Chapter_047 (1)

Wong, et al.: Maternal Child Nursing Care, 3rd Edition

Test Bank

Chapter 47: Gastrointestinal Dysfunction

MULTIPLE CHOICE

1. Nurses must be alert for increased fluid requirements when a child has which of the following?1. Fever2. Mechanical ventilation3. Congestive heart failure4. Increased intracranial pressure

ANS: 11. Correct: Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume.2. Incorrect: Respiratory rate influences insensible fluid loss and should be monitored in the mechanically ventilated child.3. Incorrect: Congestive heart failure is a case of fluid overload in children.4. Incorrect: Increased intracranial pressure (ICP) does not lead to increased fluid requirements in children.

REF: p. 1493 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Nursing Process: Assessment

2. Melena, the passage of black, tarry stools, suggests bleeding from:1. perianal or rectal area.2. hemorrhoids or anal fissures.3. upper gastrointestinal (GI) tract.4. lower GI tract.

ANS: 31, 2, and 4. Incorrect: Blood from the perianal, rectal area, hemorrhoids, or lower GI tract would be bright red.3. Correct: Melena is denatured blood from the upper GI tract or bleeding from the right colon.


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3. What type of dehydration is defined as “dehydration that occurs in conditions in which electrolyte and water deficits are present in approximately balanced proportion”?1. Isotonic dehydration2. Hypotonic dehydration3. Hypertonic dehydration4. All types of dehydration in infants and small children

ANS: 11. Correct: Isotonic dehydration is the correct term for this definition and is the most frequent form of dehydration in children.2. Incorrect: Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic.3. Incorrect: Hypertonic dehydration results from water loss in excess of electrolyte loss and is usually caused by a proportionately larger loss of water or a larger intake of electrolytes. 4. Incorrect: This definition is specific to isotonic dehydration.


4. Which of the following types of dehydration results from water loss in excess of electrolyte loss?1. Isotonic dehydration2. Isosmotic dehydration3. Hypotonic dehydration4. Hypertonic dehydration

ANS: 41. Incorrect: Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion.2. Incorrect: Isosmotic dehydration is another term for isotonic dehydration.3. Incorrect: Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic.4. Correct: Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute.


5. An infant is brought to the emergency department with the following clinical manifestations: poor skin turgor, weight loss, lethargy, and tachycardia. This is suggestive of which of the following?


1. Overhydration2. Dehydration3. Total body sodium excess4. Hypocalcemia

ANS: 21. Incorrect: Symptoms of overhydration are edema and weight gain.2. Correct: These clinical manifestations indicate dehydration.3. Incorrect: These are symptoms of dehydration. Regardless of extracellular sodium levels, total body sodium is usually depleted in dehydration.4. Incorrect: These are symptoms of dehydration. Symptoms of hypocalcemia are a result of neuromuscular irritability and manifested as jitteriness, tetany, tremors, and muscle twitching.


6. Acute diarrhea may be associated with:1. Hirschprung disease.2. antibiotic therapy.3. hypothyroidism.4. meconium ileus.

ANS: 21, 3, and 4. Incorrect: Hirschprung disease, hypothyroidism, and meconium ileus are usually manifested with constipation rather than diarrhea.2. Correct: Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be associated with antibiotic therapy.


7. Which of the following is the viral pathogen that frequently causes acute diarrhea in young children under 5 years of age?1. Giardia2. Shigella3. Rotavirus4. Salmonella

ANS: 31. Incorrect: Giardia is a bacterial pathogen that causes diarrhea.2. Incorrect: Shigella is a bacterial pathogen that is uncommon in the United States.3. Correct: Rotavirus is the most frequent viral pathogen that causes diarrhea in young children.


4. Incorrect: Salmonella is a bacterial pathogen that causes diarrhea.

REF: p. 1496; Table 47-4 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Nursing Process: Assessment

8. Which of the following is a parasite that causes acute diarrhea?1. Shigella2. Salmonella3. Giardia4. Escherichia coli

ANS: 31. Incorrect: Shigella is a bacterial pathogen.2. Incorrect: Salmonella is a bacterial pathogen.3. Correct: Giardiais a parasite that represents 15% of nondysenteric illness in the United States.4. Incorrect: E. coli is a bacterial pathogen.


9. A stool specimen from a child with diarrhea shows the presence of neutrophils and red blood cells. This is most suggestive of which of the following conditions?1. Protein intolerance2. Parasitic infection3. Fat malabsorption4. Bacterial gastroenteritis

ANS: 41. Incorrect: Protein intolerance is suspected in the presence of eosinophils.2. Incorrect: Parasitic infection is indicated by eosinophils.3. Incorrect: Fat malabsorption is indicated by foul-smelling, greasy, bulky stools.4. Correct: Neutrophils and red blood cells in stool indicate bacterial gastroenteritis.


10. Therapeutic management of the child with acute diarrhea and dehydration usually begins with which of the following?1. Clear liquids


2. Adsorbents, such as kaolin and pectin3. Orally administered rehydration solutions (ORS)4. Antidiarrheal medications such as paregoric

ANS: 31. Incorrect: Clear liquids are not recommended because they contain too much sugar, which may contribute to diarrhea.2. Incorrect: Adsorbents are not recommended.3. Correct: Orally administered rehydration solution is the first treatment for acute diarrhea.4. Incorrect: Antidiarrheals are not recommended because they do not get rid of pathogens.


11. A 5-year-old child with acute diarrhea has been rehydrated with (ORSs). The nurse should recommend that the child’s diet be advanced to include which of the following?1. Regular diet2. Clear liquids3. High-carbohydrate diet4. BRAT diet (bananas, rice, apples, and toast or tea)

ANS: 11. Correct: It is appropriate to advance to a regular diet after ORS.2. Incorrect: Clear liquids are not appropriate for hydration or after.3. Incorrect: A high-carbohydrate diet may contribute to loose stools because of the low electrolyte content and high osmolality. 4. Incorrect: The BRAT diet has very little nutritional value and is high in carbohydrates.

REF: p. 1500 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Teaching/Learning

12. A school-age child with diarrhea has been rehydrated. The nurse is discussing the child’s diet with the family. Which of the following may be tolerated the best?1. Clear liquids2. Carbonated drinks3. Applesauce and milk4. Easily digested foods

ANS: 41 and 2. Incorrect: Clear liquids and carbonated drinks have high carbohydrate content and few electrolytes. Caffeinated beverages should be avoided because caffeine is a mild diuretic.


3. Incorrect: In some children, lactose intolerance will develop with diarrhea, and cow’s milk should be avoided in the recovery stage.4. Correct: Easily digested foods such as cereals, cooked vegetables, and meats should be provided for the child. Early reintroduction of nutrients is desirable. Continued feeding or reintroduction of a regular diet has no adverse effects and actually lessens the severity and duration of the illness.

REF: p. 1501 OBJ: Cognitive Level: ApplicationSTO: Area of client needs: Physiologic Integrity/Physiologic AdaptationTOP: Integrated process: Teaching/Learning

13. A young child is brought to the emergency department with dehydration secondary to acute diarrhea and vomiting. The nurse’s assessment reveals a weight of 71 pounds, sunken eyes and capillary refill time of 5 seconds. The mother tells the nurse that the child’s usual weight is 80 pounds. Therapeutic management of this child will begin with:1. intravenous fluids.2. ORS.3. clear liquids, 1 to 2 oz. at a time.4. administration of antidiarrheal medication.

ANS: 11. Correct: In children with severe dehydration, intravenous fluids are initiated.2. Incorrect: ORS is acceptable therapy if the dehydration is not severe.3. Incorrect: Diarrhea is not managed by using clear liquids by mouth. These fluids have a high carbohydrate content, low electrolyte content, and high osmolality.4. Incorrect: Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea.

REF: p. 1495, Table 47-3 OBJ: Cognitive Level: ApplicationSTO: Area of client needs: Physiologic Integrity/Physiologic AdaptationTOP: Integrated process: Nursing Process: Implementation

14. A mother calls the clinic nurse about her 4-year-old son who has acute diarrhea. She has been giving him the antidiarrheal drug loperamide (Imodium A-D). The nurse’s response should be based on knowledge that this drug is:1. not recommended. Antidiarrheal medications are not recommended for the

treatment of acute infectious diarrhea. These medications have adverse effects such as slowed motility and can prolong the illness.

2. indicated, because it slows intestinal motility.3. indicated, because it decreases diarrhea.4. indicated, because it decreases fluid and electrolyte losses.

ANS: 1


1. Correct: Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea. These medications have adverse effects and toxicity, such as worsening of the diarrhea because of slowing of motility and ileus, or a decrease in diarrhea with continuing fluid losses and dehydration.2, 3 and 4. Incorrect: Antidiarrheal medications are not recommended in infants and small children.

REF: p. 1501; p. 1550 OBJ: Cognitive Level: AnalysisSTO: Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral TherapyTOP: Integrated process: Teaching/Learning

15. Constipation has recently become a problem for a school-age girl. She is healthy except for milk allergy and “hay fever” seasonal allergies. She has recently been treated successfully with antihistamines for the seasonal allergies. The nurse should suspect that the constipation is most likely caused by which of the following?1. Diet2. Allergies3. Antihistamines4. Emotional factors

ANS: 31, 2 and 4. Incorrect: With a change in bowel habits, the presence and role of any recently prescribed medications should be assessed.3. Correct: Constipation may be associated with drugs such as antihistamines, antacids, diuretics, opioids, antiepileptics, and iron. Because this is the only known recent change in her habits, the addition of antihistamines is most likely the etiology of the diarrhea.

REF: p. 1501 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral TherapyTOP: Integrated process: Nursing Process: Problem Identification

16. Which of the following is a high-fiber food that the nurse could recommend for a child with chronic constipation?1. Popcorn2. Cupcakes3. Avocado4. Ripe bananas

ANS: 11. Correct: Popcorn is a high-fiber food.2. Incorrect: Cake does not have significant fiber unless made with fruit or bran.3 and 4. Incorrect: Raw fruits, especially those with skins and seeds and other than ripe bananas and avocado, are high in fiber.


REF: p. 1504, p. 1505, Box 47-8 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Teaching/Learning

17. Therapeutic management of most children with Hirschsprung disease is primarily which of the following?1. Daily enemas2. Low-fiber diet3. Permanent colostomy4. Surgical removal of affected portion of bowel

ANS: 41 and 2. Incorrect: Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet, until the child is physically ready for surgery. 3. Incorrect: The colostomy that is created in Hirschsprung disease is usually temporary.4. Correct: Most children with Hirschsprung disease require surgical rather than medical management. Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter.

REF: p. 1505, p. 1506 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Physiologic AdaptationTOP: Integrated process: Nursing Process: Implementation

18. Enemas are ordered to empty the bowel preoperatively for a child with Hirschsprung disease. The enema solution should be:1. tap water.2. normal saline.3. oil retention.4. phosphate preparation.

ANS: 21. Incorrect: Plain water is not used. This is a hypotonic solution and can cause rapid fluid shift, resulting in fluid overload.2. Correct: Isotonic solutions should be used in children. Saline is the solution of choice.3. Incorrect: Oil-retention enemas will not achieve the “until clear” result.4. Incorrect: Phosphate enemas are not advised for children because of the harsh action of the ingredients. The osmotic effects of the phosphate enema can result in diarrhea, which can lead to metabolic acidosis.

REF: p. 1506 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Nursing Process: Implementation


19. A 5-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. The nurse should recognize that preparing this child is:1. not necessary because of the child’s age.2. not necessary, because the colostomy is temporary.3. necessary, and should be explained in concrete terms.4. necessary, because the child must deal with negative body image.

ANS: 31 and 2. Incorrect: It is necessary to prepare this age child for procedures.3. Correct: The child’s age dictates the type and extent of psychological preparation. When a colostomy is performed, the child who is at least preschool age is told about the procedure and what to expect in concrete terms, with the use of visual aids.4. Incorrect: The preschooler is not yet concerned with body image.

REF: p. 1506 OBJ: Cognitive Level: ApplicationSTO: Area of client needs: Psychosocial Integrity/Coping and AdaptationTOP: Integrated process: Teaching/Learning

20. The nurse is explaining to a parent how to care for a child with vomiting associated with a viral illness. Which of the following should the nurse include?1. Avoid carbohydrate-containing liquids.2. Give nothing by mouth for 24 hours.3. Brush teeth or rinse mouth after vomiting.4. Give plain water until vomiting ceases for at least 24 hours.

ANS: 31, 2, and 4. Incorrect: Administration of glucose-electrolyte solution to an alert child will help restore water and electrolytes satisfactorily. It is important to include carbohydrates to spare body protein and avoid ketosis.3. Correct: It is important to emphasize the need for the child to brush the teeth or rinse the mouth after vomiting to dilute the hydrochloric acid that comes in contact with the teeth.


21. A 4-month-old infant has gastroesophageal reflux disease (GERD) but is thriving without other complications. Which of the following should the nurse suggest to minimize reflux?1. Place in Trendelenburg position after eating.2. Thicken formula with rice cereal.3. Give continuous nasogastric tube feedings.4. Give larger, less frequent feedings.

ANS: 2


1. Incorrect: Placing the child in a Trendelenberg position would increase the reflux.2. Correct: Small frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal per ounce of formula has been recommended. Milk thickening agents have been shown to decrease the number of episodes of vomiting and to increase the caloric density of the formula. This may benefit infants who are underweight as a result of GERD.3. Incorrect: Continuous nasogastric feedings are reserved for infants with severe reflux and failure to thrive.4. Incorrect: Smaller, more frequent feedings are recommended in reflux.

REF: p. 1508 OBJ: Cognitive Level: ApplicationSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Teaching/Learning

22. A histamine-receptor antagonist such as cimetidine (Tagamet) or ranitidine (Zantac) is ordered for an infant with gastroesophageal reflux disease GERD. The purpose of this is to:1. prevent reflux.2. prevent hematemesis.3. reduce gastric acid production.4. increase gastric acid production.

ANS: 31, 2, and 4. Incorrect: These are not the modes of action of histamine-receptor antagonists.3. Correct: The mechanism of action of histamine-receptor antagonists is to reduce the amount of acid present in gastric contents and may prevent esophagitis.

REF: p. 1508 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral TherapyTOP: Integrated process: Nursing Process: Implementation

23. Which of the following clinical manifestations would be the most suggestive of acute appendicitis?1. Rebound tenderness2. Bright red or dark red rectal bleeding3. Abdominal pain that is relieved by eating4. Abdominal pain that is most intense at McBurney point

ANS: 41. Incorrect: Rebound tenderness is not a reliable sign and is extremely painful to the child.2 and 3. Incorrect: These are not signs of acute appendicitis.4. Correct: Pain is the cardinal feature. It is initially generalized and usually periumbilical. The pain localizes to the right lower quadrant at McBurney point.

REF: p. 1512 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Reduction of Risk Potential


TOP: Integrated process: Nursing Process: Assessment

24. When caring for a child with probable appendicitis, the nurse should be alert to recognize that which of the following is a sign of perforation?1. Bradycardia2. Anorexia3. Sudden relief from pain4. Decreased abdominal distention

ANS: 31. Incorrect: Tachycardia, not bradycardia, is a manifestation of peritonitis.2. Incorrect: Anorexia is already a clinical manifestation of appendicitis.3. Correct: Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation.4. Incorrect: Abdominal distention usually increases in addition to an increase in pain (usually diffuse and accompanied by rigid guarding of the abdomen).


25. The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis. Which of the following is appropriate to relieve the abdominal discomfort?1. Place in Trendelenburg position.2. Allow to assume position of comfort.3. Apply moist heat to the abdomen.4. Administer a saline enema to cleanse bowel.

ANS: 21. Incorrect: The Trendelenburg position will not help with the discomfort.2. Correct: The child should be allowed to take a position of comfort. This is usually with the legs flexed.3 and 4. Incorrect: In any instance in which appendicitis is a possibility, there is a danger in administering laxative, enemas, or applying heat to the area. Such measures stimulate bowel motility and increase the risk of perforation.


26. Which of the following statements is most associated with of Meckel diverticulum?1. It is more common in females than in males.2. It is acquired during childhood.


3. Intestinal bleeding may be mild or profuse.4. Medical interventions are usually sufficient to treat the problem.

ANS: 31. Incorrect: It is twice as common in males as in females, and complications are more frequent in males.2. Incorrect: Meckel diverticulum is the most common congenital malformation of the GI tract and is present in 1% to 4% of the general population.3. Correct: Blood stools are often a presenting sign of Meckel diverticulum. It is associated with mild to profuse intestinal bleeding.4. Incorrect: The standard therapy is surgical removal of the diverticulum.


27. Which of the following is characterized by a chronic inflammatory process that may involve any part of the gastrointestinal tract from mouth to anus?1. Crohn disease2. Ulcerative colitis3. Meckel diverticulum4. Irritable bowel syndrome

ANS: 11. Correct: The chronic inflammatory process of Crohn disease involves any part of the GI tract from the mouth to the anus but most often affects the terminal ileum.2, 3, and 4. Incorrect: These disorders do not affect the entire GI tract.

REF: p. 1515 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Physiologic AdaptationTOP: Integrated process: Nursing Process: Assessment

28. Which of the following kind of medication is used to address the primary goal of therapy for moderate to severe inflammatory bowel disease?1. Antacids2. Antibiotics3. Corticosteroids4. Antidiarrheal medications

ANS: 31 and 4. Incorrect: These are not drugs of choice to treat the inflammatory process of inflammatory bowel disease2. Incorrect: Antibiotics may be used as adjunctive therapy to treat complications.


3. Correct: Corticosteroids, such as prednisone and prednisolone, are used in short bursts to suppress the inflammatory response in inflammatory bowel disease.

REF: p. 1515; p. 1516 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral TherapyTOP: Integrated process: Nursing Process: Implementation

29. Bismuth subsalicylate, clarithromycin, and metronidazole are prescribed for a child with a peptic ulcer to:1. eradicate Helicobacter pylori.2. coat gastric mucosa.3. treat epigastric pain.4. reduce gastric acid production.

ANS: 11. Correct: This combination of drug therapy is effective in the treatment of H. pylori.2, 3 and 4. Incorrect: This drug combination is prescribed to eradicate the H. pylori.

REF: p. 1519 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral TherapyTOP: Integrated process: Nursing Process: Implementation

30. Which of the following statements best characterizes hepatitis A?1. Incubation period is 6 weeks to 6 months2. Principal mode of transmission is through the parenteral route3. Onset is usually rapid and acute4. There is a persistent carrier state

ANS: 31. Incorrect: The incubation period is approximately 3 weeks for hepatitis A.2. Incorrect: The principal mode of transmission for hepatitis A is the fecal-oral route.3. Correct: Hepatitis A is the most common form of acute hepatitis in most parts of the world. It is characterized by a rapid acute onset.4. Incorrect: Hepatitis A does not have a carrier state.

REF: p. 1520; Table 47-7 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Nursing Process: Assessment

31. Which of the following is true concerning hepatitis B?1. It cannot exist in carrier state.2. It can be prevented by HBV vaccine.3. Principal mode of transmission is fecal-oral route.


4. Immunity to all types of hepatitis develops after one attack.

ANS: 21. Incorrect: Hepatitis B has a carrier state.2. Correct: The vaccine elicits the formation of an antibody to the hepatitis B surface antigen, which is protective against hepatitis B.3. Incorrect: This is the principal mode of transmission for hepatitis A. Hepatitis B is transmitted through the parenteral route.4. Incorrect: If immunity develops after exposure to hepatitis B, it is protective only against hepatitis B. Many individuals do not develop immunity after exposure and therefore become carriers.

REF: p. 1520; Table 47-7; p. 1522 OBJ: Cognitive Level: ApplicationSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Nursing Process: Problem Identification

32. Which of the following is now recommended for the immunization of all newborns?1. Hepatitis A vaccine2. Hepatitis B vaccine3. Hepatitis C vaccine4. Hepatitis A, B, and C vaccines

ANS: 21. Incorrect: A vaccine for hepatitis A is available, but it is not yet universally recommended.2. Correct: Universal vaccination for hepatitis B is now recommended for all newborns.3. Incorrect: No vaccine is currently available for hepatitis C.4. Incorrect: Only hepatitis B is recommended for newborns.

REF: p. 1520, Table 47-7, p. 1522 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral TherapyTOP: Integrated process: Nursing Process: Implementation

33. The best chance of survival for a child with cirrhosis is:1. liver transplantation.2. treatment with corticosteroids.3. treatment with immune globulin.4. providing nutritional support.

ANS: 11. Correct: The only successful treatment for end-stage liver disease and liver failure may be liver transplantation, which has improved the prognosis for many children with cirrhosis.2, 3, and 4. Incorrect: Liver transplantation has revolutionized the approach to cirrhosis. Liver failure and cirrhosis are indications for transplantation. Liver transplantation reflects the failure of other medical and surgical measures to prevent or treat cirrhosis.


REF: p. 1523 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Physiologic AdaptationTOP: Integrated process: Nursing Process: Assessment

34. Which of the following is the earliest clinical manifestation of biliary atresia?1. Jaundice2. Vomiting3. Hepatomegaly4. Absence of stooling

ANS: 11. Correct: Jaundice is the earliest and most striking manifestation of biliary atresia. It is first observed in the sclera, may be present at birth, but is usually not apparent until age 2 to 3 weeks.2. Incorrect: Vomiting is not associated with biliary atresia.3. Incorrect: Hepatomegaly and abdominal distention are common but occur later.4. Incorrect: Stools are large and lighter in color than expected because of the lack of bile.

REF: p. 1523; p. 1524; Box 47-16 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Physiologic AdaptationTOP: Integrated process: Nursing Process: Assessment

35. The association of cleft palate with otitis media is primarily due to which of the following?1. Plugging of the eustachian tube with food particles2. Lowered resistance because of poor nutritional status3. Inefficient function of eustachian tubes and improper middle ear drainage4. Coexisting defects of middle ear and eustachian tube

ANS: 31, 2 and 4. Incorrect: These are not associated with the recurrent otitis media.3. Correct: Improper drainage of the middle ear, as a result of inefficient function of the eustachian tube, contributes to recurrent otitis media with scarring of the tympanic membrane, which leads to hearing impairment.

REF: p. 1526 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Physiologic AdaptationTOP: Integrated process: Nursing Process: Problem Identification

36. A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician explained the plan of therapy and its expected good results. However, the mother refuses to see or hold her baby. Initial therapeutic approach to the mother should be which of the following?1. Restate what the physician has told her about plastic surgery.


2. Encourage her to express her feelings.3. Emphasize the normalcy of her baby and the baby’s need for mothering.4. Help the mother recognize that negative feelings toward the child will continue

throughout childhood.

ANS: 21. Incorrect: Although this will be addressed, it is not part of the initial therapeutic approach.2. Correct: For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse must place emphasis not only on the infant’s physical needs but also on the parents’ emotional needs. The mother needs to be able to express her feelings before the acceptance of her child can occur.3. Incorrect: As the mother expresses her feelings, the nurse’s actions should convey to the parents that the infant is a precious human being. The child’s normalcy is emphasized, and the mother is assisted to recognize the child’s uniqueness.4. Incorrect: A focus on abnormal maternal-infant attachment would be inappropriate at this time.

REF: p. 1526 OBJ: Cognitive Level: AnalysisSTO: Area of client needs: Psychosocial Integrity/Coping and AdaptationTOP: Integrated process: Nursing Process: Implementation

37. Caring for the newborn with a cleft lip and palate before surgical repair includes which of the following?1. Gastrostomy feedings2. Keeping infant in near-horizontal position during feedings3. Allowing little or no sucking4. Providing satisfaction of sucking needs

ANS: 41. Incorrect: Gastrostomy feedings are usually not indicated.2. Incorrect: Feeding is best accomplished with the infant’s head in an upright position.3. Incorrect: The child requires both nutritive and nonnutritive sucking.4. Correct: Using special or modified nipples for feeding techniques helps to meet the infant’s sucking needs.

REF: p. 1527 OBJ: Cognitive Level: ApplicationSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Nursing Process: Implementation

38. A mother who intended to breastfeed has given birth to an infant with a cleft palate. Nursing interventions should include which of the following?1. Give medication to suppress lactation.2. Encourage and assist mother to breastfeed.3. Teach mother to feed breast milk by gavage.


4. Recommend use of a breast pump to maintain lactation until infant can suck.

ANS: 21. Incorrect: Because breastfeeding is an option, if the mother wishes to breastfeed, medications should not be given to suppress lactation.2. Correct: The mother who wished to breastfeed may need encouragement and support because the defect does present some logistic issues. The nipple must be positioned and stabilized well back in the infant’s oral cavity so that the tongue action facilitates milk expression.3. Incorrect: Because breastfeeding can usually be accomplished, no indication is present for gavage feedings.4. Incorrect: The suction required to stimulate milk, absent initially, may be useful before nursing to stimulate the let-down reflex.

REF: p. 1527 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Nursing Process: Implementation

39. The nurse is caring for an infant whose cleft lip was repaired. Important aspects of this infant’s postoperative care include which of the following?1. Arm restraints, postural drainage, mouth irrigations2. Cleansing suture line, supine and side-lying positions, arm restraints3. Mouth irrigations, prone position, cleansing suture line4. Supine and side-lying positions, postural drainage, arm restraints

ANS: 21. Incorrect: Postural drainage is not indicated. This would increase the pressure on the operative site when the child is placed in different positions. Mouth irrigations would not be indicated.2. Correct: The suture line should be cleansed gently after feeding. The child should be positioned on back, side or in infant seat. Elbows are restrained to prevent the child from accessing the operative site.3. Incorrect: There is no reason to perform mouth irrigations and the child should not be placed in the prone position where injury to the suture site can occur.4. Incorrect: Postural drainage is not indicated.

REF: p. 1527 OBJ: Cognitive Level: AnalysisSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Nursing process: Planning

40. During the first few days after surgery for cleft lip, the nurse should do which of the following?1. Leave infant in crib at all times to prevent suture strain.2. Keep infant heavily sedated to prevent suture strain.3. Remove restraints periodically to cuddle infant.4. Alternate position from prone to side lying to supine.


ANS: 31. Incorrect: The infant should not be left in the crib, but should be removed for appropriate holding and stimulation.2. Incorrect: Analgesia and sedation are administered for evidence of pain. Heavy sedation is not indicated.3. Correct: Remove restraints periodically, while supervised, to exercise arms and to provide cuddling and tactile stimulation.4. Incorrect: The child should not be placed in the prone position.

REF: p. 1527 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Nursing process: Planning

41. The nurse is caring for a neonate with a suspected tracheoesophageal fistula. Nursing care should include which of the following?1. Elevate head but give nothing by mouth.2. Elevate head for feedings.3. Feed glucose water only.4. Avoid suctioning unless infant is cyanotic.

ANS: 11. Correct: When a newborn is suspected of having tracheoesophageal fistula, the most desirable position is supine with the head elevated on an incline plane of at least 30 degrees. It is imperative that any source of aspiration be removed at once; oral feedings are withheld.2 and 3. Incorrect: Feedings should not be given to infants suspected of having tracheoesophageal fistulas.4. Incorrect: The oral pharynx should be kept clear of secretion by oral suctioning. This is to avoid the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx.

REF: p. 1530 OBJ: Cognitive Level: AnalysisSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Nursing process: Implementation

42. Which type of hernia has an impaired blood supply to the herniated organ?1. Hiatal hernia2. Incarcerated hernia3. Omphalocele4. Strangulated hernia

ANS: 41. Incorrect: A hiatal hernia is the intrusion of an abdominal structure, usually the stomach, through the esophageal hiatus.


2. Incorrect: An incarcerated hernia is a hernia that cannot be reduced easily. 3. Incorrect: Omphalocele is the protrusion of intraabdominal viscera into the base of the umbilical cord. The sac is covered with peritoneum and not skin.4. Correct: A strangulated hernia is one in which the blood supply to the herniated organ is impaired.

REF: p. 1531 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Nursing process: Assessment

43. Pyloric stenosis can best be described as which of the following?1. Dilation of the pylorus2. Hypertrophy of the pyloric muscle3. Hypotonicity of the pyloric muscle4. Reduction of tone in the pyloric muscle

ANS: 21, 3 and 4. Incorrect: These are not the definition of pyloric stenosis.2. Correct: Hypertrophic pyloric stenosis occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric channel.


44. Which of the following best describes the incidence of pyloric stenosis?1. Females are affected more often than males.2. African-American infants are affected more often than Caucasian infants.3. Premature infants are affected more often than full-term infants.4. Firstborn infants are affected more than later-born infants.

ANS: 41. Incorrect: The prevalence is higher in males than females.2. Incorrect: Pyloric stenosis is seen less frequently in African-American and Asian infants than in Caucasian infants.3. Incorrect: Pyloric stenosis is more common in full-term infants than in premature infants.4. Correct: First-born children and males are affected 5 times more frequently than females.



45. Which of the following observations made of the exposed abdomen is most indicative of pyloric stenosis?1. Abdominal rigidity2. Substernal retraction3. Visible peristalsis4. Marked distention of lower abdomen

ANS: 31 and 2. Incorrect: These are usually not present.3. Correct: Visible gastric peristaltic waves that move from left to right across the epigastrium are observed in pyloric stenosis.4. Incorrect: The upper abdomen is distended, not the lower abdomen.

REF: p. 1533; Box 47-19 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Nursing process: Assessment

46. A nursing responsibility when caring for an infant with suspected pyloric stenosis would be which of the following?1. Observe for projectile vomiting.2. Monitor for signs of metabolic acidosis.3. Administer large, infrequent feedings to allow for rest.4. Place infant in supine position after feedings.

ANS: 11. Correct: Projectile vomiting is one of the cardinal signs of pyloric stenosis. It is non- bilious; may be blood-tinged; usually occurs shortly after feeding, but may be intermittent; and can be ejected 3 to 4 feet from the child when in a side lying position.2. Incorrect: These infants are prone to metabolic alkalosis secondary to the loss of hydrogen ions.3 and 4. Incorrect: Preoperatively, the emphasis is on restoring fluid and electrolyte balance.

REF: p. 1534 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Nursing process: Implementation

47. Excessive vomiting can result in which of the following in an infant with pyloric stenosis?1. Hyperchloremia2. Hypernatremia3. Metabolic acidosis4. Metabolic alkalosis

ANS: 41. Incorrect: Chloride ions are lost with vomiting.


2. Incorrect: Sodium is also depleted by the vomiting.3. Incorrect: Metabolic alkalosis, not acidosis, is likely.4. Correct: Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions.


48. Invagination of one segment of bowel within another is called which of the following?1. Atresia2. Stenosis3. Herniation4. Intussusception

ANS: 41, 2, and 3. Incorrect: This definition is of intussusception, not these disorders.4. Correct: Intussusception occurs when a proximal section of the bowel telescopes into a more distal segment pulling the mesentery with it. The mesentery is compressed and angled, resulting in lymphatic and venous obstruction.

REF: p. 1534, p. 1535 OBJ: Cognitive Level: ComprehensionSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Nursing process: Assessment

49. The nurse is caring for a boy with probable intussusception. He had diarrhea before admission but, while waiting for administration of air pressure to reduce the intussusception, he passes a normal brown stool. Which of the following is the most appropriate nursing action?1. Notify practitioner.2. Measure abdominal girth.3. Auscultate for bowel sounds.4. Take vital signs, including blood pressure.

ANS: 11. Correct: Passage of a normal brown stool indicates that the intussception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic/therapeutic plan of care.2, 3, and 4. Incorrect: The first action would be to report the normal stool to the practitioner.

REF: p. 1536 OBJ: Cognitive Level: AnalysisSTO: Area of client needs: Physiologic Integrity/Reduction of Risk PotentialTOP: Integrated process: Nursing process: Implementation


50. Which of the following is an important nursing consideration in the care of a child with celiac disease?1. Refer to a nutritionist for detailed dietary instructions and education.2. Help child and family understand that diet restrictions are usually only temporary.3. Teach proper hand washing and Standard Precautions to prevent disease

transmission.4. Suggest ways to cope more effectively with stress to minimize symptoms.

ANS: 11. Correct: The main consideration is helping the child to adhere to dietary management. Considerable time is spent in explaining to the child and parents the disease process, the specific role of gluten in aggravating the condition, and those foods that must be restricted. Referral to a nutritionist would help in this process.2. Incorrect: The most severe symptoms usually occur in early childhood and adult life. Dietary avoidance of gluten should be life-long.3. Incorrect: Celiac disease is not transmissible.4. Incorrect: Celiac disease is not stress-related.


51. An infant with short bowel syndrome will be discharged home on total parenteral nutrition (TPN) and gastrostomy feedings. Nursing care should include which of the following?1. Prepare the family for impending death.2. Teach the family signs of central venous catheter infection.3. Teach the family how to calculate caloric needs.4. Secure TPN and gastrostomy tubing under the diaper to lessen risk of

dislodgement.

ANS: 21. Incorrect: The prognosis for patients with short bowel syndrome depends in part on the length of residual small intestine. It has improved with advances in TPN. 2. Correct: During TPN therapy, care must be taken to minimize the risk of complications related to the central venous access device, such as catheter infections, occlusions, or accidental removal. This is an important part of family teaching.3. Incorrect: Although parents need to be taught about nutritional needs, the caloric needs and prescribed TPN and rate are the responsibility of the health care team.4. Incorrect: The tubes should not be placed under the diapers due to risk of infection.



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