Gastrointestinal Conditions

Question 1

Many GI abnormalities originate when?

Answer 1

During fetal life; they may or may not be detected during the neonatal period.

Question 2

When obtaining a history for most GI conditions, it is important to obtain information based on:

Answer 2

food habits (what is eaten, how it is prepared, how much is eaten, when does eating occur and with whom), vitamins and nutritional supplements that may be used, and normal bowel habits, including frequency, appearance, and the use of aids, such as laxatives or enemas.

Question 3

How much does the stomach hold?

Answer 3

The newborn stomach expands from 20 mL at birth as much as 90 mL by the end of the first week of life, the stomach holds up to 3,000 mL by late adolescence.

Question 4

How is the infant’s gut different during the first year of life?

Answer 4

It is immature; some products cannot be digested and are excreted in the stool, whereas other products may be absorbed more readily, possibly leading to the development of food allergy.

Question 5

Vomiting

Introduction

Answer 5

1. Definition: the forceful emptying of stomach contents through the mouth - usually caused by a GI disorder (such as spasm of the duodenum, reverse peristalsis from blockage of the pylorus, reflux from an incompetent or lax esophageal sphincter, overdistention of the stomach from increased intake, or gastroenteritis), but may result from a non-GI disorder (such as increased intracranial pressure).
2. It is controlled by the medulla.
3. A “wet burp” or “spit up” involves either dribbling of ndigested liquids from the mouth and esophagus or their expulsion with the force of a burp and should be differentiated from vomiting.
4. The most common cause of infant vomiting is overfeeding.

Question 6

Vomiting

Assessment

Answer 6

1. Differentiate vomiting from a wet burp or spitting up.
2. Review the child’s history for frequency of episodes.
3. Assess for accompanying symptoms, such as fever, nausea, headache, and diarrhea.
4. Determine if the vomiting is projectile.
5. Determine if the vomiting is related to intake or to other activities.
6. Describe the vomitus: blood (hematemesis), bile, undigested or digested food, amount, force.
7. Note presence or absence of nausea.
8. Note the time since last ingestion of food.
9. Assess abdomen: check for bowel sounds, note distention of abdomen or areas of pain.
   a. Measure abdomen with a paper tape at the widest point, usually the umbilicus; mark the point of measurement with a pen.
10. Assess fluid and electrolyte balance, especially for dehydration (check skin turgor).
11. Assess for metabolic alkalosis from the loss of stomach acids.
12. Assess nutritional status, including growth and development.
13. **Evaluate feeding methods (amount of burping, air in nipple, feeding supine or sitting up).

Question 7

Vomiting

Interventions

Answer 7

1. Prevent aspiration during vomiting by positioning the child on their side; maintain a patent airway; perform nasotracheal or bulb suctioning, if necessary.
2. After a period of no vomiting and if an obstruction is not the cause, begin administering frequent small amounts of clear liquids.
   a. For infants: give Pedialyte.
   b. For older children: give flat noncarbonated ginger ale or cola.
3. Admin antiemetic meds only to older children; they should not be used in infants; use the rectal or intramuscular route.
4. Raise the head of the bed or sit up when feeding; place side-lying on right side or prone after feeding for a child; infants should be placed on their backs.
5. Provide skin and mouth care.
6. Measure I & Os as well as daily weight.
7. Monitor stool status.

Question 8

Gastroesophageal Reflux (GER)

Answer 8

Introduction
1. GER is the return of gastric contents into the esophagus from an incompetent or poorly developed esophageal sphincter.
2. The condition occurs almost immediately after eating and typically affects infants; it is also seen in infants and young children with spastic cerebral palsy and other conditions with decreased muscle tone.
3. Aspiriation puts them at risk for pneumonia.

Assessment
1. Assess the relationship of vomiting to feedings, positioning, and the activity level immediately after feedings.
2. Assess for failure to thrive/poor weight gain.
3. Assess for aspiration of feedings; note any relationship between apnea and GER (many infants may be placed on apnea monitors).
4. Measure the pH of gastric contents.

Interventions
1. Admin meds 30 minutes before meals to maximize the benefits of the medications.
a. H2 blockers and proton pump inhibitors are drugs used to reduce the amount of gastric acid present in gastric contents, thereby reducing esophagitis.
2. Provide thickened formula (1 tbsp cereal/1 oz formula); will need to enarge hole in nipple or use cross-cut nipple.
3. Feed child in an upright position and keep upright for 30 minutes after feed; avoid car seat sitting position.
4. Give small frequent feedings.
5. Research supports placement of infant with GER on their backs to sleep, as there is no increased risk for aspiration.
6. Prepare for surgery (Nissen fundoplication for hiatal hernia) if necessary.

Question 9

Diarrhea

Introduction

Answer 9

1. Diarrhea is the increased frequency and amount and decreased consistency of stool.
2. It occurs when water in the bowel increases from osmotic pull, with electrolyte imbalance, or when peristalsis increases, preventing water from being absorbed.
3. It may accompany gastroenteritis, an inflammation of the lining of the stomach and intestines.
4. It can result from anatomic changes, malabsorption conditions, GI allergies, or toxins.
5. It can lead to metabolic acidosis and dehydration through loss of HCO3 in the stool.
6. In infants, rotavirus is a major cause.
7. Difficile infection presents with fever, abdominal pain and often bloody diarrhea.
   a. It is the most common cause of antimicrobial-associated diarrhea; it is acquired by the fecal-oral route.

Question 10

What is the most common cause of diarrhea in infants?

Answer 10

Rotavirus

Question 11

Difficile infection symptoms

Answer 11

fever, abdominal pain, and often bloody diarrhea

Question 12

Diarrhea

Assessment

Answer 12

1. Note the amount, frequency, duration, consistency, appearance, and odor of stool; weigh diapers and note the amount of water loss.
2. Test stool for blood and other reducing substances, such as sugars, and for pH; obtain stool cultures, if ordered.
3. Assess for the presence of abdominal pain or cramping associated with stooling.
4. Assess the relationship between stooling and the time of eating or quality of intake.
5. Assess skin integrity around the anus.
6. Assess hydration status.
7. Assess abdomen; check bowel sounds, palpate for masses, distention, and pain.

Question 13

Diarrhea

Interventions

Answer 13

1. For mild diarrhea, continue regular diet.
   a. Avoid fruit juices and soft drinks because of their high osmotic load.
2. For more serious diarrhea:
   a. For infants: Initiate unlimited amounts of Oral Rehydration Solutions (Pedialyte); continue breast feeding or formula.
   b. For children > than 1 year: Encourage fluids and increase starchy foods in regular diet (rice cereal, oatmeal, toast, potatoes, carrots, white rice, applesauce, bananas); pretzels and salty crackers help meet sodium needs.
   (1) NOTE: The BRAT diet, which is bananas, rice, applcesauce, and toast, is not recommended by the American Academy of Pediatrics due to the lack of protein.
   c. IV fluids may be needed.
3. Use enteric precautions and good hand washing.
4. Measure intake and output.
5. Provide skin care around anus; apply a skin protectant; change diapers promptly.
6. Do not take child’s temperature rectally.

Question 14

Constipation

Answer 14

Introduction
1. Constipation is a decreased amount and increased consistency of stool compared to the patient’s normal pattern (children do not need to have a daily bowel movement).
2. Constipation is not necessarily synonymous with straining.
3. It may be caused by diet low in liquids or high in fat and protein.

Assessment
1. Note a hard, dry, infrequent stool.
2. Test stool for blood (guaiac test). Melena is dark, tarry stool usually associated with bleeding from the upper GI tract; it may be Hematest-positive from trauma to the rectal tissue from passing a hard mass; assess skin integrity around anus.
3. Ask child about abdominal pain during stooling or intermittent pain throughout the day.
4. Assess the child’s diet for liquids, fiber, carbohydrates, and constipating foods.
5. Measure abdominal girth.
6. Note whether child is reluctant to use the toilet in school or is consciously retaining stool.
7. May present as encopresis/fecal incontinence with involuntary soiling of clothing as impacted stool collects in colon and rectum; may appear as diarrhea as only liquid leaks around the retained stool.
a. Usually occurs after age 4
b. May be due to emotional issues or fear of using toilet and pain

Interventions
1. Lubricate around the anus to ease the passage of hard stool (may have to remove stool digitally).
2. Administer stool softeners: suppositories, mineral oil, and docusate sodium (Colace).
3. Add fiber or prune juice to the diet; increase fluid intake.
4. Administer enemas, if ordered; use isotonic solutions only.

Question 15

Cleft Lip and Palate

Introduction

Answer 15

1. Cleft lip and palate are a failure of the bone and tissue of the upper jaw and palate to fuse completely at the midline.
2. Cleft lip and palate are congenital defects, in some cases due to heredity but many other causes are implicated; the defect occurs in the first trimester of pregnancy.
3. The defects may be partial or complete, unilateral or bilateral, or may involve just the lip, just the plate, or both.
4. The condition requires a long-term tema approach to address speech defects, dental and orthodontic problems, nasal defects, and possible alterations in hearing.
5. Because it results in facial disfigurement, the condition may cause shock, guilt, and grief for the parents and may interfere with parental bonding with the child.
6. Cleft lip and palate increase the risk of aspiration, because increased open space in the mouth causes some formula to exit through the nose with we burps.
7. They also increase the risk of upper respiratory tract infection and otitis media, because the increased open space decreases natural defenses against bacterial invasion.

Question 16

Cleft Lip and Palate

Assessment

Answer 16

1. Visually inspect and palpate the palate.
2. Assess the quality of the infant’s suck; determine if the infant can form an airtight seal around a nipple.
3. Assess the child’s ability to swallow.
4. Assess for abdominal distention from swallowed air.
5. Be alert for respiratory distress when feeding.

Question 17

Cleft Lip and Palate

Interventions for cleft lip (preoperative)

Answer 17

1. Feed the infant slowly and in an upright position to decrease the risk of aspiration.
2. Burp often during feeding to eliminate swallowed air and decrease the risk of emesis.
3. Use a specialized nipple, a cleft palate nipple with a flap across the palate (palatal obturators), a medicine dropper, a syringe with rubber tubing attached to the end (aim nipple toward the side of the mouth), or manual compression to unite the edges of the cleft lip; all encouraging sucking, promote oral muscle development, and enhance the infant’s nutritional status.
4. Use gavage feedings if oral feedings are unsuccessful.
5. Administer a small amount of water after feedings to prevent formula from accumulating and mecoming a medium for bacterial browth.
6. Give small frequent feedings.
7. Hold infant while feeding and promote sucking between meals.
8. Provide psychological support to the parents; reinforce the likely success of surgery; point out the positive qualities of the infant.
9. Tell parents that cleft lips are usually corrected when the infant is 10 weeks old and weighs 10 lb (4.5 kg); the infant must be free of respiratory infections at the time of surgery.

Question 18

Cheiloplasty

Interventions for postoperative cleft lip repair

Answer 18

CLEFT LIP REPAIR
1. Cheiloplasty unites the lip and gum edges in anticipation of teeth eruption, provides a route for nuturition and sucking, and improves the infant’s appearance, which promotes parent-child bonding.
2. Maintain a patent airway; edema or narrowing of a previously large airway may make the infant appear to be in distress.
3. Observe for cyanosis, as the infant begins to breathe through the nose.
4. Maintain an intact suture line; keep the infant’s hands away from the mouth by using elbow restraints or swaddling the infant with a blanket; Steri-Strips will be used to hold the suture line in place.
5. Prevent tension on the suture line by anticipating the infant’s needs and preventing crying; do not place in prone position to avoid pressure on face.
6. Give extra care and support, because the infant cannot meet emotional needs by sucking.
7. When feeding resumes, use a special cleft lip feeder (e.g., a Haberman feeder) so they may drink from a bottle or a syringe with tubing to administer foods at the side of the mouth; this will prevent trauma to the suture line.
8. After feedings, place infant on right side to prevent aspiration.
9. To prevent crusts and scarring, clean suture line after each feeding with warm water using a Q-Tip and apply antibiotic ointment (Neosporin).
10. Monitor and treat for pain.

Question 19

Staphylorrhaphy

Interventions for cleft palate (preoperative)

Answer 19

CLEFT PALATE REPAIR
1. Be aware that the infant must be weaned from the bottle or breast before cleft palate surgery; the infant must be able to drink from a cup.
2. Feed infant with a cleft palate nipple or a Teflon implant to enhance nutritional intake.
3. Surgery is usually scheduled before age 1 year to allow for the growth of the palate and before the infant develops speech patterns to prevent speech delays; the infant must be free from ear and respiratory infections.
4. Teach the parents that the infant is susceptible to pathogens and otitis media from the altered position of the Eustachian tube.

Question 20

Staphylorrhaphy

Interventions for cleft palate (postoperative)

Answer 20

CLEFT PALATE REPAIR
1. Maintain a patent airway; position infant on the abdomen or side.
2. Anticipate edema and a decreased airway from palate closure; this may make the infant appear temporarily dyspneic.
3. Prevent trauma to the suture line by keeping hard or pointed objects (utensils, straws, frozen dessert sticks) away from the mouth; do not use suction catheters, except in emergency (use bulb syringe if necessary).
4. Use a cup to feed; do not use a nipple or pacifier.
5. Use elbow restraints to keep the child’s hands out of the mouth or have parent hold child in shuch a way as to pregent hands going in mouth.
6. Provide soft toys.
7. Start the child on clear liquids and progress to a soft diet; rinse the suture line by giving child a sip of water after each feeding.
8. Distract or hold child to try to keep the tongue away from the roof of the mouth.

Question 21

Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF)

Answer 21

Introduction
1. An atresia is the termination of a passageway; it usually refers to a pathologic closure or the absence of a normal anatomic opening.
2. A fistula is a tubelike connection between two structures.
3. These conditions occur alone or in many combinations; they may be associated with other congenital defects, especially cardiac defects; TEF may be part of a syndrome called VACTERL (Vertebral defects, Anorectal malformations, Cardiac anomalies, TEF, EA, Renal defects, and Limb defects).
4. EA occurs when the proximal end of the esophagus ends in a blind pouch; food cannot enter the stomach via the esophagus.
5. TEF occurs when there is a connection between the esophagus and the trachea.
6. TEF may result in the reflux of gastric juice after feeding that can allow acidic stomach contents to cross the fistula, irritating the trachea.
7. EA with TEF occurs when either the distal end of the esophagus ends in a blind pouch and the proximal end of the esophagus is linked to the trachea via a fistula or when the proximal end of the esophagus ends in a blind pouch and the distal portion of the esophagus is connected to the trachea via a fistula; EA with TEF is the most common of these defects with EA alone being second most common.

Assessment of TEF
1. Maternal history of polyhydraminos (excess amniotic fluid, since fetus is unable to swallow it).
2. Newborn may have excessive oral secretions.
3. Assess for choking, coughing, and intermittent cyanosis during feeding from formula that goes through the fistula into the trachea; stop feeding if this occurs.
4. Observe for abdominal distention from air that goes through the fistula into the stomach.
5. Observe for tracheal irritation from gastric acids that reflux across the fistula.

Assessment of EA with TEF
1. Assess for all signs and symptoms of EA.
2. Observe for signs of respiratory distress: coughing, choking, and intermittent cyanosis.

Interventions
1. If EA or TEF is suspected, do not feed orally; a percutaneous endoscopic gastrostomy (PEG) tube may be inserted; keep the tube open and suspended above the child for release of gas.
2. Maintain a patent airway; have suction equipment available.
3. If feeding the child via gastrostomy tube after surgery, anticipate abdominal distention from air; keep the child upright during feedings to reduce the chance to regurgitated stomach contents and aspiration pneumonia, and keep the tub open and elevated before and after feedings.
4. Gastrostomy feeds should be administered either by gravity or by feeding pump.
5. Explain to parents how the surgery ligates the TEF and reanastomoses the esophageal ends; expect a staged repair in many instances.

Question 22

Pyloric Stenosis

Answer 22

Introduction
1. Pyloric stenosis is an increasing hyperplasia and hypertrophy of the circular muscle at the pylorus, which narrows the pyloric canal as it exits the stomach.
2. The defect is most commonly seen in boys around 4 weeks of life.
3. Emesis may be Hematest positive, but it will not contain bile; it will increase in amount and force as the obstruction increases and will become projectile.

Assessment
1. Be aware that symptoms seldom appear during the first two weeks of life.
2. May palpate for an olive-size bulge below the right costal margin.
3. May observe for projectile emesis during or shortly after feedings (preceded by reverse peristaltic waves [going left to right] but not by nausea).
4. Note that the child will resume eating after vomiting.
5. Evaluate for poor weight gain and symptoms of malnutrition despite the child’s apparent hunger.
6. Assess for metabolic alkalosis and dehydration from frequent emesis.

Interventions
1. Provide small, frequent feedings with the head of the bed elevated; burp the child frequently.
2. Position the child to prevent the aspiration of vomitus, preferably on the right side for children and on their backs for infants with the head of the bed raised 30 degrees.
3. Correct any electrolyte imbalance.
4. An NG tube may be inserted and kept open and elevated for gastric decompression.
5. Prepare for pyloromyotomy, where the overdeveloped muscle around the pyloric valve is split, thereby spreading open the muscle and enlarging the pylorus to relieve the obstruction.

Question 23

Intussusception

Answer 23

Introduction
1. **Is the telescoping or invagination of a bowel segment into itself, the most common site being the ileocecal valve; it usually occurs between 3 and 24 months. **
2. The condition may result from polyps, hyperactive peristalsis, an abnormal bowel lining, or for no known cause.
3. Initially, it causes inflammation and swelling at the affected site; edema eventually causes obstruction and necrosis from occlusion of the blood supply to the bowel.
4. Intussusception can be acute or chronic. Untreated, it may lead to peritonitis.

Assessment
1. Note a sudden attack of acute abdominal pain in a previously well child; the child shrieks and draws the knees to the chest.
2. Observe for an increase in bile-stained vomitus.
3. Note the passage of a red currant jelly-like stool (red blood and mucus).
4. Assess for a distended and tender abdomen.
5. Note pallor and agitation.

Interventions
1. Prepare for a barium enema or water-soluble contrast with air pressure to confirm the condition and reduce the invagination by hydrostatic pressure.
2. Be aware that, if enemas fail to reduce the invagination, surgery may be required to resect the gangrenous portion; a temporary colostomy may be necessary.

Question 24

Hirschsprung Disease

Congenital Aganlionic Megacolon

Answer 24

Introduction
1. Parasympathetic ganglionic cells are absent in a segment of the colon (usually at the distal end of the large intestines); the lack of nerve innervation causes a lack of or alteration in peristalsis in the affected part.
2. As stool enters the affected part, it remains there until additional stool pushes it through; the affected part of the colon dialates; a mechanical obstruction may result.

Assessment
1. Observe for liquid or ribbon-like stools; only fluid can pass the obstruction caused by stool.
2. Assess for a distended abdomen from stool impaction.
3. Assess for nausea, vomitus, anorexia, lethargy, weight loss, and failure to thrive.
4. Prepare for barium studies and a biopsy of the large intestines to confirm condition.
5. Be alert for signs and symptoms of enterocolitis, volvulus, and shock, which can occur from this condition.

Interventions
1. Surgery to bypass the affected area or a resection of the aganglionic portion may be done with or without a colostomy

Question 25

Imperforate Anus

Answer 25

Introduction 1. An imperforate anus is an atresia of the anal opening; the infant may have no anal opening onto the skin wall, or the rectum may end in a blind pouch. 2. A fistula to the vagina in females or to the urethra in males may also be present. Assessment 1. Observe to see from which orifice stool is excreted. 2. Assess for signs and symptoms of impaction from the inability to pass stool. 3. Measure abdominal girth to evaluate abdominal distention. Interventions 1. **Do not take the infant's temperature rectally unless stool has been excreted from the rectum, due to risk of perforation.** 2. After surgical reconstruction of the anus and the formation of a temporary colostomy, keep the infant prone with the hips elevated. 3. Keep site clean.

Question 26

Appendicitis

Answer 26

Introduction 1. Inflammation and obstruction of the blind sac at the end of the cecum results in ischemia, gangrene, perforation, and peritonitis. 2. Suggested causes include infections, dietary intake, constipation, and parasites. 3. It is common in school-age children. Assessment 1. Symptoms are variable, making a quick and accurate diagnosis difficult. 2. **Assess for abdominal pain and tenderness that begins as diffuse, then localizes in the LRQ at McBurney's point.** 3. **Note rebound tenderness, especially in the LRQ.** 4. Note fever, an increased WBC count, and behavioral changes. 5. Assess for decreased bowel sounds, nausea, vomiting, and anorexia. 6. Assess for abdominal distention, abdoninal rigidity, and guarding. 7. **Note symptoms of peritonitis if a rupture occurs (fever, sudden relief of pain followed by a diffuse pain); this is a surgical emergency.** Interventions 1. Most cases of appendicitis are now treated with antibiotics rather than surgery. 2. If surgery is planned, position the child preoperatively in a semi-Fowler or right side-lying position. 3. **Do not apply heat, as it may cause the appendix to rupture and lead to peritonitis.** 4. Child may return from surgery with a drain and an NG tube attached to low intermittent suction. 5. Resume oral nutrition when bowel sounds reappear. 6. Administer antibiotics and pain medicaitons.

Question 27

Inflammatory Bowel Disease

Answer 27

Introduction 1. Inflammatory bowel disease consists of Crohn's disease (regional enteritis) and ulcerative colitis. a. Ulcerative colitis involves contiguous GI ulcers; Crohn's disease involves patchy lesions. b. Ulcerative colitis causes more blood loss than Crohn's disease. c. Ulcerative colitis attcks the mucuosa of the bowel; Crohn's disease affects all layers of the bowel wall. d. Ulcerative colitis usually involves the large intestines; Crohn's disease can occur at any point along the GI tract. 2. Inflammatory bowel disease is diagnosed on the basis of results of a barium enema, biopsy of the GI mucosa, and stool studies. 3. Edema and inflammation of the bowel produces ulceration, bleeding, diarrhea, and abdominal distention. 4. Chronic exacerbation may delay growth and development, including sexual development. 5. The disease, which commonly occurs in adolescents, is exacerbated by emotional factors, but its cause is unknown. Assessment 1. Assess for weight loss, anorexia, nausea, and vomiting. 2. Test stool for blood. 3. Observe for diarrhea. 4. Test for anemia and signs of hypovolemia. 5. Assess for pain. Interventions 1. Administer analgesics and antispasmodics to decrease abdominal pain. 2. Administer corticosteroids to decrease bowel inflammation. 3. Administer immunomodulators (methotrexate and cyclosporine). 4. Promote stress reduction through relaxation, distraction, and enhanced self-image and self-esteem. 5. Withhold food and fluids, using parenteral nutrition in place of feeding to rest the bowel; or provide a high-protein, high-calorie, low-residue, low-fat diet with vitamin supplementation. 6. Be aware that when conditions are not amenable to medical treatment, a colectomy, ileostomy, or ileo-anal pull-through may be performed.

Question 28

Celiac Disease

Answer 28

Introduction 1. An absence of an enzyme in the intestinal mucosal cells causes the villi of the proximal small intestine to atrophy and decreases intestinal absorption. 2. **The disease is a response to gluten intolerance (inability to absorb rye, oat, wheat, and barley glutens).** Assessment 1. **Assess for steatorrhea (fatty stools) and chronic diarrhea from fat malabsorption.** 2. Assess for generalized malnutrition and failure to thrive from the malabsorption of protein and carbohydrates. 3. Evaluate for osteoporosis and coagulation difficulty from the malabsorption of fat-soluable vitamins. 4. Assess for abdominal pain. 5. Observe for irritability from anemia. 6. Prepare the child for an intestinal biopsy to diagnose the condition. 7. Differentiate celiac disease from a gluten intolerance where no intestinal damage occurs and removing gluten from the diet resolves symptoms. Interventions 1. **Eliminate gluten from the diet.** 2. **Give the child corn and rice products, soy and potato flour, and all fresh fruits.** 3. Replace vitamins and calories; give small frequent meals.

Question 29

What needs to be evaluated when malabsorption of fat-soluable vitamins is present?

Answer 29

In celiac disease, check for osteoporosis and coagulation.

Question 30

Necrotizing Entercolitis

Answer 30

Introduction 1. Necrotizing entercolitis is common in premature infants during the neonatal period; it is also seen in babies with cardian defects due to lack of oxygenated perfusion to the gut. 2. It can also result from various factors that cause vascular compromise, such as asphyxia. a. **Blood flow to the GI tract is compromised as oxygenated blood is diverted to the brain and heart.** 3. **Bowel mucosa becomes necrotic, thereby decreasing protective mucus.** 4. **Gas-forming bacteria invade the necrotic tissue.** 5. **Formula feedings may exacerbate conditions, because food provides a nutritional base for bacteria to grow.** Assessment 1. Observe for abdominal distention. 2. **Monitor for an increase in gastric residual (the amount not digested and left in the stomach from the previous feeding); note vomiting.** 3. **Assess stool for blood and sugar.** 4. Note lethargy, apnea with bradycardiam hypotension, and an unstable temperature. 5. Check abdominal X-ray and/or ultrasound for increased GI gas. 6. Note an increase in daily abdominal girth measurements. Interventions 1. **Rest the bowel; use parenteral nutrition and allow nothing by mouth.** 2. **Use an NG tube connected to low suction to decompress the abdomen.** 3. Administer antibiotics as prescribed. 4. Reduce stress by maintaining body temperature and by handling the infant only when necessary. 5. Prepare family for the possibility of a colostomy if the necrotic bowel is surgically removed; this may result in short-bowel syndrome resulting in possible lifelong reliance on TPN (total parenteral nutrition). 6. Be aware that abdominal perforation can lead to overwhelming sepsis, shock, and death.

Question 31

Biliary Atresia

Answer 31

Introduction 1. Is the obliteration or absence of extrahepatic biliary structures; its cause is unknown. 2. This congenital anomaly can cause liver familure and death. Assessment 1. **Observe for jaundice early in infancy, often with pruritis (itching), causing irritability in the neonate.** 2. **Observe for dark urine from hyperbilirubinemia and pale stools from the absence of bile.** 3. Assess for hepatomegaly, ascites, and splenomegaly. 4. Expect irritability. 5. Assess for failure to thrive or poor weight gain from decreased absorption of fat-soluble vitamins. 6. Note whether laboratory tests show increased conjugated bilirubin, cholesterol, alkaline phosphatase levels, and prolonged prothrombin time. 7. Prepare for a liver biopsy to diagnose the condition. Interventions 1. **Give fat-soluable vitamins (A,D, E, and K) in watermiscible form.** 2. Surgery (the Kasai procedure) is done to form a substitute duct; this is a temporary "fix" until a liver transplantation can be done.

Question 32

Parasitic Worms

Answer 32

Introduction 1. Worms are acquired through the skin or by ingesting dirty or raw vegetables containing helminth eggs. 2. The eggs hatch and travel by the GI tract or blood to the gut, where they attach and thrive. 3. Infestation is commonly caused by unsanitary disposal of stool and lack of hand washing. 4. Symptoms depend on the worm type and load, as well as on the degree of intestinal damage and irritation. 5. Pinworm is the most common worm infestation. a. The worms are 5 to 10 mm long. b. **They live in the cecum and crawl to the anus at night to deposit eggs in the perianal area.** c. The cycle repeats itself when the child scratches the anus and puts the hand to the mouth. d. **The condition can be diagnosed by using an adhesive tape test.** (1) Tape is put across the anus at night. (2) The worms lay eggs on the tape. (3) The tape can be removed in the morning and used as a microscope slide to diagnose. a. Oral medicaitons for pinworms will color the stool red, this is not related to bleeding. Assessment 1. Assess for bloody diarrhea leading to anemia; test for blood in stool. 2. Assess for failure to thrive related to malabsorption. 3. Assess for abdominal distention, anorexia, nausea, and vomiting 4. Expect intense anal pruritus and scratching if the child is infested with pinworms. Interventions 1. Teach the child and parents sanitary stool disposal techniques. 2. Review proper hand washing before meals and after toileting. 3. Urge them to wash fruits and vegetables before eating. 4. Advise the child to wear shoes in infested areas. 5. Administer medication appropriate to the type of infestation.

Question 33

Viral Hepatitis

Answer 33

Introduction 1. Inflammation of the liver due to one of five or more viruses a. **Hepatitis A virus is passed by the fecal-oral route**, most commonly by poor sanitation or in day care centers; incubation period is 4 weeks, and GI symptoms are usually mild. Good hand washing after toileting and diaper changes, as well as environmental controls, can prevent this form. b. **Hepatitis B virus is transmitted via blood and body secretions**, as well as vertically from mother to fetus; it can be acute or chronic and can result in the long-term sequelae of cirrhosis, liver cancer, or fulminant hepatitis; incubation is 50 to 180 days. c. **Hepatitis C virus is predominatly parenterally spread** with an incubation of 14 to 180 days; it causes severe liver damage and frequently results in the need for a liver transplant. d. Hepatitis D virus occurs in conjunciton with hepatitis B virus. e. Hepatitis E virus is similar in transmission to hepatitis A. 2. Diagnosis is made by identifying the antigenic markers and the body's immune response. Assessment 1. Prodromal symptoms may include anorexia, malaise, easily fatigued, and possibly a fever. 2. Assess for nausea, vomiting, epigastric or right upper quadrant abdominal discomfort. 3. Assess for hepatomegaly and increased abdominal girth. 4. **Assess for jaundice, dark urine, and pale stools.** 5. Assess liver funciton tests (transaminases) and bilirubin levels. 6. Assess for a history of blood transfusions, sexual activity, needle sharing of any substances, poor sanitation, ingestion of hepatotoxic drugs, exposure to blood or body secretions of an infected individual, as in diaper changing. Interventions 1. Administer hepatitis immune globulin (HBIG) for contact with hepatitis B. 2. Administer hepatitis immunization series to infants and adolescents if not already protected. 3. **Implement standard precautions; stress good hand washing and hygienic environmental measures.** 4. Management for noncritical cases is supportive and symptomatic and usually takes place in the home environment; promote rest, fluids, and good nutrition. Neonatal hepatitis B (HBV) 1. Infant born to HBV-positive mothers ahve 70% to 90% risk of HBV infection. 2. Eighty percent to 90% of infected infants become chronic HBV carriers; more than 25% of these infants die of primary hepatocellular carcinoma or cirrhosis.

Question 34

The child receiving enteral feedings

Answer 34

These include feedings delivered directly into the stomach or intestines by either an NG tube, a nasojejunal tube, or a gastrostomy tube. 1. NG tubes stiffen when left in place for long periods of time and can cause irritaiton to mucous membranes. 2. Soft NG tubes are made of Silastic and come with a wire stylet that is used only for inserting the tube and then is removed (do not discard, as it can be reused for re-insertion). 3. When inserting an enteral tube, if resistance is encountered, withdraw the tube and try again; use of force may cause perforation. a. **pH testing of aspirate is the most reliable way to verify placement, secondary to X-ray; it should be < 5 or < 6 if the child is taking an H2 blocker.** b. The practice of injecting air into the NG tube and listening over the abdomen with a stethoscope for a 'popping sound' is no longer acceptable practice as it is not evidence-based. 4. Gastrostomy tubes are placed surgically or by endoscopic methods (PEG tube); a gastrostomy tube that is skin level is called a "button" gastrostomy. Feedings can be continuous or intermittent; they can be delivered by a pump or by gravity. **Nonnutritive sucking has multiple benefits for the infant recceiving enteral feeds**, including improved weight gain, increased alert states, and decreased restlessness.

Question 35

Acetaminophen Therapeutic Dosing and Poisoning

Answer 35

Introduction 1. Acetaminophen is an analgesic, antipyretic agent that does not inhibit platelet aggregation and does not affect inflammation as with aspirin. 2. **Appropriate dosing is 10-15mg/Kg/dose. Must have appropriate dose to be effective.** 3. Hepatotoxicity occurs at plasma levels greater than 200ug/mL. Assessment 1. Assess for GI distress, such as nausea, vomiting, diarrhea, and abdominal pain. 2. **Monitor for liver damage 24 to 36 hours after the overdose.** Intervention 1. Administer an antidote, such as acetylcysteine (Mucomyst).

Question 36

What is the most common assessment finding in a child with ulcerative colitis? a. Constipation b. Blood diarrhea c. Anal fissures d. Abdominal distention

Answer 36

b Ulcerative colitis is one form of infalmmatory bowel disease (IBD) involving symmetrical and continguous bowel ulcers attacking the mucosa of the bowel wall in the large intestine. The edema and inflammation in the bowel lead to bloody diarrhea, abdominal pain/cramping, weight loss, anorexia, nausea, and vomiting.

Question 37

When caring for a 12-month-old infant with dehydration and metabolic acidosis, the nurse expects to see: a. A reduced white blood cell count b. A decreased platelet count c. Shallow respirations d. Tachypnea

Answer 37

d A child with metabolic acidosis will develop compensatory tachypnea in order to blow-off CO2 (physiologic acid), and thereby reduce the overall acidosis.

Question 38

Which symptoms would be seen in a newborn with tracheoesophageal fistula? a. Drooling and diarrhea b. Increased mucous production and oral secreitons c. Air distention in the stomach and vomiting d. Persistent cyanosis and visible peristaltic waves

Answer 38

b Tracheoesophageal fistula involves the communicaiton between the trachea and esophagus. Infants born with this condition have symptoms of respiratory distress and difficulty managing oral secretions.

Question 39

Johnny is suspected of having Hirschsprung's disease. The nurse would expect the child's history of present illness to include which of the following? a. Anemia, abdominal distention, and fecal soiling b. Abdominal distention and constipation c. Bloody diarrhea, fever, and vomiting d. Irritability and severe abdominal cramps

Answer 39

b Hirschsprung's disease is a congenital anomaly of decreased intestinal motility resulting in mechanical obstruction of the intestine. Clinical manifestations in the newborn include vomiting, constiptation, and abdominal distention. Older infants and children with Hirschsprung's disease will have chronic constipation with ribbon-like stools and chronic abdominal distention. This condition is not associated with anemia, vomiting, fecal soiling, or bloody diarrhea.

Question 40

What clinical manifestations would most likely be present in a 7-month-old infant suspected of having intussusception? a. Abdominal pain, vomiting, olive shaped mass to the right of the umbilicus b. Anorexia, abdominal distention, and constipation c. Malnouished-looking child, fever, and diarrhea d. Inconsolable crying, abdominal pain, and sausage-shaped mass in the right lower quadrant

Answer 40

d Intussusception is an acute condition involving the telescoping of one portion of the bowel causing acute lymphatic and venous obstruction that results in ischemia, mucous backflow into the intestine, and leaking of blood into the intestine. The classic sign is current jelly stools. A palpable sausage-shaped mass can sometimes be felt in the right lower quadrant of the abdomen. Other clinical manifestations include episodic acute abdominal pain with drawing up of the knees and inconsolability. Bilious vomiting may also be present. The child usually appears otherwise well nourished.

Question 41

Which of the following assessments would you expect to note when caring for a child with pyloric stenosis? a. Projectile vomiting of bile-tinged emesis b. Non-projectile vomiting of non-bilious emesis c. Metabolic Alkalosis d. Non-projectile vomiting of bilious emesis

Answer 41

c Pyloric stenosis is the narrowing of the pyloric sphincter at the outlet of the stomach. As the pylorus becomes more hypertrophied, manifestations appear. Clinical manifestations include projectile vomiting of NON-bilious vomitus, visible peristaltic waves across the epigastrium, signs of malnutrition, and dehydration. Infants present with markedly abnormal electrolytes with signs of metabolic alkalosis revealing an increased serum pH and bicarbonate levels.

Question 42

The nurse is caring for a toddler who ingested an unknown amount of medicaiton. A nasogastric tube (NG) for charcoal administration is ordered. In order to verify the placement of the NG tube, the nurse should: a. Instill air and auscultate over the upper left epigastrium for a popping sound. b. Assume correct platement if there is no choking or decreased oxygen saturations. c. Instill air and auscultate the upper chest to ensure the tube is not in the lungs. d. After the tube is placed, obtain a chest x-ray

Answer 42

d

Question 43

Amelia is a 3-month-old infant who is receiving tube feeds due to a temporary malformation in the GI system. Which of the following should the nurse encourage Amelia's mother to do during her feedings? a. Sing or play music that is calming to Amelia. b. Stroke Amelia's head or talk ot her during the feeding. c. Give Amelia a pacifier during the feeding. d. Encourage Amelia to sleep during the feeding.

Answer 43

c Nonnutritive sucking is offered concurrently with a feeding and is associated with a positive contented feeling and increased growth and development.

Question 44

Four-year-old Drew has been vomiting for 24 hours. Several labs have been ordered. The nurse would expect the results to show which of the following? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

Answer 44

b The loss of stomach acide is associated iwth vomiting leads to metabolic alkalosis

Question 45

The nurse is caring for 18-month-old Kobe who has moderate diarrhea. Which of the following should be included in Kobe's plan of care? a. Encourage Kobe to drink apple juice and sports drinks. b. Have kobe eat only bananas, rice, applesauce, and toast (BRAT diet) c. Ensure that lal of Kobe's diapers are weighed. d. Keep Kobe NPO for 4-6 hours to see if the diarrhea subsides.

Answer 45

c The hospitalized child with diarrhea should be placed on strict intake and output measures that include the weighing of diapers. Juices and sports drinks should be avoided as the sugar content causes increased dehydration. The BRAT diet has been shown to be lacking in adequate nutrition and is no longer recommended. It is not necessary for the child with diarrhea to be NPO.

Question 46

Tonya is a 6-month-old female who has vomiting and diarrhea. Which of the following would indicate that the infant's condition has worsened, progressing to severe dehydration? a. Increased heart rate b. Sunken fontanel c. Dry mucus membranes d. Decreased capillary refill

Answer 46

d Early signs of dehydration include a sunken fontanel, dry mucus membranes, and increased heart rate. A decrease in capillary refill is a sign of severe dehydration.

Question 47

A solution containing glucose should never be given as a bolus as it could lead to ...

Answer 47

cerebral edema and death

Question 48

You are caring for an infant who weighs 8 kg and has an order for 50 mg of acetaminophen. Which of the following is true about this dose? a. It is non-therapeutic. b. It is non-therapeutic and not safe. c. It is an overdose and not safe. d. It is an appropriate dose.

Answer 48

a **Acetaminophen's dosage range is 10-15 mg/kg per dose. ** This dosage is too low and is not therapeutic.

Question 49

The pediatric clinic nurse is evaluating 6-year-old Elizabeth who has chronic constipation. Which of the following should be included in the nurse's dietary recommendations to Elizabeth and her family? a. Increase liquids and fat while decreasing protein and fiber. b. Increase liquids and protein while decreasing fiber and fat. c. Increase liquids and fiber while decreasing protein and fat. d. Increase liquids, fiber, and protein, while decreasing fat.

Answer 49

c The constipated child should have dietary modificaitons that include increasing lidquids and fiber and decreasing fat and protein.

Question 50

Brad is a 5-year-old being evaluated for encopresis. Which of the followign would the nurse expect to hear while obtaining Brad's history? a. Brad has adjusted well to kindergarten. b. Brad has fatty stools that float in the toilet water. c. Brad typically has soft formed stools 2-3 times a day. d. Brad has been having liquid stool stain his underwear.

Answer 50

d Encopresis is the involuntary leakage of stool in a previously potty-

Question 51

The nurse provides education on cleft lip and palate to a group of nursing students. It is apparent that more education is needed when a student states that these infants are at risk for: a. Pneumonia b. Otitis media c. Altered bonding with parents d. Gastroesophageal reflux

Answer 51

d Cleft lip and palate are associated with aspiration and pneumonia as well as otitis media. Bonding can be altered as parents may not cope well with the disfiguring defect. There is not an increased incidence of gastroesophageal reflux.

Question 52

The mother of an infant with cleft lip and palate asks the nurse why the lip and palate aren't being repaired at the same time. The nurse's best response is: a. "They prefer to schedule the repairs separately to avoid using too much anesthesia." b. "The palate is generally not repaired until the baby has begun talking." c. "The palate needs to have an opportunity to grow, and the repair requires that the baby be drinking from an open cup, usually between 6 to 12 months of age." d. "It sounds like you have some unanswered questions. I can arrange to have you speak to the surgeon."

Answer 52

c

Question 53

The nurse is caring for a 12-month-old toddler who has just had a repair of a cleft palate. Which of the following should be included in the plan of care? a. Positiont he child so that secretions drain from the mouth and suction her with a soft tipped catheter. b. Encourage the mother to hold and rock her frequently. c. Attempt to keep the child from crying, encourage her to hold her favorite stuffed animal, and use her pacifier when upset. d. Keep the child hydrated by offering her juice and liquids in a bottle.

Answer 53

b The child who has had a repair of a cleft palate should not do any activities that would interfere with the integrity of the suture line.

Question 54

Which of the following would be the best toy for an 11-month-old recovering from a cleft palate repair? a. A rattle b. A mobile c. A teething ring d. A toy hammer to bang

Answer 54

b The key intervention following cleft palate surgery is to keep anything out of the mouth in order to prevent injury to the suture line.

Question 55

When reviewing the history of an infant with tracheoesophageal fistula (TEF), the nurse would expect to find: a. Feedings tolerated for a few days, then projectile vomiting. b. The infant's mother stated that she barely looked pregnant and never needed to wear maternity clothes. c. The infant continuously appeared hungry despite being fed every 2 hours. d. The infant appeared to have a lot of secretions and became cyanotic when fed.

Answer 55

d A child with TEF is at risk for aspiration and respiratory distress due to excessive secreitons and disruption of the communication between the esophagus and the trachea. Children with TEF become cyanotic when fed and should be NPO with the head of the bed elevated. Suction and ventilation equipment is needed at the bedside. Although the child with esophageal atresia may experience projectile vomiting, feedings are not tolerated at all. The mothers of children with TEF usually have polyhydramnios (an excess of amniotic fluid) and may appear larger than other pregnant women.

Question 56

The nurse is caring for a newborn with suspected TEF. During the first feeding, he became cyanotic, coughed, and choked. Which of the following would the nurse expect to be part of the care? a. Allow his mother to feed him Pedialyte slowly in a monitored area, stopping all feedings 6 hours before surgery. b. Begin IV fluids an dIV antibiotics. c. Admit him to the ICU and apply 100% oxygen. d. Allow the parents to visit him in the PICU, but not hold him until just before his surgery.

Answer 56

b Oral feedings are immediately stopped when a child is suspected of having TEF. An IV is started and fluids are administered to prevent dehydration. IV antibiotics are started to prevent and treat penumonia that is caused from aspiraiton.

Question 57

The nurse is reviewing information on pyloric stenosis. Which of the following reflects accurate information? a. It only occurs in males. b. Vomiting will gradually become more projectile and contain more bile as the pylorus muscle tickens. c. Surgical correction inolves spreading open the muscle around the pyloric valve. d. A sausage-shaped mass can be palpated in the lower abdomen.

Answer 57

c Surgical correction involves spreading open the muscle around the pyloric valve thereby relieving the obstruction by enlarging the pylorus. Although it occurs more frequently in males, it can also occur in females. Vomiting will gradually become more projectile as the pylorus muscle thickens, but it will not contain bile. An olive-shapped mass can be palpated in the right upper abdomen.

Question 58

The nurse in a pediatric clinic asks a mother to bring her baby in for evaluation. The nurse suspects that the baby will be tested for pyloric stenosis when the mother states the following: a. "My baby spits up a little 45 minutes after every feeding." b. "My baby vomits right before I begin to give his next feeding." c. "When my baby vomits, it is forceful and green." d. "My baby still wants to eat right after he vomits."

Answer 58

d Infants with pyloric stenosis vomit within 30 minutes after feeding. Their vomitus can contain blood, but not bile, as the feeding does not advance beyond the pylorus which is above the location where bile enters the GI tract. Infants remain hungry after vomiting and usually want to feed again.

Question 59

The nurse is presenting a review on necrotizing entercolitis (NEC). The nurse knkows that more information is needed when one of the students states which of the following? a. "Infants who receive CPR are at risk for developing NEC." b. "When the bowel dies, more mucus invades the bowel." c. "Extra gas would be seen on x-ray." d. "Bacteria can grow in formula."

Answer 59

b When the bowel becoes necrotic, protective mucus is decreased. Infants who receive CPR are at risk for developing NEC as blood is diverted away from the bowel. Extra gas can be seen on x-ray. Formula feedings can exacerbate the condition as formula provides a medium for bacteria to grow.

Question 60

The nurse is caring for 2-month-old Sophia, who has been diagnosed with biliary atresia. When reviewing Sophia's history, the nurse would expect to find that: a. Sophia's urine has been very pale. b. Sophia has been having black tarry stools. c. Sophia has had very poor weight gain. d. Sophia has had a bluish tint to her sclera.

Answer 60

c In biliary atresia, the unconjugated bilirubin is trapped within the liver leading eventually to liver failure. Symptoms include jjaundice, dark urine, light stools, and yellow sclera. The infant typically has failure to thrive and does not gain weight.

Question 61

The nurse is caring for a toddler diagnosed with intussusception who is lethargic with a heart rate of 166 and a blood pressure of 60/42. His abdomen is rigid, and the child does not respond vigorously when examined. The nurse correctly expects: a. The child will immediately be brought to the operating room for surgical correction. b. The child will be brought to the radiology department for an attempt at reduction with an enema. c. The child will be closely observed in the emergency room to see if his condition changes. d. The child will be encouraged to increase his consumption of clear liquids.

Answer 61

a Although most cases of intussusception are reduced by enema, the child in this senario is in shock. The child may have experienced a perforation in the bowel which represents a surgical emergency.

Question 62

When developing a postoperative plan of care for an infant scheduled for cleft lip repair, the nurse should assign highest priority to which intervention? a. Comforting the child as quickly as possible. b. Maintaining the child in a prone position. c. Restraining the child's arms at all times, using elbow restraints or swaddling the infant with arms secured. d. Avoiding disturbing any crusts that form on the suture line.

Answer 62

c Nursing interventions following cleft lip repair focu on monitoring for repiratory distress and maintaining an intact suture line. The infant should be placed on his back for sleeping and the infant's arms should be kept away from his mouth which can be accomplished with elbow restraints or swaddling with the arms secured.

Question 63

Which of the following would be the best toy for an 11-month-old recovering from a cleft palate repair? a. A rattle b. A mobile c. A teething ring d. A toy hammer to bang

Answer 63

b The key intervention following cleft palate surgery is to keep anything out of the mouth in order to prevent injury to the suture line. Therefore, all things that can be placed in the mouth would be contraindicated for the child status post cleft palate repair. A crib mobile wou dbe the safest option.

Question 64

When reviewing the history of an infant with tracheoesophageal fistula (TEF), the nurse would expect to find: a. Feedings tolerated for a few days, then projectile vomiting. b. The infant's mother stated that she barely looked pregnant and never needed to wear maternity clothes. c. The infant continuously appeared hungry despite being fed every 2 hours. d. The infant appeared to have a lot of secretions and became cyanotic when fed.

Answer 64

d The child with TEF is at risk for aspiraiton and respiratory distress due to excessibe secrtions and disruption of the cummunication between the esophagus and the trachea. Children with TEF become cyanotic when fed and should be NPO with the head of the bed elevated. Suction and ventilation equipment is needed at the bedside. Although the chid with esophageal atresia may experience projectile vomiting, feedings are not tolerated at all. The mothers of children with TEF usually have polyhydramnios (an excess of amniotic fluid) and may appear larger than other pregnant women.

Question 66

The nurse is caring for a newborn with suspected TEF. During the first feeding, he became cyanotic, coughed, and choked. Which of the following would the nurse expect to be part of the care? a. Allow his mother to feed him Pedialyte slowly in a monitored area, stopping all feedings 6 hours before surgery. b. Begin IV fluids and IV antibiotics. c. Admit him to the ICU and apply 100% oxygen. d. Allow the parents to visit him in the PICU, but not hold him until just before his surgery.

Answer 66

b Oral feedings are immediately stopped when a child is suspected of having TEF. An IV is started and fluids are administered to prevent dehydration. IV antibiotics are started to prevent and treat pneumonia that is caused from aspiration. Oxygen is only used for hypoxia and is delivered in the lowest amount to keep oxygen saturations greater than 94%. Parents are encouraged to stay in the ICU and hold the baby as much as possible.

Question 67

A 1-day-old neonate is suspected to have tracheoesophageal fistula. Which nursing intervention is most appropriate for this infant? a. Avoid suctioning unless cyanosis occurs. b. Elevating the head of the bed and giving nothing by mouth. c. Elevating the neonate's head for 1 hour after feedings. d. Give the neonate only glucose water for the first 24 hours.

Answer 67

b A child with TEF is at risk for aspiraiton and respiratory distress due to disruption of communication between the esophagus and the trachea. The child should be NPO and should have the head of the bed elevated. Suction equpiment is needed to handle excess secreitons. Ventilation equipment is indicated due to the risk for respiratory distress.

Question 68

The nurse is reviewing information on pyloric stenosis. Which of the following reflects accurate information? a. It only occurs in males. b. Vomiting will gradually become more projectile and contain more bile as the pylorus muscle thickens. c. Surgical correction involves spreading open the muscle around the pyloric valve. d. A sausage-shaped mass can be palpated in the lower abdomen.

Answer 68

c Surgical correction involves spreading open the muscle around the pyloric valve thereby relieving the obstruction by enlarging the pylorus. Although it occurs more frequently in males, it can also occur in females. Vomiting will gradually become more projectile as the pylorus muscle thickens, but it will NOT contain bile. An olive-shaped mass can be palpated in the right upper abdomen.

Question 69

The nurse in a pediatric clinic asks a mother to bring her baby in for evaluation. The nurse suspects that the baby will be tested for pyloric stenosis when the mother states the following: a. "My baby spits up a little 45 minutes after every feeding." b. "My baby vomits right before I begin to give his next feeding." c. "When my baby vomits, it is forceful and green." d. "My baby still wants to eat right after he vomits."

Answer 69

d Infants with pyloric stenosis vomit within 30 minutes after feeding. Their vomitus can contain blood, but not bile, as the feeding does not advance beyond the pylorus which is above the location where bile enters the GI tract. Infants remain hungry affter vomiting and usually want to feed again.

Question 70

Which of the following is accurate concerning inflammatory bowel disease (IBD)? a. Ulcerative colitis attacks all but the mucosa of the bowel. b. Crohn's disease affects all layers of the bowel wall. c. Ulcerative colitis usually involves the small intestine. d. Crohn's disease causes more blood loss.

Answer 70

b Ulcerative colitis generally causes more blood loss than Crohn's disease. Ulcerative colitis attack sthe mucosa of the bowel while Crohn's disease affects all layers of the bowel wall. Ulcerative colitis usually inolves the large intestine.

Question 71

A 12-year-old with IBD has recently developed mouth ulcers and arthritis in his joints. Which of the following is likely occurring? a. The child likely has Crohn's disease. b. The child likely has ulcerative colitis. c. The child has a secondary inflammatory response unrelated to IBD. d. The medications used to treat IBD have caused mouth ulcers and arthritis.

Answer 71

a Crohn's disease affects all lengths (mouth to anus) and all depths of the GI tract. Mouth ulcerations may be a manifestation. Ulcerative colitis only affects the large intestine.

Question 72

Which of the following lunch trays is appropriate for a 6-year-old with pneumonia and celiac disease? a. Beef and barley soup, vanilla pudding, and orange juice b. Pizza, applesauce, and sprite (lemon fresh) c. Cheeseburger, corn chips, and milk d. Grilled chicken and corn

Answer 72

d Children with celiac disease should avoid foods that contain barley, wheat, oats, and rye. Corn is generally well tolerated.

Question 73

The nurse is caring for 2-month-old Sophia, who has been diagnosed with biliary atresia. When reviewing Sophia's history, the nurse would expect to find that: a. Sophia's urine has been very pale. b. Sophia has been having black tarry stools. c. Sophia has had very poor weight gain. d. Sophia has had a bluish tint to her sclera.

Answer 73

c In biliary atresia, the unconjugated bilirubin is trapped within the liver leading eventually to liver failure. Symptoms include jaundice, dark urine, light stools, and yellow sclera. The infant typically has failure to thrive and dose not gain weight.