Question 1

An infant is born with an esophageal atresia and tracheoesophageal fistula. Which preoperative nursing diagnosis is the priority for this infant?

Accepted Answer

Risk for aspiration related to regurgitation is the priority nursing diagnosis because the anatomical defect of esophageal atresia with tracheoesophageal fistula allows gastric contents to enter the trachea, leading to a high risk of aspiration.

Question 2

A nurse is preparing for the delivery of a newborn with a known diaphragmatic hernia defect. Which equipment does the nurse ensure is prepared at the bedside?

Accepted Answer

Intubation setup is crucial because a diaphragmatic hernia can cause respiratory distress, and the newborn may require immediate intubation to secure the airway and ensure adequate ventilation.

Question 3

A child with severe gastroenteritis is admitted to a semiprivate room on the pediatric unit. The charge nurse should place this client with which roommate?

Accepted Answer

Placing a child with severe gastroenteritis with another child with gastroenteritis minimizes the risk of spreading infection, as they are likely to have similar or the same pathogens. Other options increase the risk of spreading infections to vulnerable patients or those with different conditions.

Question 4

The nurse is evaluating an infant's tolerance of feedings after a pyloromyotomy. Which finding indicates that the infant is not tolerating the feeding?

Accepted Answer

Emesis after two feedings indicates that the infant is not tolerating the feeding and may need further evaluation or adjustment of the feeding plan. The other options are normal findings during feeding for an infant after a pyloromyotomy.

Question 5

A school-age client is recovering after abdominal surgery. The nurse is planning care for the return of bowel function. Which intervention should be included in the client's plan of care?

Accepted Answer

Ambulation is a key intervention to promote the return of bowel function after abdominal surgery as it stimulates peristalsis and helps prevent complications such as ileus.

Question 6

A 3-day-old preterm infant is diagnosed with necrotizing enterocolitis. The nurse plans care around the frequent radiographs. How frequently should the nurse anticipate that the radiology staff will bring the portable machine to the nursery?

Accepted Answer

Necrotizing enterocolitis requires frequent radiographs to monitor its progression. Therefore, the radiology staff will likely bring the portable machine to the nursery every 6 hours to allow for frequent monitoring and assessment of the infant's condition.

Question 7

The nurse is administering several medications to an infant with neurologic impairment and delay. Which medication is a proton pump inhibitor that is administered for gastroesophageal reflux?

Accepted Answer

Proton pump inhibitors (PPIs) like omeprazole are commonly used to treat gastroesophageal reflux in infants with neurological impairment and delay. Ranitidine is an H2 blocker that is also used for reflux, but it is not a PPI. Phenytoin is an anticonvulsant medication and glycopyrrolate is used to reduce saliva and secretions, but neither of these medications are used to treat reflux.

Question 8

A newborn is diagnosed with Hirschsprung disease. Which clinical manifestations found on assessment support this newborn's diagnosis?

Accepted Answer

Failure to pass meconium and abdominal distension are common clinical manifestations of Hirschsprung disease. This is due to a lack of normal peristalsis and inability to pass stool through the affected area of the bowel. Acute diarrhea, dehydration, currant jelly or gelatinous stools, pain, and altered electrolytes are not typical findings of Hirschsprung disease.

Question 9

A child experienced a lacerated spleen in a motor vehicle accident. Which is the highest-priority nursing intervention on admission to the pediatric intensive care unit (PICU) following surgery?

Accepted Answer

Observing for signs of hypovolemic shock is the highest-priority nursing intervention as a lacerated spleen can cause significant bleeding, leading to hypovolemic shock, which can be life-threatening. Maintaining IV fluids, implementing strict bedrest, and administering blood products are all important interventions, but observing for signs of hypovolemic shock takes the highest priority.

Question 10

The nurse is providing instruction to the parents of an infant with a colostomy. Which statement by the parents indicates appropriate understanding of the teaching session?

Accepted Answer

Watching for skin irritation around the stoma is a sign of appropriate understanding of the need for care and monitoring of the colostomy site. Option A is incorrect because changing the colostomy bag with each wet diaper may not be necessary and could cause unnecessary irritation to the infant's skin. Option B may not be necessary for all patients and is not the most important aspect of colostomy care. Option D is incorrect because bleeding is not a normal part of colostomy care and should be reported to the healthcare provider if it occurs.

Question 11

The nurse is caring for a school-age client who had an appendectomy after a ruptured appendix. Which orders does the nurse anticipate for this client? Select all that apply.

Accepted Answer

Antibiotics are necessary to treat infection after a ruptured appendix. An NG tube is often used to decompress the stomach and prevent vomiting. Vital signs every 4 hours help monitor the patient's condition. Frequent monitoring of bowel sounds is important to assess the return of bowel function. A clear liquid diet is not typically started immediately after surgery for a ruptured appendix.

Question 12

The nurse is caring for a 5-month-old with biliary atresia. The mother asks why the healthcare provider wants her child to take the medication, cholestyramine. What would the nurse's response be?

Accepted Answer

Cholestyramine is a medication used in biliary atresia to decrease itching, which is a common symptom of liver disease. It works by binding to the bile acids in the gastrointestinal tract and removing them from the body, which can help reduce the buildup of these acids in the skin and relieve itching.

Question 13

The nurse is preparing to ambulate a school-age client who had an appendectomy. In addition to pharmacological pain management, the nurse can use which nonpharmacological pain-management strategy for this client?

Accepted Answer

Placing a pillow on the abdomen can help reduce pain and discomfort during ambulation following an appendectomy. Heat and cold therapies may not be appropriate immediately following surgery, as they can increase swelling or interfere with wound healing. It is important to follow the healthcare provider's orders and surgical team recommendations for pain management post-operatively.

Question 14

An infant born with an omphalocele defect is admitted to the intensive-care nursery. Which instruction from the nurse manager to the unlicensed assistive personnel is most appropriate?

Accepted Answer

Omphalocele is a birth defect where the infant's intestine or other abdominal organs are outside of the body because of a hole in the belly button (navel) area. The most appropriate initial action is to prepare a warmer to maintain the infant's body temperature and prevent hypothermia, as these infants are at risk for temperature instability due to their exposed abdominal contents.

Question 15

The nurse is caring for the newborn with hyperbilirubinemia. What nursing diagnoses would the nurse address? Select all that apply.

Accepted Answer

Hyperbilirubinemia in newborns can lead to dehydration (deficient fluid volume) due to phototherapy, risk for impaired attachment due to separation from parents during treatment, and risk for imbalanced body temperature due to the need for phototherapy lights.

Question 16

The nurse educator is preparing an in-service on the basic functions of the gastrointestinal (GI) system. Which statements will the nurse educator include in the in-service? Select all that apply.

Accepted Answer

The answer of The nurse educator is preparing an in-service...

Question 17

The nurse is planning postoperative care for an infant after a cleft-lip repair. Which nursing intervention is most appropriate for this infant?

Accepted Answer

Supine or side-lying positioning is the most appropriate for an infant after a cleft-lip repair. Prone positioning should be avoided because pressure on the surgical site can cause bleeding or dehiscence. Suctioning with a Yankauer device can also cause trauma to the surgical site and should be avoided. Soft elbow restraints may be necessary to prevent the infant from touching the surgical site, but they should not be tight and should be monitored regularly.

Question 18

A neonate is fed 20 mL of formula every three hours by orogastric lavage. At the beginning of this feeding, the nurse aspirates 15 mL of gastric residual. Which action by the nurse is the most appropriate?

Accepted Answer

Aspirating 15 mL of gastric residual in a neonate who is being fed 20 mL every three hours is a significant amount and indicates delayed gastric emptying. Withholding the feeding and notifying the healthcare provider is the most appropriate action to prevent potential complications from overfeeding or aspiration.

Question 19

A child with inflammatory bowel disease is prescribed prednisone daily. At which time is it most appropriate for the family to administer the prednisone?

Accepted Answer

Prednisone should always be taken with meals to minimize gastrointestinal side effects.

Quiz 25: Alterations in Gastrointestinal Function