Therefore, this child probably has a good chance of being potty trained and will not need to wear protective pads. Extra fl uids and a high-fi ber diet are not required to prevent constipation. Children with high anorectal anomalies may or may not achieve continence.
CN: Physiological adaptation;
CL: Evaluate
20.
3. After surgical repair for an imperforate anus, the infant should be positioned either supine with the legs suspended at a 90-degree angle or on either side with the hips elevated to prevent pres- sure on the perineum. A neonate who is placed on the abdomen pulls the legs up under the body, which puts tension on the perineum, as does positioning the neonate on the back with the legs extended straight out.CN: Physiological adaptation;
CL: Synthesize
21.
3. The neonate responds to pain with total body movement and brief, loud crying that ceases with distraction. After age 6 months, an infant reacts to pain with intense physical resistance and tries to escape by rolling away. A toddler reacts to pain by withdrawing the affected part.CN: Health promotion and maintenance;
CL: Apply
22.
2. Encouraging the parents to hold their neonate promotes parent–infant attachment. Parent–infant bonding is based on a relationship that begins when the parent fi rst touches the infant. Both the parents and the infant have predictable steps that they go through in this process. Explaining that the parents can visit at any time promotes bonding only if they do visit with, talk to, and hold the newborn.
Asking the parents to help monitor intake and output at this time may be too anxiety-producing, thus interfering with bonding. Helping the parents plan for the infant’s discharge involves them in the newborn’s care and is important. However, it is not the fi rst step in the development of bonding.
CN: Psychosocial adaptation;
CL: Synthesize
The Client with Pyloric Stenosis
23.
3. The vomitus of an infant with hypertro- phic pyloric stenosis contains gastric contents, mucus, and streaks of blood. The vomitus does not contain bile or stool because the pyloric constriction is proximal to the ampulla of Vater.CN: Physiological adaptation;
CL: Analyze
15.
4. When initiating oral feedings after surgical repair of a TEF, it is best to follow a plan of care in conjunction with observation of the infant’s needs and behavior. When the infant’s needs and behavior are overlooked, plans are likely to be unsatisfactory and are more likely to meet the nurse’s needs rather than the infant’s needs. After a surgical procedure, infants initially tolerate small amounts of fl uids offered more frequently better than larger amounts offered less often. Smaller amounts cause less bloat- ing as the infant becomes used to feeding again.Although infants accept feedings more readily from their mother or from someone who feeds the infant repeatedly, the priority is to meet the infant’s nutri- tional needs based on the infant’s behavior.
CN: Basic care and comfort; CL: Create
28.
2. For the client with a nursing diagnosis of Defi cient fl uid volume related to vomiting, the outcome would focus on restoration of fl uid bal- ance. Typically, the nurse would evaluate the client for evidence of dehydration. Parameters would include assessment of the client’s weight for loss or decreased skin turgor. Abdominal distention is caused by the stenosis and is not relieved until the child has surgery. The child may have increased respiratory effort due to abdominal distention; how- ever, to evaluate the outcome related to fl uid defi cit, the nurse should weigh the infant. The nurse should record the amount of emesis, but evaluation of the outcome is accomplished by weighing the infant.CN: Physiological adaptation;
CL: Evaluate
29.
4. Restating or rephrasing a mother’s response provides the opportunity for clarifi ca- tion and validation. It also helps to focus on what the mother is saying and address her concerns and feelings. Although surgery is the most effective treatment for pyloric stenosis, stating this ignores the mother’s feelings and does not give her an opportunity to express them. Telling the mother not to worry also ignores the mother’s feelings. Addi- tionally, this type of statement gives the mother premature reassurance, which may turn out to be false. Asking the mother if she thinks the problem indicates that she is not a good mother implies such an idea. It does not allow her to express her con- cerns and feelings and therefore is not a therapeutic response.CN: Psychosocial adaptation;
CL: Synthesize
30.
1. Clear liquids containing glucose and electrolytes are usually prescribed 4 to 6 hours after surgery. If vomiting does not occur, formula or breast milk then can be gradually substituted for clear liquids until the infant is taking normal feedings.CN: Physiological adaptation;
CL: Evaluate
31.
4. Giving the infant a pacifi er would help meet non-nutritive sucking needs and ensure oral gratifi cation. Additionally, sucking aids in calming the infant. Holding the infant to decrease fussiness and restlessness is more effective in an older infant.Also, the reason for the infant’s fussiness needs to be explored. Hanging a mobile over the crib frequently does not decrease fussiness. After surgery to correct pyloric stenosis, feeding the infant more formula would lead to vomiting, putting additional stress on the operative site.
CN: Reduction of risk potential;
CL: Synthesize
24.
1. Infants with pyloric stenosis usually have some degree of dehydration because of vomiting of the stomach contents. Therefore, a priority nursing diagnosis would be Defi cient fl uid volume related to prolonged vomiting. A nursing priority would be to restore fl uid and electrolyte balance. Pyloric stenosis involves the pyloric valve distal to the stomach, not the respiratory tract. In addition, swallowing is not impaired with pyloric stenosis. Even though vomit- ing occurs, a normal infant should be able to protect the airway. Therefore, Ineffective airway clearance would be inappropriate. Imbalanced nutrition: Less than body requirements could be applicable but would not be the priority diagnosis. Bowel inconti- nence and abdominal pain are not typically associ- ated with pyloric stenosis.CN: Physiological adaptation;
CL: Analyze
25.
1. Unless the infant is in hypovolemic shock, obtaining a baseline weight is an important fi rst action because the weight is used to calculate the child’s fl uid and electrolyte needs. The intravenous fl uid rate and the amounts of electrolytes to be added to the fl uid are based on the infant’s weight.The weight also helps determine the infant’s degree of dehydration. The intravenous infusion is initiated once the weight has been obtained. The child with pyloric stenosis typically experiences vomiting and is at risk for fl uid volume defi cit and metabolic aci- dosis. As a result, oral food and fl uids are withheld and the infant is allowed nothing by mouth. Fluid replacement is given intravenously. Orientation can wait until treatment is under way.
CN: Physiological adaptation;
CL: Synthesize
26.
1. Pyloric stenosis involves hypertrophy of the pylorus muscle distal to the stomach and obstruction of the gastric outlet resulting in vom- iting, metabolic acidosis, and dehydration. Tele- scoping of the bowel is called intussusception.Overfeeding, feeding too quickly, or underfeeding is not associated with pyloric stenosis.
CN: Physiological adaptation;
CL: Evaluate
27.
3. Normal serum potassium levels are 3.5 to 4.5 Meq/L. Elevated potassium levels can cause life threatening cardiac arrhythmias. The nurse must verify that the client has the ability to clear potas- sium through urination before administering the drug.Infants with pyloric stenosis frequently have low potas- sium levels due to vomiting. A level of 3.4 Meq/L is not unexpected and should be corrected with the ordered fl uids. The lab value does not need to be redrawn as the fi ndings are consistent with the infant’s condition.
CN: Pharmacological and parenteral therapies; CL: Synthesize
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36.
1. The fi rst action is to check the placement of the tube to ensure that it is in the correct position.To check tube position, the nurse should aspirate the tube with a syringe. A return of gastric contents indicates that the end of the tube is in the stomach.
Another method is to inject a small amount of air while auscultating with a stethoscope over the epi- gastric area. The tube is irrigated with normal saline, not distilled water, and only after the position of the tube is confi rmed. The suction level should not be increased, because doing so could damage the mucosa. Rotating the tube could irritate or trauma- tize the nasal mucosa.
CN: Reduction of risk potential;
CL: Synthesize
37.
2. Development of a paralytic ileus postop- eratively is a functional obstruction of the bowel.Bowel sounds initially may be hyperactive, but then they diminish and cease. Measurement of urine spe- cifi c gravity provides information about fl uid and electrolyte status. The fi rst stool and the amount of gastric output provide information about the return of gastric function.
CN: Physiological adaptation;
CL: Analyze
38.
1. Infants who have had an interruption in their normal routine and experiences, such as hos- pitalization and surgery, typically manifest behav- ior changes when discharged. The infant’s normal routine has been signifi cantly altered, so it will take time to reestablish another routine. Calorie require- ments at home will continue to be the same as those in the hospital. The infant does not need more calo- ries at home. The surgical procedure corrected the problems, so the infant should not continue to have abdominal cramping.CN: Physiological adaptation; CL: Create
The Client with Inguinal Hernia
39.
1. Abdominal distention and a redness of the inguinal swelling are signifi cant fi ndings. Their presence in conjunction with area tenderness and inability to reduce the hernia indicate an incarcer- ated hernia. An incarcerated hernia can lead to strangulation, necrosis, and gangrene of the bowel.Other fi ndings associated with strangulation include irritability, anorexia, and diffi culty in defecation.
Irritability is nonspecifi c and could be caused by various factors. A palpable, thickened spermatic cord on the affected side is diagnostic of inguinal hernia and would be an expected fi nding. A wet dia- per indicates that urine is being excreted, a fi nding unrelated to inguinal hernia.
CN: Physiological adaptation;
CL: Analyze
32.
2. The parents’ ability to verbalize the infant’s care realistically indicates that they are working through their fears and concerns. This behavior demonstrates an understanding of the infant’s condition and needs. Without further data, the fact that the parents have to get away could be interpreted as ineffective coping, possibly suggest- ing that they are unable to handle the situation. Con- tinuing to ask about the child’s general condition even after answers have been given does not suggest effective coping. The parents are demonstrating that they are unsure of themselves as parents or are hoping for positive information. Exhibiting fear that they will disturb the infant does not suggest effec- tive coping. This behavior indicates that they are uncertain or lack knowledge about infants.CN: Psychosocial adaptation;
CL: Analyze
33.
4. Following pyloromyotomy the infant should be positioned with the head elevated and slightly on the right side to promote gastric emptying;the parents have positioned their infant correctly. The infant should be positioned on the right side, not the left side. When the child is in a crib, the head can be elevated and the infant can be propped on the right side. The infant can use a pacifi er if needed.
CN: Physiological adaptation;
CL: Evaluate
The Client with Intussusception
34.
2. The infant with intussusception experi- ences acute episodes of colic-like abdominal pain.Typically, the infant screams and draws the knees to the chest. Between these episodes of acute abdomi- nal pain, the infant appears comfortable and normal.
Feeding does not precipitate episodes of pain. Addi- tionally, a 4-month-old infant typically would not be ingesting solid foods. Pain exhibited by crying that occurs when the infant is placed in a reclining position, as in the mother’s arms, is not associated with intussusception. This type of cry may indicate that the infant wants attention, wants to be held, or needs to have a diaper change.
CN: Physiological adaptation;
CL: Analyze
35.
1. For the infant with intussusception, stools characteristically have the appearance of currant jelly because of the intestinal infl ammation and hemorrhage resulting from intestinal obstruction.These stools occur later in the course of the disease process. Questions that focus on urination, vomit- ing, and food intake do not elicit information about the effects of intussusception.
CN: Physiological adaptation;
CL: Analyze
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44.
3. Because of possible stress on the suture line, physical activities such as bicycle riding, phys- ical education classes, weight-lifting, and wrestling are contraindicated for about 3 weeks.CN: Basic care and comfort; CL: Evaluate
The Client with Hirschsprung’s Disease
45.
2. Infants with Hirschsprung’s disease typi- cally display failure to thrive, with poor weight gain due to malabsorption of nutrients. Therefore, the nurse would expect to see a child who weighs less than that which is expected for height and age.A distended, rather than a scaphoid-shaped, abdo- men would be noted. Cyanosis of fi ngers and toes is associated with congenital heart disease. Hyperac- tive deep tendon refl exes are associated with upper motor neuron problems, such as cerebral palsy.
CN: Physiological adaptation;
CL: Analyze
46.
3. By encouraging parents to ask questions during information-sharing sessions, the nurse can clarify misconceptions and determine the parents’understanding of information. A better understand- ing of what is happening allows the parents to feel some control over the situation. Assessing the ade- quacy of the parents’ coping skills is important but secondary to encouraging them to express their con- cerns. The questions they ask and their interactions with the nurse may provide clues to the adequacy of their coping skills. The nurse should never give false reassurance to parents. At this point, there is no way for the nurse to know whether the child will be fi ne. Written materials are appropriate for aug- menting the nurse’s verbal communication. How- ever, these are secondary to encouraging questions.
CN: Psychosocial adaptation;
CL: Synthesize
47.
3. The primary defect in Hirschsprung’s disease is an absence of autonomic parasympathetic ganglion cells in the distal portion of the colon.Thus, the nerves at the end of the large colon are missing. Absence of a rectal opening refers to an imperforate anus. A tube between the trachea and esophagus refers to a tracheoesophageal fi stula.
Presence of a tight muscle below the stomach refers to pyloric stenosis.
CN: Physiological adaptation;
CL: Evaluate
48.
3. Before intestinal surgery, dietary intake is limited to clear liquids for 24 to 48 hours. A clear liquid diet meets the child’s fl uid needs and avoids the formation of fecal material in the intestine.40.
3. If nonoperative reduction is successful, delaying surgery for 2 to 3 days allows the edema and infl ammation in the inguinal area to subside.Thus, the area to be operated will appear more nor- mal, helping to decrease the risk of complications.
The preoperative preparation for a herniorrhaphy is minimal and is not the reason for delaying the surgery. Typically, the infant is fed until a few hours before surgery to prevent dehydration. Trusses do not prevent incarceration, and there is no reason to use a truss preoperatively.
CN: Physiological adaptation; CL: Apply
41.
2. The best way to prepare a 7-month-old infant psychologically for surgery is to have the pri- mary caretaker stay with the child. Infants in the sec- ond 6 months of life commonly develop separation anxiety. Therefore, the priority in this case is to sup- port the child by having the parent present. Teaching the mother what to expect may decrease her anxiety;this is important because infants sense anxiety and distress in parents, but the priority in this case is to have the parent present. Actual play and acting out life experiences are appropriate for preschool-age children. Allowing an infant to play with surgical equipment would be inappropriate and dangerous.
CN: Psychosocial adaptation;
CL: Synthesize
42.
1. Changing a diaper as soon as it becomes soiled helps prevent wound infection, the most common complication after inguinal hernia repair in an infant secondary to possible wound contami- nation with urine and stool. Because the surgical wound is unlikely to separate, an abdominal binder is unnecessary. The incision may or may not be covered with a dressing. If a dressing is not used, the physician may apply a topical spray to protect the wound. Restraining the infant’s hands is unnec- essary if the diaper is applied snugly. The infant would be unable to get the hands into the diaper close to the surgical site.CN: Safety and infection control;
CL: Create
43.
3. The incision must be kept as clean and dry as possible. Therefore, daily sponge baths are given for about 1 week postoperatively. Cleaning the infant’s face and diaper area should occur at least daily and continuously, not limited to a 2-week period. Because this type of surgery results in a wound that heals through primary intention, the skin will heal and cover the wound in 2 to 3 days.Therefore, it is not necessary to use sterile gauze to cleanse the incision; clean technique is acceptable.
Because the incision must be kept as clean and dry, full tub baths are inappropriate.
CN: Reduction of risk potential;
CL: Synthesize
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bulk in the stool. Fat is necessary for brain growth in the fi rst year of life. A high-residue diet would result in bulkier stools and increased gas production, which will collect in the colostomy bag. Therefore, a high-residue diet is not indicated.
CN: Basic care and comfort; CL: Apply
53.
2. Toilet-training is commonly more diffi cult for children who have undergone surgery for Hirschsprung’s disease than it is for other children.This is because of the trauma to the area and the associated psychological implications. Abdominal distention is an early sign of infection and therefore the parents need to report it to the physician. Typi- cally, dietary restrictions are not required. Usually the infant is placed on an age-appropriate diet. Vita- min supplementation is not necessary if the infant’s dietary intake is adequate.
CN: Physiological adaptation;
CL: Evaluate