When assessing a child for possible intussusception, which of the following would be least likely to provide valuable information?
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Solution
Family history
Because intussusception is not believed to have a familial tendency, obtaining a family history would provide the least amount of information.
Options A, B, and D: Stool inspection, pain pattern, and abdominal palpation would reveal possible indicators of intussusception. Current, jelly-like stools containing blood and mucus are an indication of intussusception. Acute, episodic abdominal pain is characteristics of intussusception. A sausage-shaped mass may be palpated in the right upper quadrant.
A newborn’s failure to pass meconium within the first 24 hours after birth may indicate which of the following?
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Solution
Hirschsprung disease
Failure to pass meconium within the first 24 hours after birth may be an indication of Hirschsprung disease, a congenital anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment.
Options B, C, and D: Failure to pass meconium is not associated with celiac disease, intussusception, or abdominal wall defect.
Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea?
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Solution
Hirschsprung disease
For the child with Hirschsprung disease, fever and explosive diarrhea indicate enterocolitis, a life-threatening situation. Therefore, the physician should be notified immediately.
Option B: Generally, because of the intestinal obstruction and inadequate propulsive intestinal movement, antidiarrheals are not used to treat Hirschsprung disease.
Option C: The child is acutely ill and requires intervention, with monitoring more frequently than every 30 minutes.
Option D: Hirschsprung disease typically presents with chronic constipation.
Which of the following would the nurse expect to assess in a child with celiac disease having a celiac crisis secondary to an upper respiratory infection?
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Solution
Watery diarrhea
Episodes of celiac crises are precipitated by infections, ingestion of gluten, prolonged fasting, or exposure to anticholinergic drugs. Celiac crisis is typically characterized by severe watery diarrhea.
Option A: Respiratory distress is unlikely in a routine upper respiratory infection.
Option B: Irritability, rather than lethargy, is more likely.
Option D: Because of the fluid loss associated with the severe watery diarrhea, the child’s weight is more likely to be decreased.
Discharge teaching for a child with celiac disease would include instructions about avoiding which of the following?
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Solution
Wheat
Children with celiac disease cannot tolerate or digest gluten. Therefore, because of its gluten content, wheat and wheat-containing products must be avoided.
Options A, B, and D: Rice, milk, and chicken do not contain gluten and need not be avoided.
Which of the following parameters would the nurse monitor to evaluate the effectiveness of thickened feedings for an infant with gastroesophageal reflux disease (GERD)?
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Solution
Vomiting
Thickened feedings are used with GER to stop the vomiting. Therefore, the nurse would monitor the child’s vomiting to evaluate the effectiveness of using the thickened feedings.
Options B and C: No relationship exists between feedings and characteristics of stools and uterine.
Option D: If feedings are ineffective, this should be noted before there is any change in the child’s weight.
Which of the following nursing diagnoses would be inappropriate for the infant with gastroesophageal reflux (GER)?
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Solution
Altered oral mucous membranes
GERD is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac) sphincter. No alteration in the oral mucous membranes occurs with this disorder.
Options A, B, and C: Fluid volume deficit, risk for aspiration, and altered nutrition are appropriate nursing diagnoses.
While assessing a child with pyloric stenosis, the nurse is likely to note which of the following?
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Solution
Projectile vomiting
Projectile vomiting is a key symptom of pyloric stenosis.
Option A: Regurgitation is seen more commonly with GERD.
Option B: Steatorrhea occurs in malabsorption disorders such as celiac disease.
Option D: “Currant jelly” stools are characteristic of intussusception.
When providing postoperative care for the child with a cleft palate, the nurse should position the child in which of the following positions?
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Solution
Prone
Postoperatively children with cleft palate should be placed on their abdomens to facilitate drainage.
Option A: If the child is placed in the supine position, he or she may aspirate.
Option C: Using an infant seat does not facilitate drainage.
Option D: Side-lying does not facilitate drainage as well as the prone position.
While assessing a newborn with cleft lip, the nurse would be alert that which of the following will most likely be compromised?
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Solution
Sucking ability
Because of the defect, the child will be unable to from the mouth adequately around the nipple, thereby requiring special devices to allow for feeding and sucking gratification.
Option B: Respiratory status may be compromised if the child is fed improperly or during postoperative period
Option C: Locomotion would be a problem for the older infant because of the use of restraints.
Option D: GI functioning is not compromised in the child with a cleft lip.