GI/Cleft Lip
The nurse is caring for a 4-month-old who has just had an isolated cleft lip repaired. Select the best position for the child in the immediate post-operative period.
1. Right side-lying.
2. Left side-lying.
3. Supine.
4. Prone.
What is 3?
Rationale: The supine position is preferred because there is decreased risk of the infant rubbing the suture line.
The parent of a 3-year-old is shocked to hear the diagnosis of Wilms tumor and says, “How could I have missed a lump this big?” Which is the nurse’s best response?
1. “Do not be hard on yourself. It’s easy to overlook something that has probably been growing for months when we see our children on a regular basis.”
2. “I understand you must be very upset. Your child would have had a better prognosis had you caught it earlier.”
3. “It really takes a trained professional to recognize something like this.”
4. “Do not blame yourself. This mass grows so fast that it was probably not noticeable a few days ago.”
What is 4?
Rationale: The tumor is fast-growing and could very easily not have been evident a few days earlier.
The nurse is caring for an 8-week-old infant being evaluated for pyloric stenosis. Which statement by the parent would be typical for a child with this diagnosis?
1. “The baby is a very fussy eater and just does not want to eat.”
2. “The baby tends to have a very forceful vomiting episode about 30 minutes after most feedings.”
3. “The baby is always hungry after vomiting so I refeed.”
4. “The baby is happy in spite of getting really upset after spitting up.”
What is 3?
Rationale: Infants with pyloric stenosis are always hungry and often appear malnourished.
An 8-year-old with type 1 diabetes mellitus is complaining of a headache and dizziness and is visibly perspiring. Which of the following should the nurse do first?
1. Administer glucagon intramuscularly.
2. Offer the child 8 oz of milk.
3. Administer rapid-acting insulin lispro (Humalog).
4. Offer the child 8 oz of water or calorie-free liquid.
What is 2?
Rationale: Milk is best to give for mild hypoglycemia, which would present with the symptoms described.
Which priority item should be placed at the bedside of a newborn with myelomeningocele?
1. A bottle of normal saline.
2. A rectal thermometer.
3. Extra blankets.
4. A blood pressure cuff.
What is 1?
Rationale: Before the surgical closure of the sac, the infant is at risk for infection. A sterile dressing is placed over the sac to keep it moist and help prevent it from tearing.
The parent of a newborn asks, “Will my baby spit out the formula if it is too hot or too cold?” Select the nurse’s best response.
1. “Babies have a tendency to reject hot fluids but not cold fluids, which could result in abdominal discomfort.”
2. “Babies have a tendency to reject cold fluids but not hot fluids, which could result in esophageal burns.”
3. “Your baby would most likely spit out a formula that was too hot, but your baby could swallow some of it, which could result in a burn.”
4. “Your baby is too young to be physically capable of spitting out fluids and will automatically swallow anything.”
What is 4?
Rationale:
Swallowing is a reflex in infants younger than 6 weeks.
Which child is at risk for developing glomerulonephritis?
1. A 3-year-old who had impetigo 1 week ago.
2. A 5-year-old with a history of five UTIs in the previous year.
3. A 6-year-old with new-onset type 1 diabetes.
4. A 10-year-old recovering from viral pneumonia.
What is 1?
Rationale: Impetigo is a skin infection caused by the streptococcal organism that is commonly associated with glomerulonephritis.
The parent of a 5-year-old state that the child has been having diarrhea for 24 hours, vomited twice 2 hours ago, and now claims to be thirsty. The parent asks what to offer the child because the child is refusing Pedialyte. Select the nurse’s most appropriate response.
1. “You can offer clear diet soda such as Sprite and ginger ale.”
2. “Pedialyte is really the best thing for your child, who, if thirsty enough, will eventually drink it.”
3. “Pedialyte is really the best thing for your child. Allow your child some choice in the way to take it by offering small amounts in a spoon, medicine cup, or syringe.”
4. “It really does not matter what your child drinks as long as it is kept down. Try offering small amounts of fluids in medicine cups.”
What is 3?
Rationale: Pedialyte is the first choice, as recommended by the American Academy of Pediatrics. Offering the child appropriate choices may allow the child to feel empowered and less likely to refuse the Pedialyte. Small, frequent amounts are usually better tolerated.
The nurse receives a call from the mother of a 6-month-old who describes her child as alternately sleepy and fussy. She states that her infant vomited once this morning and had two episodes of diarrhea. The last episode contained mucus and a small amount of blood. She asks the nurse what she should do. Select the nurse’s best response.
1. “Your infant will need to have some tests in the emergency room to determine if anything serious is going on.”
2. “Try feeding your infant in about 30 minutes; in the event of repeat vomiting, bring the infant to the emergency room for some tests and intravenous rehydration.”
3. “Many infants display these symptoms when they develop an allergy to the formula they are receiving; try switching to a soy-based formula.”
4. “Do not worry about the blood and mucus in the stool; it is not unusual for infants to have blood in their stools because their intestines are more sensitive.”
What is 1?
Rationale: The mother should be told not to give the infant anything by mouth and bring the infant immediately to the emergency room.
Which should be the priority nursing diagnosis for a 12-hour-old newborn with a myelomeningocele at L2?
1. Altered bowel elimination related to neurological deficits.
2. Potential for infection related to the physical defect.
3. Altered nutrition related to neurological deficit.
4. Disturbance in self-concept related to physical disability.
What is 2?
Rationale: Because this infant has not had a repair, the sac is exposed. It could rupture, allowing organisms to enter the cerebrospinal fluid, so this is the priority.
The nurse is caring for a newborn with a cleft lip and palate. The mother states, “I will not be able to breastfeed my baby.” Select the nurse’s best response.
1. “It sounds like you are feeling discouraged. Would you like to talk about it?”
2. “Sometimes breastfeeding is still an option for babies with a cleft lip and palate. Would you like more information?”
3. “Although breastfeeding is not an option, you have the option of pumping your milk and then feeding it to your baby with a special nipple.”
4. “We usually discourage breastfeeding babies with cleft lip and palate as it puts them at an increased risk for aspiration.”
What is 2?
Rationale: Some mothers are able to breastfeed their infants who have cleft lip and palate. The breast can help fill in the cleft and help the infant create suction.
Which combination of signs is commonly associated with glomerulonephritis?
1. Massive proteinuria, hematuria, decreased urinary output, and lethargy.
2. Mild proteinuria, increased urinary output, and lethargy.
3. Mild proteinuria, hematuria, decreased urinary output, and lethargy.
4. Massive proteinuria, decreased urinary output, and hypotension.
What is 3?
Rationale: Mild-to-moderate proteinuria, hematuria, decreased urinary output, and lethargy is common findings in glomerulonephritis.
A 4-month-old is brought to the emergency department with severe dehydration. The heart rate is 198, and her blood pressure is 68/38. The infant’s anterior fontanel is sunken. The nurse notes that the infant does not cry when the intravenous line is inserted. The child’s parents state that she has not “held anything down” in 18 hours.
The nurse obtains a finger-stick blood sugar of 94. Which would the nurse expect to do immediately?
1. Administer a bolus of normal saline.
2. Administer a bolus of D10W.
3. Administer a bolus of normal saline with 5% dextrose added to the solution.
4. Offer the child an oral rehydrating solution such as Pedialyte.
What is 1?
Rationale:
Dehydration is corrected with the administration of an isotonic solution, such as normal saline or lactated Ringer solution.
The nurse is caring for a child due for surgery on a Wilms tumor. The child’s procedure will consist of which of the following?
1. Only the affected kidney will be removed.
2. Both the affected kidney and the other kidney will be removed in case of recurrence.
3. The mass will be removed from the affected kidney.
4. The mass will be removed from the affected kidney, and a biopsy of the tissue of
the unaffected kidney will be done.
What is 1?
Rationale: The treatment of a Wilms tumor involves the removal of the affected kidney.
The nurse is caring for an infant with myelomeningocele who is going to surgery later today for closure of the sac. Which would be a priority nursing diagnosis before surgery?
1. Alteration in parent-infant bonding.
2. Altered growth and development.
3. Risk of infection.
4. Risk for weight loss.
What is 3?
Rationale: A normal saline dressing is placed over the sac to prevent tearing, which would allow the cerebrospinal fluid to escape and microorganisms to enter and cause an infection.
The parents of a newborn diagnosed with a cleft lip and palate ask the nurse when their child’s lip and palate will most likely be repaired. Select the nurse’s best response.
1. “The palate and the lip are usually repaired in the first few weeks of life so that
the baby can grow and gain weight.”
2. “The palate and the lip are usually not repaired until the baby is approximately
6 months old so that the mouth has had enough time to grow.”
3. “The lip is repaired in the first few months of life, but the palate is not usually repaired until the child is 3 years old.”
4. “The lip is repaired in the first few weeks of life, but the palate is not usually repaired until the child is 18 months old.”
What is 4?
Rationale: The lip is repaired in the first few weeks of life, but the palate is not usually repaired until the child is 18 months old.
The parent of a child with glomerulonephritis asks the nurse why the urine is such a funny color. Which is the nurse’s best response?
1. “It is not uncommon for the urine to be discolored when children are receiving steroids and blood pressure medications.”
2. “There is blood in your child’s urine that causes it to be tea-colored.”
3. “Your child’s urine is very concentrated, so it appears to be discolored.”
4. “A ketogenic diet often causes the urine to be tea-colored.”
What is 2?
Rationale: Blood in the child’s urine causes it to be tea-colored.
The nurse is caring for a newborn with esophageal atresia. When reviewing the mother’s history, which would the nurse expect to find?
1. Maternal polyhydramnios.
2. Pregnancy lasting more than 38 weeks.
3. Poor nutrition during pregnancy.
4. Alcohol consumption during pregnancy.
What is 1?
Rationale: Maternal polyhydramnios is present because the infant cannot swallow and absorb the amniotic fluid in utero.
Which would the nurse expect to assess on a 3-week-old infant with developmental dysplasia of the hip (DDH)?
1. Excessive hip abduction.
2. Femoral lengthening of an affected leg.
3. Asymmetry of gluteal and thigh folds.
4. Pain when lying prone.
What is 3?
Rationale: In DDH, asymmetrical thigh and gluteal
folds are frequently present.
Which should be included in the plan of care for a newborn with myelomeningocele who will have a surgical repair tomorrow?
1. Offer formula every 3 hours.
2. Turn the infant back to front every 2 hours.
3. Place a wet dressing on the sac.
4. Provide pain medication every 4 hours.
What is 3?
Rationale: Priority care for an infant with a myelomeningocele is to protect the sac. A wet dressing keeps it moist with less chance of tearing.
The nurse is caring for a newborn who has just been diagnosed with tracheoesophageal fistula and is scheduled for surgery. Which should the nurse expect to do in the pre-operative period?
1. Keep the child in a monitored crib, obtain frequent vital signs, and allow the parents to visit but not hold their infant.
2. Administer intravenous fluids and antibiotics.
3. Place the infant on 100% oxygen via a non-rebreather mask.
4. Have the mother feed the infant slowly in a monitored area, stopping all feedings 4 to 6 hours before surgery.
What is 2?
Rationale: Intravenous fluids are administered to prevent dehydration because the infant is NPO. Intravenous antibiotics are administered to prevent pneumonia because aspiration of secretions is likely.
A parent asks the nurse how to prevent the child from having minimal change nephrotic syndrome (MCNS) again. Which is the nurse’s best response?
1. “It is very rare for a child to have a relapse after having fully recovered.”
2. “Unfortunately, many children have cycles of relapses, and there is very little that can be done to prevent it.”
3. “Your child is much less likely to get sick again if sodium is decreased in the diet.”
4. “Try to keep your child away from sick children because relapses have been associated with infectious illnesses.”
What is 4?
Rationale: Exposure to infectious illness has been linked to the relapse of nephrotic syndrome.
The nurse is caring for an infant with pyloric stenosis. The parent asks if any future children will likely have pyloric stenosis. Select the nurse’s best response.
1. “You seem worried; would you like to discuss your concerns?”
2. “It is very rare for a family to have more than one child with pyloric stenosis.”
3. “Pyloric stenosis can run in families. It is more common among males.”
4. “Although there can be a genetic link, it is very unusual for girls to have pyloric stenosis.”
What is 3?
Rationale: Pyloric stenosis can run in families, and it is more common in males.
Which should the nurse stress to the parents of an infant in a Pavlik harness for treatment of developmental dysplasia of the hip (DDH)?
1. Put socks on over the foot pieces of the harness to help stabilize the harness.
2. Use lotions or powder on the skin to prevent rubbing of straps.
3. Remove harness during diaper changes for ease of cleaning diaper area.
4. Check under the straps at least two to three times daily for red areas.
What is 4?
Rationale: Checking under straps frequently is
suggested to prevent skin breakdown.
Which should the nurse prepare the parents of an infant for following surgical repair and closure of a myelomeningocele shortly after birth? The infant will:
1. Not need any long-term management and should be considered cured.
2. Not be at risk for urinary tract infections or movement problems.
3. Have continual drainage of cerebrospinal fluid, needing frequent dressing changes.
4. Need lifelong management of urinary, orthopedic, and neurological problems.
What is 4?
Rationale: Although immediate surgical repair decreases infection, morbidity, and mortality rates, these children will require lifelong management of neurological, orthopedic, and elimination problems.