stomach is relaxed. c) There are recurrent paroxysmal bouts of abdominal pain. d) A partial or complete intestinal obstruction occurs.
In this disorder the sphincter that leads into the stomach is relaxed. Correct 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.
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. Which of the following conditions should the nurse suspect in this case? a) Necrotizing enterocolitis b) Short-bowel/short-gut syndrome c) Intussusception d) Volvulus with malrotation
Intussusception Explanation: Intussusception, the invagination of one portion of the intestine into another, usually occurs in the second half of the first year of life. Children with this disorder suddenly draw up their legs and cry as if they are in severe pain; they may vomit. After the peristaltic wave that caused the discomfort passes, they are symptom-free and play happily. In approximately 15 minutes, however, the same phenomenon of intense abdominal pain strikes again. After approximately 12 hours, blood appears in the stool and possibly in vomitus, described as a "currant jelly" appearance. Volvulus with malrotation and necrotizing 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 girl with an intestinal virus has been vomiting and has become dehydrated. She says she is mildly thirsty, her skin turgor is poor, and her skin is dry and cool. Her serum sodium level is normal. The nurse recognizes that she has which type of dehydration? a) Hypotonic b) Isotonic c) Hypertonic d) Acidotic
Isotonic Correct Explanation: Signs and symptoms of isotonic dehydration include the following: mild thirst; poor skin turgor; dry, cool skin; decreased urine output; irritability; and a normal sodium level. Signs and symptoms of hypotonic dehydration include the following: moderate thirst; very poor skin turgor; clammy, cool skin; decreased urine output; lethargy; and a reduced sodium level. Signs and symptoms of hypertonic dehydration include the following: extreme thirst; moderate skin turgor; warm skin; decreased urine output; extreme lethargy; and an increased sodium level. Acidotic is not a type of dehydration.
A father brings his 10-year-old daughter in to the physician's office with jaundice, headache, fever, and anorexia, symptoms she has had for the past few days. The nurse should suspect infection of which organ in this client? a) Stomach b) Esophagus c) Small intestines d) Liver
Liver Correct Explanation: No matter which virus is involved, hepatitis is a generalized body infection with specific intense liver effects. Type A occurs in children of all ages and accounts for approximately 30% of instances. With hepatitis A, children notice headache, fever, and anorexia. Jaundice occurs as liver function slows.
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? a) Upper right b) Lower right c) Upper left d) Lower left
Lower right Correct Explanation: 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, which of the following would the nurse identify as a risk factor for this condition? a) Mother age 42 with pregnancy b) Maternal use of acetaminophen in third trimester c) Preterm birth d) History of hypoxia at birth
Mother age 42 with pregnancy Explanation: Advanced maternal age is a risk factor for cleft lip and palate. Drugs such as anticonvulsants, steroids, and other medications during early pregnancy are considered risk factors. Acetaminophen is not associated with an increased risk for cleft lip and palate. Preterm birth is not a risk factor for the development of cleft lip and palate. Hypoxia or anoxia is a risk factor for the development of necrotizing enterocolitis.
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. Which of the following would indicate that the child is regurgitating as opposed to vomiting? a) Is curdled and extremely sour smelling b) Continues until stomach is empty c) Is projected 1 ft away from infant d) Only occurs with feeding
Only occurs with feeding Correct Explanation: Regurgitation typically occurs only with feeding, runs out of the mouth with little force, smells barely sour and is only slightly curdled, appears to cause no pain or distress, occurs only once per feeding, and amounts to only about 1 to 2 tsp. Vomiting may occur at times other than feeding, is forceful and is typically projected 1 ft or more away from infant, is extremely sour smelling and curdled, is typically accompanied by crying, continues until the stomach is empty, and amounts to the full stomach contents.
The nurse caring for an 18-month-old infant with Meckel diverticulum knows that the most common clinical manifestation of this condition is: a) Dehydration b) Respiratory distress c) Ischemia d) Painless rectal bleeding
Painless rectal bleeding Correct Explanation: 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.
The nurse is caring for a child admitted with congenital aganglionic megacolon. Which of the following clinical manifestations would likely have been noted in the child with this diagnosis? a) Chronic cough b) Irregular breathing c) Persistent constipation d) Prolonged bleeding
Persistent constipation Correct Explanation: Congenital aganglionic megacolon, also called Hirschsprung disease, is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Prolonged bleeding is a manifestation of hemophilia. A chronic cough is noted in the child with cystic fibrosis. Irregular breathing occurs in children with seizures.
In caring for an infant diagnosed with pyloric stenosis, the nurse would anticipate doing which of the following? a) Changing the infant's diet to lactose-free b) Medicating the infant with analgesics c) Preparing the infant for surgery d) Assisting in doing a barium enema procedure on the infant
Preparing the infant for surgery Correct Explanation: A surgical procedure called a pyloromyotomy (also known as a Fredet-Ramstedt operation) is the treatment of choice for pyloric stenosis.
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. Which of the following is the correct rationale for this intervention? a) Prevention of hypoglycemia b) Reduction of hypertension c) Prevention of T-cell rejection of the transplanted liver d) Maintenance of electrolyte balance
Prevention of hypoglycemia Correct 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 caring for a child admitted with pyloric stenosis. Which of the following clinical manifestations would likely have been noted in the child with this diagnosis? a) Severe abdominal pain b) Explosive diarrhea c) Frequent urination d) Projectile vomiting
Projectile vomiting Correct Explanation: During the first weeks of life, the infant with pyloric stenosis often eats well and gains weight and then starts vomiting occasionally after meals. Within a few days the vomiting increases in frequency and force, becoming projectile. The child may have constipation, and peristaltic waves may be seen in the abdomen, but the child does not appear in severe pain. Urine output is decrease and urination is infrequent.
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 of the following conditions should the nurse suspect in this child? a) Pyloric stenosis b) Gastroesophageal reflux c) Peptic ulcer disease d) Appendicitis
Pyloric stenosis Correct Explanation: With pyloric stenosis, at 4 to 6 weeks of age, infants typically begin to vomit almost immediately after each feeding. The vomiting grows increasingly forceful until it is projectile, possibly projecting as much as 3 to 4 feet. Infants are usually hungry immediately after vomiting because they are not nauseated. A definitive diagnosis can be made by watching the infant drink. If a pyloric stenosis is present, the sphincter feels round and firm, approximately the size of an olive in the right abdomen. Peptic ulcer disease in neonates usually presents with hematemesis (blood in vomitus) or melena (blood in the stool). Gastroesophageal reflux involves a small (1-2 tsp) volume and is not forceful. Appendicitis typically begins with anorexia for 12 to 24 hours; children do not eat and do not act like their usual selves. Nausea and vomiting may then occur, followed by diffuse abdominal pain.
The nurse is collecting data for a child with idiopathic celiac disease. The caregiver tells the nurse that her child has bulky and greasy stools. The nurse recognizes that the child has which of the following? a) Invagination b) Steatorrhea c) Polyuria d) Pica
Steatorrhea Correct Explanation: Intestinal malabsorption with steatorrhea (fatty stools) is a condition brought about by various causes, one being idiopathic celiac disease. Pica is the ingestion of nonfood substances, invagination is the telescoping of a portion of the bowel, and polyuria is a dramatic increase in the urinary output.
The caregiver of a child diagnosed with celiac syndrome tells the nurse that the child has large amounts of bulky stools and what looks like fat in his stools. The clinical manifestation this caregiver is describing is which of the following? a) Severe diarrhea b) Current jelly stools c) Steatorrhea d) Projectile stools
Steatorrhea Correct Explanation: The term celiac syndrome is used to designate the complex of malabsorptive disorders. Intestinal malabsorption with steatorrhea (fatty stools) is a condition brought about by various causes.
If an adolescent has hepatitis B, what would be an important nursing action? a) Conscientious collection of stool for ova and parasites b) Strict enforcement of standard precautions c) Strict calculation of caloric and vitamin B intake d) Close observation to detect cerebral hallucinations
Strict enforcement of standard precautions Correct Explanation: Hepatitis B is spread through contaminated blood. Standard precautions help prevent contact with this.
The nurse is caring for a 6-month-old infant who was admitted to the emergency room 24 hours ago with signs of severe diarrhea. The infant's rectal temperature is 104° F, with weak and rapid pulse and respirations. The skin is pale and cool. The child is on IV rehydration therapy, but the diarrhea is persisting. The infant has not voided since being admitted. Which of the following is the priority nursing intervention? a) Feed the child a cracker b) Administer antibiotic therapy c) Administer IV potassium d) Take a stool culture
Take a stool culture Correct Explanation: Treatment of severe diarrhea focuses on regulating electrolyte and fluid balance by initiating a temporary rest for the GI tract, oral or IV rehydration therapy, and discovering the organism responsible for the diarrhea. All children with severe diarrhea or diarrhea that persists longer than 24 hours should have a stool culture taken to determine if bacteria are causing the diarrhea, and if so, a definite antibiotic therapy can be prescribed. Because a side effect of many antibiotics is diarrhea, antibiotics should not routinely be used to treat diarrhea without an identifiable bacterial cause. Before the initial IV fluid is changed to a potassium solution, be certain the infant or child has voided—proof that the kidneys are functioning; in this case, the child is not voiding yet. The child should not be fed a cracker, as the GI tract should be rested until the diarrhea stops.
Which of the following is most correct regarding the gastrointestinal system of the child? a) The child's gastrointestinal system is fully matured when the child is born. b) The child cannot break down and use complex carbohydrates in the same way the adult can. c) The enzymes secreted by the child's liver and pancreas are much greater in amount than in the adult. d) The speed with which food passes through the gastrointestinal tract in the child is much slower than in the adult.
The child cannot break down and use complex carbohydrates in the same way the adult can. Correct Explanation: In the GI tract of the newborn the enzymes secreted by the liver and pancreas are reduced. Thus, the infant cannot break down and use complex carbohydrates. In the infant, food moves through the GI tract with increased speed. The GI tract matures and the capacity of the GI tract increases as the child gets older. (less)
The nurse is working with the mother of a newborn. The mother asks why a baby needs small feedings at frequent intervals. The nurse explains to the mother that this is necessary because in the infant a) Peristaltic action is absent in the lower portion of the bowel b) The pylorus has not been fully formed c) Food moves more slowly through the GI tract d) The enzymes secreted by the liver and pancreas are reduced
The enzymes secreted by the liver and pancreas are reduced Correct Explanation: In the newborn the enzymes secreted by the liver and pancreas are reduced. Thus, the infant cannot break down and use complex carbohydrates. As a result, the newborn diet must be adjusted to allow for this immaturity. By the age of 4 to 6 months, the needed enzymes are usually sufficient in amount. The smaller capacity of the infant's stomach and the increased speed at which food moves through the GI tract require feeding smaller amounts at more frequent intervals. In addition, the small capacity of the colon leads to a bowel movement after each feeding. The pyloric spincter is formed, but is lax and does not have bearing on the frequency of feeding.
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 of the following features indicates a geographic tongue rather than thrush? a) The patches are thick and white plaques on the tongue. b) There are plaques on the buccal mucosa. c) The patches are light in color on the tongue. d) There are white patches on the erupted teeth.
The patches are light in color on the tongue. Correct 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.
In understanding the gastrointestinal system, the nurse recognizes that this system includes the stomach and intestines as well as which of the following? a) Nerves throughout the abdomen b) The pharynx and esopagus c) A protective cushion lining the organs d) The brain and spinal cord
The pharynx and esopagus Correct Explanation: The main organs of the gastrointestinal (GI) or digestive system are the mouth, pharynx (throat), esophagus, stomach, small intestine, large intestine, rectum, and anal canal. The brain, spinal column and nerves are part of the nervous system and there is a protective coating surrounding the nerves.
The nurse is discussing the diagnosis of intussuseption with a group of peers. Which of the following is an accurate statement regarding this disorder? a) The infant is pale, cries weakly, and has spasms of pain continuously. b) The disorder is seen most often in female infants under the age of 3 months. c) The stools of the infant are called currant jelly stools and consist of blood and mucuous. d) There is a telescoping of the lower part of the bowel up over the upper part of the bowel.
The stools of the infant are called currant jelly stools and consist of blood and mucuous. Correct Explanation: 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 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 colic? a) In this disorder the sphincter that leads into the stomach is relaxed. b) A partial or complete intestinal obstruction occurs. c) A thickened, elongated muscle causes an obstruction at the end of the stomach. d) There are recurrent paroxysmal bouts of abdominal pain.
There are recurrent paroxysmal bouts of abdominal pain. Explanation: Colic consists of recurrent paroxysmal bouts of abdominal pain and is fairly common in young infants. Congenital aganglionic megacolon is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. 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. Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus is relaxed and allows gastric contents to be regurgitated back into the esophagus.
Which of the following occurs in the gastrointestinal system of the child with Hirschsprung disease? a) There is an invagination or telescoping of one portion of the bowel into a distal portion. b) There is a relaxed sphincter in the lower portion of the esophagus. c) There is a partial or complete mechanical obstruction in the intestine. d) There is a severe narrowing of the lumen of the pylorus.
There is a partial or complete mechanical obstruction in the intestine. Correct Explanation: Congenital aganglionic megacolon, also called Hirschsprung disease, is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin.
Constipation may be initially caused by psychological problems. a) True b) False
True Explanation: 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 6-month-old boy is diagnosed with pyloric stenosis. When you take a health history from his mother, which symptom would you expect to hear her describe? a) Chronic diarrhea b) Vomiting about 2 hours after feeding c) Refusal to eat d) Vomiting immediately after feeding
Vomiting immediately after feeding Correct Explanation: A narrowing of the pyloric valve leads to projectile vomiting soon after eating.
A 7-year-old boy has experienced severe diarrhea resulting from an intestinal virus. The nurse is concerned that the child will develop an acid-base imbalance. Which of the following blood test results would indicate that the boy is experiencing metabolic acidosis? a) pH of 7.25, HCO3 of 20 mEq/L b) pH of 7.35, HCO3 of 24 mEq/L c) pH of 7.4, HCO3 of 26 mEq/L d) pH of 7.5, HCO3 of 29 mEq/L
pH of 7.25, HCO3 of 20 mEq/L Correct Explanation: The pH of blood is normally slightly alkaline, ranging from 7.35 to 7.45. The level of bicarbonate (HCO3) in arterial blood is normally 22 to 26 mEq/L. Metabolic acidosis results from diarrhea as a great deal of sodium is lost with stool. With metabolic acidosis, arterial blood gas analysis will reveal a decreased pH (under 7.35) and a low HCO3 value (near or below 22 mEq/L). With metabolic alkalosis, pH will be elevated (near or above 7.45), and HCO3 level will be near or above 28 mEq/L.
You care for a 12-year-old girl with Crohn's disease. A primary assessment you would want to make when caring for her would be to note if a) her joints are not swollen. b) she has a temperature. c) she has a headache. d) lung sounds are clear.
she has a temperature. Correct Explanation: Because Crohn's disease leads to patches of inflammation in the bowel, the temperature increases if more patches become involved.
The nurse is assessing a child with suspected necrotizing enterocolitis. Which of the following would the nurse expect to find? Select all that apply. a) Tachypnea b) Bilious vomiting c) Clay-colored stools d) Hyperirritability e) Abdominal distention
• Abdominal distention • Bilious vomiting Explanation: Assessment findings associated with necrotizing enterocolitis include abdominal distention and tenderness, bloody stools, feeding intolerance characterized by bilious vomiting, sepsis, lethargy, apnea, and shock.
The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac syndrome. Which of the following foods would be permitted in the diet of the child with celiac syndrome? (Select all that apply) a) Wheat bread b) oatmeal c) Applesauce d) Bananas e) Corn bread f) Skim milk
• Applesauce • Bananas • Skim milk Correct Explanation: The child is usually started on a gluten-free, low-fat diet. Skim milk, banana flakes and bananas are usually well tolerated. Lean meats, puréed vegetables, and fruits are gradually added to the diet. Wheat, rye, oat products, corn flour and cornmeal are not included in the diet.
A mother brings her 2-week-old newborn to the doctor's office because the child has been experiencing gastroesophageal reflux over the past week. Which of the following interventions should the nurse recommend to the mother at this point? (Select all that apply.) a) Consult a pediatric surgeon regarding having a myotomy procedure performed b) Consult the physician regarding having botulinum toxin injected into the lower esophageal sphincter c) Feed the infant a formula thickened with rice cereal d) If breastfeeding, switch to formula e) Keep the infant upright in an infant chair for 1 hour after feeding f) Feed the infant while holding her in an upright position
• Feed the infant a formula thickened with rice cereal • Feed the infant while holding her in an upright position • Keep the infant upright in an infant chair for 1 hour after feeding Explanation: The traditional treatment of GI reflux is to feed infants a formula thickened with rice cereal (1 tbsp of cereal per 1 oz of formula or breast milk) while holding them in an upright position and then keeping them upright in an infant chair for 1 hour after feeding so gravity can help prevent reflux. There is no need for the mother to switch from breastfeeding to formula. Injection of botulinum toxin into the lower esophageal sphincter and a myotomy procedure are interventions that would be considered only if the problem does not disappear with feeding solid food and maintaining the child in a more upright position during and following feeding; they would not be appropriate at this point.
The nurse examining an infant forms the following diagnosis: "Risk for impaired skin integrity related to effects of diarrhea." This diagnosis would be most appropriate for which of the following disease states (select all that apply): a) Congenital diaphragmatic hernia b) Meckel diverticulum c) Ulcerative colitis d) Inflammatory bowel disease e) Crohn disease f) Pyloric stenosis
• Inflammatory bowel disease • Crohn disease • Ulcerative colitis Explanation: Inflammatory bowel disease (IBD) is a group of diseases characterized by inflammation of the GI tract and diarrhea. Crohn disease (CD) and ulcerative colitis (UC) are the most common forms of IBD and account for more than 80% of all cases.
A group of nursing students are reviewing information about celiac disease. The students demonstrate understanding of this disorder when they identify which of the following as classic symptoms? Select all that apply. a) Diarrhea b) Failure to thrive c) Steatorrhea d) Constipation e) Polycythemia f) Sunken abdomen
• Steatorrhea • Constipation • Diarrhea • Failure to thrive Explanation: Classic symptoms of celiac disease include steatorrhea, constipation, diarrhea, failure to thrive, weight loss, abdominal distention or bloating (not a sunken abdomen), and anemia (not polycythemia).
The nurse caring for a patient with Crohn disease knows that long-term complications for this patient might include (select all that apply): a) Short-bowel syndrome b) Gallstones c) Pancreatitis d) Stricture e) Intra-abdominal abscess formation f) Fistula
• Stricture • Fistula • Intra-abdominal abscess formation • Short-bowel syndrome Explanation: Crohn disease is a recurrent disease. Long-term complications may include stricture, fistula, and intra-abdominal abscess formation. Individuals with severe disease who require extensive resection of diseased bowel may be left with short bowel syndrome and long-term dependence on PN.
A nurse is assessing an infant who has been vomiting and experiencing diarrhea. Which of the following would indicate to the nurse that the infant is experiencing severe dehydration? Select all that apply. a) Pink moist oral mucosa b) Sunken fontanels c) Slightly decreased urine output d) Cool mottled extremities e) Bradycardia
• Sunken fontanels • Bradycardia • Cool mottled extremities Explanation: Severe dehydration would be indicated by sunken fontanels, increased heart rate progressing to bradycardia, cool mottled or dusky extremities, dry oral mucosa, and significantly decreased urine output of less than 1 mL/kg/hour. Pink moist oral mucosa and slightly decreased urine output would suggest mild dehydration.
