NCLEX Pediatric: GI Metabolic Endocrine Questions
Pediatric: GI Metabolic Endocrine NCLEX Practice Questions
Question 1.
The nurse in the pediatric medical-surgical unit is caring for a 9-year-old child admitted with diabetes insipidus. Which of the following signs does the nurse recognize as characteristic of diabetes insipidus?
(a) Weight gain
(b) Increased urine specific gravity
(c) Increased urination
(d) Serum sodium 130 mEq/L
Answer:
(c) Increased urination
Explanation:
Diabetes insipidus is due to a deficiency of antidiuretic hormone, which causes increased urinary output and fluid loss. This can lead to dehydration, hypernatremia, excessive thirst, weakness, and constipation. Causes of diabetes insipidus include head trauma, brain injury, meningitis, or encephalitis.
Rationale:
(a) is incorrect because diabetes insipidus causes fluid loss, which causes 'weight loss.
(b) is incorrect because increased urine specific gravity is due to concentrated urine or syndrome of inappropriate antidiuretic hormone (SIADH).
(d) is incorrect because diabetes insipidus leads to increased serum sodium concentration, or greater than 145 mEq/L.
Question 2.
The parent of a 6-year-old diagnosed with diabetes mellitus asks why self-monitoring of blood glucose is recommended. What knowledge does the nurse base the explanation on?
(a) It is less expensive
(b) It is more accurate than lab testing
(c) Parents and children are better able to manage the diabetes
(d) Frequent self-monitoring can slow the progression of the disease
Answer:
(c) Parents and children are better able to manage the diabetes
Explanation:
Diabetes is a condition of lack of insulin or insulin resistance that increases blood sugar levels. Data collected through frequent self-monitoring of blood sugar helps the child and parents to determine how different activities and foods affect blood sugar levels. The child and parents can then better manage the diabetes by adjusting insulin dosage based on results of the blood sugar tests.
Rationale:
(a) is incorrect because blood glucose monitoring is more expensive but provides improved management.
(b) is incorrect because self-monitoring is equivalent to lab testing. Most home glucose meters on the market today measure glucose from plasma, which is the same way blood glucose is measured in the clinical setting.
(d) is incorrect because self-monitoring allows for better diabetes control but does not directly slow progression or prevent complications of the disease. For example, peripheral neuropathy is a late complication of diabetes that tends to occur after an individual suffers from diabetes for many years, but blood glucose monitoring does not prevent this type of complication or progression.
Question 3.
A 10-year-old girl with diabetes type 1 is in the clinic for an upper respiratory infection. Her parents report she is not eating and ask the nurse what action is best. What is the best recommendation by the nurse?
(a) Give her half of her morning dose of insulin
(b) Substitute simple carbohydrates or liquids with calories for solid food
(c) Allow plenty of unsweetened, clear liquids for prevention of dehydration
(d) Take her to the emergency room immediately
Answer:
(b) Substitute simple carbohydrates or liquids with calories for solid food
Explanation:
Diabetes type 1 is a condition of lack of insulin production in the islet cells of the pancreas, leading to increased blood sugar. Diabetic “sick day rules” apply whenever a patient with diabetes is ill, overly stressed, or sick. A “sick day diet” of simple carbohydrates or liquids with calories will maintain normal blood sugar levels and decrease the risk of hypoglycemia. Other “sick day rules” include taking the normally ordered dose of insulin or oral antidiabetic agent, checking blood glucose every 3 to 4 hours, checking urine for ketones, and eating small meals frequently.
Rationale:
(a) is incorrect because the child should receive the regular dose of insulin, despite decreased appetite.
(c) is incorrect because calories are needed to prevent hypoglycemia.
(d) is incorrect because diabetes and minor illnesses such as a respiratory infection can be managed safely at home. The healthcare provider should be contacted to report abnormal blood glucose, fever, vomiting, or diarrhea.
Question 4.
A 12-year-old boy is admitted to the pediatric medical-surgical unit for suspected hypothyroidism. Which of the following is a common clinical manifestation of juvenile hypothyroidism?
(a) Insomnia
(b) Diarrhea
(c) Dry skin
(d) Accelerated growth
Answer:
(c) Dry skin
Rationale:
Explanation:
Hypothyroidism is decreased thyroid activity including decreased production of thyroid hormones. Manifestations include dry skin, mental decline, constipation, cold intolerance, and weight gain.
Rationale:
(a) is incorrect because hypothyroidism causes sleepiness. Insomnia is a symptom of hyperactive thyroid.
(b) is incorrect because diarrhea is a symptom of hyperthyroidism. Hypothyroidism causes constipation.
(d) is incorrect because decelerated growth and development occurs in children with hypothyroidism.
Question 5.
The nurse in the pediatric unit is caring for a child admitted to investigate potential growth hormone deficiency. When discussing possible metabolic alterations with the parents, which of the following should the nurse include?
(a) Hypercalcemia
(b) Hypoglycemia
(c) Diabetes insipidus
(d) Hyperglycemia
Answer:
(b) Hypoglycemia
Explanation:
Growth hormone stimulates growth of internal body organs and assists in maintaining normal blood sugar levels. Growth hormone deficiency can lead to hypoglycemia.
Rationale:
(a) is incorrect because hypercalcemia is associated with hyperparathyroidism.
(c) is incorrect because diabetes insipidus is due to posterior pituitary disorder. Growth hormone deficiency, in rare cases, can lead to type 2 diabetes mellitus.
(d) is incorrect because hyperglycemia is due to lack of insulin.
Question 6.
The nurse in the pediatric medical-surgical unit is caring for a 14-year- old boy admitted with Graves’ disease. When planning care, which of the following is a priority nursing goal for this adolescent?
(a) Encouraging adequate fluid intake to relieve constipation
(b) Allowing the adolescent to make decisions regarding taking his medications
(c) Verbalizing the importance of medication regimen adherence
(d) Developing alternative educational plans
Answer:
(c) Verbalizing the importance of medication regimen adherence
Explanation:
Graves’ disease is an auto-immune disorder and the leading cause of hyperactivity of the thyroid gland. The medication regimen includes taking specific medications, sometimes two to three times each day. The adolescent must understand the importance of adherence to the medication regimen and verbalize intent to comply.
Rationale:
(a) is incorrect because a patient with Graves’ disease does need adequate fluids to prevent dehydration from diarrhea but not to relieve constipation.
(b) is incorrect because although it is appropriate to encourage the adolescent patient to take an active role in his care, decisions about medications should not be made by the individual. The priority regarding medications is to teach the adolescent about compliance with the medication schedule and not to skip or alter doses.
(d) is incorrect because managing Graves’ disease does not require alternative educational plans. Adolescents place a high priority on social interaction with peers. The patient should be encouraged to continue attending school and social events as well as participating in athletic and leisure activities, despite a diagnosis of Graves’ disease (which is non¬debilitating and non-contagious).
Question 7.
A 6-year-old girl is in the clinic with her parents for precocious puberty. Which of the following is the most appropriate intervention for the child?
(a) Prepare age-appropriate educational materials regarding the use of birth control for the child
(b) Explain the importance of having the child develop relationships with her peers
(c) Reassure the parents that the risk for sexual abuse is not increased due to her appearance
(d) Counsel the parents that there is no treatment currently for precocious puberty
Answer:
(b) Explain the importance of having the child develop relationships with her peers
Explanation:
Precocious puberty is early onset of secondary sex characteristics in young children. (Puberty onset before the age of 9 in girls is considered “early.”) The child needs to be treated according to her chronologic age and interact with peers of the same age group to encourage age- appropriate behavior and social interactions.
Rationale:
(a) is incorrect because birth control is not appropriate for a 6-year-old and will not delay precocious puberty. Gonadotropin-releasing hormone blocker medications can be administered to delay the progression of puberty. The parents should also be counseled about how to appropriately talk to the child about how her body is changing.
(c) is incorrect because research shows that there is an increased risk for sexual abuse due to precocious puberty.
(d) is incorrect because gonadotropin-releasing hormone blocker is administered for precocious puberty.
Question 8.
A 10-year-old boy recently diagnosed with growth hormone (GH) deficiency is beginning treatment with GH. Which of the following instructions does the nurse give the parents regarding administration of the GH injections?
(a) Encourage the boy to give himself the injection at bedtime
(b) Administer the injection to the child after meals
(c) Give the medication before meals after checking blood glucose
(d) Encourage the boy to administer his GH injection on arising in the „ morning, before breakfast
Answer:
(a) Encourage the boy to give himself the injection at bedtime
Explanation:
Growth hormone injection treatment is prescribed for children who have been diagnosed with growth hormone (GH) deficiency and other conditions causing short stature. Because natural growth hormone is released mainly during sleep in children, GH treatment is more effective when injections are given at bedtime in order to closely approximate the normal physiologic release of GH. Children age 10 and older should be encouraged to participate in their own care by learning how to give themselves the injections under the supervision of an adult to ensure proper dosage and injection technique. Self-injection has been shown to increase children’s self-esteem and to feel some sense of control of their care.
Rationale:
(b) is incorrect because after meals does not closely approximate physiologic release of GH, and the child should be encouraged to give himself the injections.
(c) is incorrect because GH injections are given at bedtime, not before meals, and do not require checking blood glucose before administration.
(d) is incorrect because giving GH in the morning does not closely approximate physiologic nocturnal release of GH.
Question 9.
A 3-day-old neonate with ambiguous genitalia is diagnosed with congenital adrenogenital hyperplasia. Which of the medications does the nurse anticipate administering?
(a) Vitamin D
(b) Cortisone
(c) Stool softeners
(d) Calcium carbonate
Answer:
(b) Cortisone
Explanation:
Congenital adrenogenital hyperplasia is a genetic condition that prevents the adrenal glands from producing certain enzymes involved in the synthesis of cortisol or aldosterone, or both. This affects growth and development in children. The nurse would anticipate administering cortisone due to this hormone deficiency. Additionally, the nurse would anticipate a blood karyotype test in the infant with ambiguous genitalia to establish the chromosomal sex.
Rationale:
(a) is incorrect because vitamin D is not part of congenital adrenogenital hyperplasia treatment. Vitamin D supplementation is encouraged for breastfed newborns who may not receive enough sun exposure to stimulate the body’s own production of vitamin D.
(c) is incorrect because stool softeners are not part of congenital adrenogenital hyperplasia treatment. Stool softeners should be used very cautiously in newborns, as they can lead to diarrhea and dehydration.
(d) is incorrect because calcium carbonate is not part of congenital adrenogenital hyperplasia treatment. In children, calcium carbonate is most often used to treat a calcium deficiency.
Question 10.
The parents of a newborn in the family clinic ask the nurse why the infant needs blood tests. What is the best response by the nurse regarding priority outcomes of mandatory newborn screening for metabolic disorders?
(a) “The tests are performed so we can make appropriate community referrals.”
(b) “This helps us provide education regarding raising a special needs , child.”
(c) “The test assists with early identification of genetically transmitted metabolic diseases.”
(d) “It helps us with early identification of electrolyte imbalances.”
Answer:
(c) “The test assists with early identification of genetically transmitted metabolic diseases.”
Explanation:
Newborns are routinely screened with blood testing for metabolic disorders such as phenylketonuria, congenital hypothyroidism, and congenital adrenal hyperplasia. Infants with these disorders may not show symptoms until it’s too late to provide adequate treatment, thus the need for early detection in mandatory newborn blood screenings.
Rationale:
(a) is incorrect because community referrals are not made until after a specific diagnosis is made.
(b) is incorrect because education is not the primary goal of mandatory screening.
(d) is incorrect because electrolyte imbalances are not metabolic disorders and are not the priority outcome assessed with newborn screening.
Question 11.
The nurse in the pediatric unit is caring for children with metabolic and endocrine disorders. Which of the following endocrine disorders can cause exophthalmos?
(a) Hypothyroidism
(b) Hyperthyroidism
(c) Hypoparathyroidism
(d) Hyperparathyroidism
Rationale
(b) Hyperthyroidism
Explanation:
Exophthalmos is protrusion of the eyeballs, which is sometimes seen with hyperthyroidism. Other more serious causes of exophthalmos in children include acute intracranial hypertension, rhabdomyosarcoma, and neuroblastoma.
Rationale:
(a) is incorrect because hypothyroidism does not cause exophthalmos. Hypothyroidism causes weight gain, fatigue, constipation, and delayed growth in children.
(c) is incorrect because hypoparathyroidism does not cause exophthalmos. Hypoparathyroidism causes imbalances in calcium and phosphorus levels.
(d) is incorrect because hyperparathyroidism does not cause exophthalmos. Hyperparathyroidism causes too much calcium in the blood and a deficiency of calcium in the bones, leading to bone fragility in children, among other vaguer symptoms.
Question 12.
A 3-month-old is admitted to the pediatric intensive care unit for hypertrophic pyloric stenosis after several days of vomiting. Which of the following nursing diagnoses is priority?
(a) Deficient fluid volume related to prolonged vomiting
(b) Ineffective airway clearance related to impaired swallowing
(c) Imbalanced nutrition: less than body requirements related to prolonged vomiting
(d) Anxiety related to loss of body control
Answer:
(a) Deficient fluid volume related to prolonged vomiting
Explanation:
Hypertrophic pyloric stenosis is obstruction of the gastric outlet due to jiypertrophy and hyperplasia of the pylorus, which is the most common cause of vomiting in infants. Dehydration is common in infants with pyloric stenosis, due to the large amount of fluid ingested that does not reach the small intestine for proper absorption. Replacement of fluids and electrolytes is priority.
Rationale:
(b) is incorrect because swallowing is not affected by pyloric stenosis. The infant with acute pyloric stenosis is at risk for aspiration but does not necessarily have the inability to clear the airway.
(c) is incorrect because imbalanced nutrition is an appropriate nursing diagnosis but not a greater priority than fluid status.
(d) is incorrect because infants do not typically experience anxiety related to body control. (Even if infant anxiety was present, this would be a psychosocial concern, which would not be a greater priority than fluid balance, which is a greater physical need.)
Question 13.
The nurse in the family practice clinic is interviewing the mother of an infant who has suspected intussusception. Which of the following questions does the nurse ask to obtain the most useful history?
(a) “Is your child eating normally?”
(b) “How often has your child been vomiting?”
(c) “What do your infant’s stools look like?”
(d) “When did your child last urinate?”
Answer:
(c) “What do your infant’s stools look like?”
Explanation:
Intussusception is invagination of the intestines into adjoining intestinal lumen (usually the ileum into the cecum and colon) which causes bowel obstruction and blocked blood and lymph circulation. It is a medical emergency which requires surgical intervention to repair the defect. Stools commonly look like currant jelly because of mucus, inflammation, and hemorrhage in the bowel. The diagnosis can often be made on assessment of the infant’s behavior and stool alone. Other symptoms include a tender, distended abdomen, the child drawing their knees up to their abdomen, and vomiting. Sometimes a sausage-shaped mass can be palpated in the upper right abdominal quadrant. Intussusception is most commonly seen in children ages 3-months to 3-years.
Rationale:
(a) is incorrect because feeding history is not as relevant to intussusception as stool appearance.
(b) is incorrect because vomiting history is not specific to intussusception.
(d) is incorrect because urination history is not relevant to intussusception.
Question 14.
The healthcare provider has reduced an infant’s hernia and schedules the herniorrhaphy in two days. When the parents ask why the procedure is delayed, what is the best response by the nurse?
(a) “Delaying the procedure ensures proper preparations are made with the surgical team.”
(b) “Delaying the procedure allows swelling and inflammation in the area to subside.”
(c) “Surgery cannot be attempted unless your infant has worn a truss for 48 hours.”
(d) “We must make sure your child has nothing to eat or drink for 8 to 12 hours before the surgeiy.”
Answer:
(b) “Delaying the procedure allows swelling and inflammation in the area to subside.”
Explanation:
Hernia is protrusion of a section of intestine through a weak spot in the „ abdominal wall, and herniorrhaphy is surgical repair of a hernia. Swelling and inflammation occur after reduction of a hernia, and risk of complications decreases when surgery is delayed, allowing time for the inflammation to decrease.
Rationale:
(a) is incorrect because the delay between hernia reduction and repair is not for the purpose of preparation.
(c) is incorrect because the infant does not need to wear a truss.
(d) is incorrect because NPO status in infants is generally required for 3 to 6 hours before surgery, depending on the surgeon’s orders.
Question 15.
The nurse in the family practice clinic is assessing an infant diagnosed with Hirschsprung’s disease. Which of the following does the nurse expect to find?
(a) Scaphoid abdomen
(b) Cyanosis of distal extremities
(c) Hyperactive reflexes
(d) Weight less than normal for height and age
Answer:
(d) Weight less than normal for height and age
Explanation:
Hirschsprung’s disease is a disease of the large intestine that interferes with the passage of stool due to nerve cells in the colon missing at birth. Failure to thrive is common in children with Hirschsprung’s disease, and due to malabsorption of nutrients, children weigh less than normal. Symptoms include failure to pass meconium, refusal to suck, and abdominal distention.
Rationale:
(a) is incorrect because the abdomen is distended in Hirschsprung’s disease.
(b) is incorrect because cyanosis is related to congenital heart disease.
(c) is incorrect because infant hyperreflexia can reflect epilepsy or other central nervous system disorder but is not related to Hirschsprung’s disease.
Question 16.
An 18-lb., 8-month-old infant is admitted to the emergency room for severe diarrhea. Which of the following findings would alert the nurse to notify the healthcare provider?
(a) Hyperactive bowel sounds
(b) Depressed anterior fontanel
(c) 72 mL pale yellow urine over the past four hours
(d) Absence of tenting during skin turgor assessment
Answer:
(b) Depressed anterior fontanel
Explanation:
A depressed anterior fontanel is indicative of infant dehydration, which should be reported to the healthcare provider immediately. Rapid breathing and a weak, rapid pulse are other signs of infant dehydration.
Rationale:
(a) is incorrect because hyperactive bowel sounds are consistent with diarrhea and not a reason to contact the healthcare provider.
(c) is incorrect because 72 mL pale yellow urine is normal for an 8-month- old who weighs 18-lbs. Normal urine output for an infant is 1-3 ml/kg/hr. The converted weight is 8.16 kg, so the expected normal output for this child is 8-25 ml/hr. If the child’s urinary output was less than 8 mL/hr., this would indicate dehydration.
(d) is incorrect because skin tenting is a sign of dehydration. If the nurse notes an absence of skin turgor, this indicates the patient is adequately hydrated and this does not need to be reported to the healthcare provider.
Question 17.
A 3-year-old girl is admitted to the pediatric medical-surgical unit with gastroenteritis. Which of the following interventions does the nurse initiate to prevent the spread of disease?
(a) Observe standard precautions
(b) Administer antibiotics as soon as possible
(c) Send a stool sample to the lab for culture
(d) Provide the patient with eating utensils which can be sterilized
Answer:
(a) Observe standard precautions
Explanation:
Gastroenteritis is irritation and inflammation of the stomach and intestinal lining, which is usually viral and highly contagious. Standard precautions should be used when caring for the child with gastroenteritis.
Rationale:
(b) is incorrect because antibiotics are not generally used for treating gastroenteritis unless a specific bacterial agent has been identified as the cause. Treatment typically includes increased oral fluids, IV fluids if necessary to maintain hydration, and anti-parasitic drugs if the cause is a parasite.
(c) is incorrect because the purpose of sending a stool sample to the lab for culture is to determine the infection-causing agent, not to prevent the spread if the illness.
(d) is incorrect because eating utensils for a patient with gastroenteritis should be disposable.
Question 18.
The nurse is reviewing the medical record of a 3-week-old boy admitted for Hirschsprung’s disease. Which of the following symptoms led the parents to seek care for the infant?
(a) Diaphragmatic pain
(b) Vomiting
(c) Regurgitation
(d) Foul smelling, ribbon-like stool
Answer:
(d) Foul smelling, ribbon-like stool
Explanation:
Hirschsprung’s disease is a disease of the large intestine that interferes with the passage of stool due to nerve cells missing from the colon at birth. Inadequate motility causes mechanical obstruction of the intestine. Chronic constipation, due to the condition, causes foul smelling, ribbon¬like stool.
Rationale:
(a) is incorrect because diaphragmatic pain is not common in Hirschsprung’s disease, and a 3-week-old infant is not able to communicate such specific pain.
(b) is incorrect because vomiting is not a finding in Hirschsprung’s disease.
(c) is incorrect because regurgitation is not a finding in Hirschsprung’s disease.
Question 19.
The nurse is caring for a 3-month-old girl diagnosed with intussusception. When assessing the infant, which of the following does the nurse expect to find?
(a) Watery diarrhea
(b) Ribbon-like stool
(c) Profuse, projectile vomiting
(d) Blood and mucous in stools
Answer:
(d) Blood and mucous in stools
Explanation:
Intussusception is invagination of the intestines into adjoining intestinal lumen which causes bowel obstruction. Symptoms include blood and
mucous in stool, severe cramping and abdominal pain, and currant jelly¬, like stool.
Rationale:
(a) is incorrect because watery diarrhea is not characteristic of intussusception.
(b) is incorrect because ribbon-like stool is not characteristic of intussusception but rather a common finding with Hirschsprung’s disease.
(c) is incorrect because profuse, projectile vomiting is not characteristic of intussusception.
Question 20.
The nurse is teaching the parents of a 2-year-old with a hernia about hernia strangulation signs. The nurse would inform the parents which sign would require notification of the healthcare provider?
(a) Fever
(b) Diarrhea
(c) Vomiting
(d) Foul-smelling stool
Answer:
(c) Vomiting
Explanation:
A hernia is protrusion of a section of the intestine through a weak spot in the abdominal wall. A strangulated hernia is a medical emergency in which the blood supply to the affected area of the intestine is cut off. The nurse would inform the parents of symptoms of a strangulated hernia: vomiting, severe abdominal pain, abdominal distention, and intestinal obstruction, any of which requires notification of the healthcare provider.
Rationale:
(a) is incorrect because fever may require notification of the healthcare provider but is not a sign of strangulation.
(b) is incorrect because diarrhea does not occur with a strangulated hernia.
(d) is incorrect because foul-smelling stool is not consistent with a strangulated hernia.
Question 21.
The nurse is teaching the parents of a child diagnosed with hepatitis A about care and prevention of transmission. Which of the following statements by the parents indicates more education is needed?
(a) “Handwashing is important.”
(b) “We should feed our child a high-fat diet.”
(c) “We will clean contaminated surfaces with bleach.”
(d) “We understand that early treatment with gamma-globulins can help our child.”
Answer:
(b) “We should feed our child a high-fat diet.”
Explanation:
Hepatitis is inflammation of the liver due to viral infection. In order to provide rest for the liver, a low-fat diet should be offered to the child.
Rationale:
(a) is incorrect because handwashing is appropriate with hepatitis A as it is commonly transmitted on the hands after fecal contamination.
(c) is incorrect because cleaning with bleach is appropriate in a home in which a person with hepatitis A is living.
(d) is incorrect because it is a true statement; early treatment with gamma-globulin A post-exposure is beneficial to the patient with hepatitis A.
Question 22.
The nursing student on the pediatric medical unit is learning about phenylketonuria (PKU). The nursing student learns what about PKU?
(a) That it is an autosomal-dominant disorder
(b) That it primarily affects the gastrointestinal system .
(c) Treatment includes restricting tyramine
(d) All states require screening for the disorder
Answer:
(d) All states require screening for the disorder
Explanation:
PKU is an autosomal recessive disorder of metabolism that causes buildup of phenylalanine in the body. Intellectual delay, seizures, behavioral problems, and mental disorders can result if PKU goes untreated. All states require infant screening for PKU.
Rationale:
(a) is incorrect because PKU is an autosomal recessive disorder, which means that both parents carry the gene, even though neither may show symptoms of the condition. In addition to PKU, cystic fibrosis, Tay- Sach’s disease, and sickle cell disease are also autosomal recessive. Autosomal-dominant disorders require only one parent to pass the gene to the offspring. Marfan syndrome, Von Willebrand disease, and Huntington’s disease are autosomal dominant.
(b) is incorrect because PKU affects all body systems.
(c) is incorrect because treatment of PKU includes restriction of phenylalanine, not tyramine.
Question 23.
The nurse in the pediatric emergency room is caring for an 18-month-old who has been experiencing vomiting. The nurse places the toddler in which position for sleep?
(a) Supine
(b) Side-lying
(c) Prone with head elevated
(d) Prone with head turned sideways
Answer:
(b) Side-lying
Explanation:
It is important to maintain the airway and prevent aspiration in a child who is vomiting. Side-lying is the most appropriate position to place the child.
Rationale:
(a) is incorrect because supine increases the risk of aspiration.
(c) is incorrect because prone with head elevated will not prevent aspiration.
(d) is incorrect because prone with head turned sideways will not prevent aspiration.
Question 24.
The nurse is caring for a 2-week-old infant and notes the healthcare provider has recorded a suspected diagnosis of esophageal atresia with tracheoesophageal fistula (TEF). Which of the following statements is appropriate for the nurse to make when discussing care with the infant’s parents?
(a) “The initial TEF treatments are usually successful, and children with this anomaly rarely require surgery.”
(b) “An oral feeding tube can provide your child with nutrition until the TEF has been corrected.”
(c) “Choking with feeding is common with a TEF, so we will monitor closely for aspiration.”
(d) “We will limit fluids through the child’s peripheral IV to prevent fluid volume overload.”
Answer:
(c) “Choking with feeding is common with a TEF, so we will monitor closely for aspiration.”
Explanation:
Tracheoesophageal fistula is a failure of the esophagus to develop as one continuous tube from the back of the pharynx down to the stomach. An
opening can form between the esophagus and trachea, which is marked „ by coughing and choking during feeding and can cause cyanosis.
Rationale:
(a) is incorrect because TEF requires surgical repair.
(b) is incorrect because an oral feeding tube is not used in children with TEF. A gastrostomy tube or parenteral nutrition is used until the TEF is repaired surgically.
(d) is incorrect because babies with TEF generally receive fluids and antibiotics through an umbilical catheter, not a peripheral IV, and fluids need to be maintained, not limited.
Question 25.
The nurse in the neonatal intensive care unit (NICU) is caring for an infant diagnosed with pyloric stenosis. When assessing the infant, which of the following does the nurse expect to find?
(a) Watery diarrhea
(b) Projectile vomiting
(c) Increased urine output
(d) Vomiting large amounts of bile
Answer:
(b) Projectile vomiting
Explanation:
Hypertrophic pyloric stenosis is obstruction of the gastric outlet due to hypertrophy and hyperplasia of the pylorus, which is the most common cause of vomiting in infants. Symptoms include projectile vomiting, irritability, hunger, crying, dehydration, decreased urine output, and constipation.
Rationale:
(a) is incorrect because constipation is associated with pyloric stenosis due to decreased stomach contents moving into the small intestine for absorption.
(c) is incorrect because decreased urine output is associated with pyloric stenosis due to dehydration from decreased water absorption.
(d) is incorrect because non-bilious vomiting is associated with pyloric stenosis.