Pedi Gastro Q&A test 3

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1.

2.

3.

1. A nurse is assessing an infant. Which

of the following are clinical
manifestations of hypertrophic pyloric
stenosis? (Select all that apply.)
A.`Projectile vomiting
B. Dry mucus membranes
C. Currant jelly stools
D. Sausage-shaped abdominal mass
E. Constant hunger

1. A. CORRECT: A client who has a pyloric stricture has thickening of the pyloric
sphincter, resulting in projectile vomiting.
B. CORRECT: A client who has pyloric stricture is unable to consume adequate food and
fluid, resulting in dehydration. Dry mucous membranes is a clinical manifestation of
hypertrophic pyloric stenosis.
C. INCORRECT: A client who has intussusception have bloody mucus stools, resulting in
currant jelly stools.
D. INCORRECT: A client who has intussusception have telescoping intestine, resulting
sausage shaped abdominal mass.
E. CORRECT: A client who has pyloric stricture is unable to consume adequate food and
fluid, resulting in constant hunger.
NCLEX Connection: Physiological Adaptations, Pathophysiology

2. A nurse is caring for a child who has

Hirschsprung disease. Which of the
following is an appropriate action for the
nurse to take?
A. Encourage a high-fiber, low-protein,
low-calorie diet.
B. Prepare the family for surgery.
C. Place an NG for decompression.
D. Initiate bedrest.

2. A. INCORRECT: A client who has Hirschsprung disease is encouraged to eat a lowfiber, high-protein, high-calorie diet.
B. CORRECT: A client who has Hirschsprung disease requires surgery to remove the
affected segment of the intestine. Preparing the family for surgery is an appropriate action
for the nurse to take.
C. INCORRECT: A client who has Hirschsprung disease is managed nutritionally.
Placing an NG for decompression is not an appropriate action for the nurse to take.
D. INCORRECT: A client who has Meckel's diverticulum is placed on bedrest to prevent
further bleeding.
NCLEX Connection: Reduction of Risk Potential, Therapeutic Procedures

The clinic nurse reviews the record of an

infant and notes that the health care
provider has documented a diagnosis of
suspected Hirschsprung's disease. The
nurse reviews the assessment findings
documented in the record, knowing that
which symptom most likely led the
mother to seek health care for the infant?

4. Foul-smelling ribbon-like stools

Rationale:
Hirschsprung's disease is a congenital anomaly also known as congenital aganglionosis
or aganglionic megacolon. It occurs as the result of an absence of ganglion cells in the
rectum and other areas of the affected intestine. Chronic constipation beginning in the
first month of life and resulting in pellet-like or ribbon-like stools that are foul-smelling
is a clinical manifestation of this disorder. Delayed passage or absence of meconium
stool in the neonatal period is also a sign. Bowel obstruction especially in the neonatal
period, abdominal pain and distention, and failure to thrive are also clinical
manifestations. Options 1, 2, and 3 are not associated specifically with this disorder.

1. Diarrhea
2. Projectile vomiting
3. Regurgitation of feedings
4. Foul-smelling ribbon-like stools
4.

A child is hospitalized because of

persistent vomiting. The nurse should
monitor the child closely for which
problem?
1. Diarrhea
2. Metabolic acidosis
3. Metabolic alkalosis
4. Hyperactive bowel sounds

5.

The nurse admits a child to the hospital

with a diagnosis of pyloric stenosis. On
assessment, which data would the nurse
expect to obtain when asking the mother
about the child's symptoms?
1. Watery diarrhea
2. Projectile vomiting
3. Increased urine output
4. Vomiting large amounts of bile

3. Metabolic alkalosis
Rationale:
Vomiting causes the loss of hydrochloric acid and subsequent metabolic alkalosis.
Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of
bicarbonate. Diarrhea might or might not accompany vomiting. Hyperactive bowel
sounds are not associated with vomiting.

2. Projectile vomiting
Rationale:
In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes narrowing
of the pyloric canal between the stomach and the duodenum. Clinical manifestations of
pyloric stenosis include projectile vomiting, irritability, hunger and crying, constipation,
and signs of dehydration including a decrease in urine output.

6.

The nurse is preparing to care for a child with a

diagnosis of intussusception. The nurse reviews
the child's record and expects to note which
symptom of this disorder documented?
1. Watery diarrhea
2. Ribbon-like stools
3. Profuse projectile vomiting
4. Bright red blood and mucus in the stools

7.

A 1-year-old child is diagnosed with

intussusception, and the mother of the child
asks the nurse to describe the disorder. Which
statement is correct about intussusception?
1. "It is an acute bowel obstruction."
2. "It is a condition that causes an acute
inflammatory process in the bowel."
3. "It is a condition in which a distal segment of
the bowel prolapses into a proximal segment of
the bowel."
4. "It is a condition in which a proximal segment
of the bowel prolapses into a distal segment of
the bowel."

8.

A mother brings her 5-week-old infant to the

health care clinic and tells the nurse that the
child has been vomiting after meals. The mother
reports that the vomiting is becoming more
frequent and forceful. The nurse suspects pyloric
stenosis and asks the mother which assessment
question to elicit data specific to this condition?
1. "Are the stools ribbon-like and is the infant
eating poorly?"
2. "Does the infant suddenly become pale, begin
to cry, and draw the legs up to the chest?"
3. "Does the vomit contain sour undigested food
without bile, and is the infant constipated?"
4. "Does the infant cry loudly and continuously
during the evening hours but nurses or takes
formula well?

9.

After hydrostatic reduction for intussusception,

the nurse should expect to observe which client
response?
1. Abdominal distention
2. Currant jelly-like stools
3. Severe colicky-type pain with vomiting
4. Passage of barium or water-soluble contrast
with stools

4. Bright red blood and mucus in the stools

Rationale:
Intussusception is a telescoping of one portion of the bowel into another. The
condition results in an obstruction to the passage of intestinal contents. A child
with intussusception typically has severe abdominal pain that is crampy and
intermittent, causing the child to draw in the knees to the chest. Vomiting may
be present, but is not projectile. Bright red blood and mucus are passed through
the rectum and commonly are described as currant jelly-like stools. Watery
diarrhea and ribbon-like stools are not manifestations of this disorder.
4. "It is a condition in which a proximal segment of the bowel prolapses into a
distal segment of the bowel."
Rationale:
Intussusception occurs when a proximal segment of the bowel prolapses into a
distal segment of the bowel. It is not an acute bowel obstruction, but it is a
common cause in infants and young children. It is not an inflammatory
process.

3. "Does the vomit contain sour undigested food without bile, and is the infant
constipated?"
Rationale:
Option 3 presents classic symptoms of pyloric stenosis. Stools that are ribbonlike and a child who is eating poorly are signs of congenital megacolon
(Hirschsprung's disease). An infant who suddenly becomes pale, cries out, and
draws the legs up to chest is demonstrating physical signs of intussusception.
Crying during the evening hours, appearing to be in pain, eating well, and
gaining weight are clinical manifestations of colic.

4. Passage of barium or water-soluble contrast with stools

Rationale:
Intussusception is the telescoping of one portion of the bowel into another.
Hydrostatic reduction may be necessary to resolve the condition. After
hydrostatic reduction, the nurse observes for the passage of barium or watersoluble contrast material with stools. Options 1 and 2 are clinical indicators of
intussusception. Option 3 is a sign of an unresolved gastrointestinal disorder.

10.

An emergency department nurse is

performing an assessment on a
child with a suspected diagnosis of
intussusception. Which
assessment question for the
parents will elicit the most specific
data related to this disorder?

4. "Can you describe the type of pain that the child is experiencing?"
Rationale:
A report of severe colicky abdominal pain in a healthy, thriving child between 3 and 17 months
of age is the classic presentation of intussusception. Typical behavior includes screaming and
drawing the knees up to the chest. Options 1, 2, and 3 are important aspects of a health history
but are not specific to the diagnosis of intussusception.

1. "Does the child have any food

allergies?"
2. "What do the bowel movements
look like?"
3. "Has the child eaten any food in
the last 24 hours?"
4. "Can you describe the type of
pain that the child is
experiencing?"
11.

A child is diagnosed with

Hirschsprung's disease. The nurse
is teaching the parents about the
cause of the disease. Which
statement, if made by the parent,
supports that teaching was
successful?

1. "Special cells are not present in the rectum, which caused the disease."
Rationale:
Hirschsprung's disease also is known as congenital aganglionosis or megacolon. It results
from the absence of ganglion cells in the rectum and, to various degrees, up into the colon.
Option 2 describes celiac disease. Option 3 describes irritable bowel syndrome. Option 4
describes lactose intolerance.

1. "Special cells are not present in

the rectum, which caused the
disease."
2. "The protein part of wheat,
barley, rye, and oats is not being
digested fully."
3. "The disease occurs from
increased bowel motility that leads
to spasm and pain."
4. "The disease occurs because of
inability to tolerate sugar found in
dairy products."
12.

A child is diagnosed with

intussusception. On performing an
assessment of the child, the nurse
keeps in mind which finding as a
characteristic of this disorder?
1. The presence of fecal
incontinence
2. Incomplete development of the
anus
3. The infrequent and difficult
passage of dry stools
4. Invagination of a section of the
intestine into the distal bowel

4. Invagination of a section of the intestine into the distal bowel

Rationale:
Intussusception is an invagination of a section of the intestine into the distal bowel. It is the
most common cause of bowel obstruction in children aged 3 months to 6 years. The presence
of fecal incontinence describes encopresis. Encopresis generally affects preschool and schoolaged children. Incomplete development of the anus describes imperforate anus, and this
disorder is diagnosed in the neonatal period. The infrequent and difficult passage of dry stools
describes constipation. Constipation can affect any child at any time, although the incidence
peaks at age 2 to 3 years.

13.

The nurse is reviewing the laboratory results for an infant

with suspected hypertrophic pyloric stenosis. What
should the nurse expect to note as the most likely finding
in this infant?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis

14.

The nurse is reviewing the laboratory test results for an

infant suspected of having hypertrophic pyloric stenosis.
The nurse should expect to note which value as the most
likely laboratory finding in this infant?
1. Blood pH of 7.50
2. Blood pH of 7.30
3. Blood bicarbonate of 22 mEq/L
4. Blood bicarbonate of 19 mEq/L

15.

The mother of an infant diagnosed with Hirschsprung's

disease asks the nurse about the disorder. What should
the nurse tell the mother about the disease?
1. It is complete small intestinal obstruction.
2. It is congenital aganglionosis or megacolon.
3. It is severe inflammation of the gastrointestinal tract.
4. It is condition that causes the pyloric valve to remain
open

16.

An infant is seen in the health care provider's office for

complaints of projectile vomiting after feeding. Findings
indicate that the child is fussy and is gaining weight but
seems to never get enough to eat. Pyloric stenosis is
suspected. Which prescription would the nurse
anticipate having the highest priority in the care of this
child?

2. Metabolic alkalosis
Rationale:
Laboratory findings in an infant with hypertropic pyloric stenosis
include metabolic alkalosis as a result of the vomiting that occurs in
this disorder. Additional findings include decreased serum
potassium and sodium levels, increased pH and bicarbonate level,
and decreased chloride level. Options 1, 3, and 4 are incorrect.

1. Blood pH of 7.50
Rationale:
Laboratory findings in an infant with hypertrophic pyloric stenosis
include metabolic alkalosis due to vomiting. These include increased
blood pH and bicarbonate level, decreased serum potassium and
sodium levels, and a decreased chloride level. The normal pH is 7.35
to 7.45. The normal bicarbonate is 22 to 27 mm Hg.

2. It is congenital aganglionosis or megacolon.

Rationale:
Hirschsprung's disease is also known as congenital aganglionosis
or megacolon. It is the result of an absence of ganglion cells in the
rectum and to varying degrees upward in the colon. The remaining
options are incorrect descriptions.

2. Prepare the family for surgery for the child.

Rationale:
Infants with projectile vomiting after feeding that are fussy should be
suspected of pyloric stenosis. The treatment for this diagnosis is
surgery. The other options are treatment measures that may be
prescribed for gastroesophageal reflux.

1. Administer predigested formula.

2. Prepare the family for surgery for the child.
3. Administer omeprazole (Prilosec) before feeding.
4. Instruct the parents to keep a log of feedings and any
reflux present.
17.

A nurse is reviewing the health care provider's

documentation in the record of a child admitted with a
diagnosis of intussusception. The nurse expects to note
that the health care provider has documented which
manifestation?
1. Scleral jaundice
2. Projectile vomiting
3. Currant jelly stools
4. Pale-colored and hard stools

3. Currant jelly stools

Rationale:
In the child with intussusception, bright red blood and mucus are
passed through the rectum, resulting in what is commonly described
as currant jelly stools. The child classically presents with severe
abdominal pain that is crampy and intermittent, causing the child to
draw the knees in to the chest. Vomiting may be present, but not
projectile. Options 1 and 4 are not manifestations of this disorder.

18.

The nurse is collecting data on an infant

with a diagnosis of suspected
Hirschsprung's disease. Which question to
the mother will most specifically elicit
information regarding this disorder?
1. "Does your infant have diarrhea?"
2. "Is your infant constantly vomiting?"
3. "Does your infant constantly spit up
feedings?"
4. "Does your infant have foul-smelling,
ribbon-like stools?"

19.

The nurse is developing a plan of care for

an infant being admitted with
hypertrophic pyloric stenosis who is
scheduled for pyloromyotomy. In the
preoperative period, which position
should the nurse suggest to document in
the plan of care?

4. "Does your infant have foul-smelling, ribbon-like stools?"

Rationale:
Chronic constipation, beginning in the first month of life and resulting in pellet-like
or ribbon stools that are foul-smelling, is a clinical manifestation of Hirschsprung's
disease. Delayed passage or absence of meconium stool in the neonatal period is the
primary sign. Bowel obstruction, especially in the neonatal period, abdominal pain
and distention, and failure to thrive are also clinical manifestations. Options 1, 2, and
3 are not specific clinical manifestations of this disorder.

2. Prone with the head of the bed elevated

Rationale:
In the preoperative period, the infant is positioned prone with the head of the bed
elevated to reduce the risk of aspiration. Options 1, 3, and 4 are inappropriate
positions for preventing this risk.

1. In an infant seat placed in the crib

2. Prone with the head of the bed elevated
3. Supine with the head at a 90-degree
angle
4. Supine with the head of the bed at a 30degree angle
20.

21.

The nurse is caring for a client with a

suspected intestinal obstruction. In what
order would the nurse perform the
abdominal assessment?
1. Auscultate for presence of bowel sounds.
2. Observe the contour of the abdomen.
3. Palpate to determine areas of
tenderness.
4. Percuss to identify solid areas verses air.

Answer: 2,1,4,3
Rationale
Assessment of the abdomen should include inspection first to observe for contour,
symmetry, and any skin abnormalities. Auscultation is the next step. This is done
prior to palpation and percussion to prevent the alteration of bowel sound. Next,
palpation is used to detect any tenderness or rigidity. Finally, percussion is performed
to determine if any fluid, distention, or masses exist. (Lewis, et al, 8 ed., p. 908910.)

An infant is diagnosed with pyloric

stenosis and is admitted for repair. The
mother begins to cry and says, "I guess I
am not a very good mother." What is the
best nursing response?
1. Don't cry your baby is going to be just
fine. 2. This is really a hard time for you,
isnt it? Can I call someone? 3. Have you
talked with the doctor about the cause of
the problem? 4. Tell me, what makes you
feel that you are not a good mother?

Answer: 4
Rationale This option focuses on therapeutic communication: a reflective, clarifying
comment about what the mother has just said and encouragement to describe her
feelings. The question asks for interpretation of mothers comment. The other options
do not encourage expression of feelings, or they are blocks to therapeutic
communication. (Potter, Perry, ed., p. 32.)

22.

A 6weekold infant is
brought by her parent into
the clinic. The parent
explains to the nurse that
after feedings the infant
vomits real strong. The
nurse recognizes the
symptoms of projectile
vomiting. The nurse would
correlate this symptom
with what condition?
1. Tracheoesophageal
fistula
2. Pyloric stenosis
3. Intussusception
4. Volvulus

Answer: 2
Rationale
Vomiting in an infant with pyloric stenosis begins to develop between 4 and 6 weeks of age. The
vomiting grows increasingly forceful until it is projectile, possibly projecting as much as 3 to 4 feet.
Breastfed infants begin developing symptoms at approximately 6 weeks, because the curd of breast milk
is smaller than that of cow's milk, and it passes through a hypertrophied muscle more easily. Symptoms
of volvulus often follow those related to intestinal obstruction and include constipation, colicky
abdominal pain, nausea, and abdominal distention. Symptoms of intussusception are characterized by
sudden, severe abdominal pain vomiting and abdominal distention infant may pass a bloody stool (i.e.,
currant-jelly appearance). Symptoms of tracheoesophageal fistula include choking, coughing, and
intermittent cyanosis during feeding, along with abdominal distention these are diagnosed most often at
birth with the first feeding. (Hockenberry, Wilson, 9 ed., p. 1322.)