NU 171 Maternal Child Nursing Exam 2
Questions with Correct Answers
Differences in the pediatric GI system - ANSWERS-Decreased resistance to bacterial
and viral infections
-Easily dehydrate
-Increased nutritional needs
-Immature hepatic function
Fluid and Electrolyte imbalance - ANSWERS-Dehydration: Excessive loss of body water
--> Mild,Moderate, and severe
-Increased risk: Less than 2 years of age
Nursing Assessment Findings for dehydration and hypovolemia - ANSWERS-
Dehydration: Extremity,color,urine output,BUN and specific gravity,Mucous
membranes,Lethargy,Turgor,Pulse,Fontanels, Tears
-Hypovolemic Shock: Rapid weak pulse,Mottling,Hypotension, Changes in LOC
Dehydration Nursing Care - ANSWERSAssessment: Monitor, Admin fluids either by PO
or IV, Admin IV potassium
Monitor Lab Values: Serum pH; metabolic acidosis vs alkalosis, Electrolytes:
NA,K,Cl,Ca,Mg, Hct levels, BUN levels and specific gravity
Nursing Care: Vomiting - ANSWERS-Hold PO intake
-Electrolyte enriched drink: Infant break feeding; feed through shorter more frequent
sessions
-Appropriate foods and fluids
-Dehydration nursing care
-Administer medications as ordered by PCP: Zofran, Phenergan, make sure the child is
3 or older
Nursing Care: Diarrhea - ANSWERS-Standard precautions/Transmission-based
-Feed through diarrhea episode
-Children complex carbs: Rice,Potatoes,Wheat,bread,lean meats,yogurt,fruits and
vegetables
-Refer to nursing assessment/care for dehydration
-Rehydrate: Fluids to avoid/Fluids to include: -isotonic (the patient has lost = amounts of
fluids and electrolytes)-hypotonic (the child has lost more electrolytes than fluid) -
Hypertonic (The child lost more fluid than electrolytes)
-Brat diet
-Admin antibiotics if needed
-lactose free diet
,-Educate parent: Avoid antidiarrheal medications,Obtain temperature,appropriate foods
and fluids,know when to call, prevent spread of infection
-collect stool specimens
Nursing Care: Vomiting & Diarrhea - ANSWERS-Educate the parents: Avoid OTC
medications, Appropriate foods and fluids, Preventing the spread of infection
When does the parents need to call the HCP when there child is vomiting or has
diarrhea? - ANSWERS-Bile (green) or blood-tinged (red or brown) vomit
-Any episode of forceful vomiting in a newborn or vomiting that continues for more than
a few hours
-If an infant refuses to eat or drink anything for more than a few hours
-Moderate to severe dehydration: dry mouth, no tears while crying, not urinating in 4-
6hrs (babies) 6-8 (older kids)
-Abdominal pain that is severe, even if it comes and goes
-Bloody bowel movements
-Fever higher than 102 once or fever higher than 101 for more than 3 days
-Behavioral changes, including lethargy or decreased responsiveness
Tracheosophogeal Fistula (TEF)/ Esophageal Atresia Detection - ANSWERSA
congenital anomaly in which the trachea & esophagus are connected or fail to seperate
-During pregnancy: Polyhydramnios or gastric bubble noted on the US
-After birth: Feeding problems (3 c's Coughing,choking,cyanosis),Abdominal
distention,Drooling
TEF and esophageal atresia treatment - ANSWERS-Emergency Surgery to be done
immediately in stages for survival
-G~Tube
Pre-operative nursing care for TEF and esophageal atresia treatment - ANSWERS-
Feeding status prior to surgery
-Removal of secretions
-Positioning for drainage of secretions prior to surgery
-Monitor:For respiratory distress and provide O2 as needed
imperforate anus - ANSWERS-The lower end of GI tract and anus cogentially
malformed
-Nursing Diagnosis: Confirmed by x-ray or MRI
-Treatment: Colostomy,surgery
Imperforate Anus Pre-op Care - ANSWERS-assess appearance of anus;lack of
muscular anus
-Failure of; meconium stool
-Assessment; ( a wink and a stink)
-IVFs
-Feeding status;NPO
, pyloric stenosis - ANSWERS-Narrowing pyloric sphincter (lower end of the stomach)
-Pyloric muscles enlarges
-Prevents stomach from emptying properly may lead to obstruction
-2-->3 weeks old
-First born males
-Genetic predisposition
-Diagnosis
Pyloric stenosis s/s, nursing diagnosis, treatment - ANSWERS-S&S: Projectile
vomiting,weight loss,possible mass,peristaltic
waves,hunger,dehydration,alkalosis,electrolyte loss.
-Nursing Diagnosis: Risk for fluid volume deficit, altered nutrition,risk for injury
-Diagnosis: Ultrasound
-Medical treatment: Pyloromyotomy
Pyloromyotomy: Nursing Care
pre-op and Post-op - ANSWERSPre-op:
-Assess/monitor
-Feedings
-Daily weight
- I & O's
-Electrolytes/Labs
-Replace electrolytes/fluids as ordered
Post-op:
-Increase feeds slowly glucose water at beginning and add formula/breast milk until
feeds 2-3 days later
-Proper positioning: fowlers and on the right side
-Incision site care:REEDA
-Monitor hydration status --> daily weights, I & O's, fontanelles, mucous membranes,
skin turgor
-Pain management
REEDA - ANSWERSredness, edema, ecchymosis, drainage, approximation
Celiac disease/Pathophysiology - ANSWERS-Disease of small intestines
-Can not tolerate foods with gluten or protein portions of: Barley,Rye,Oats, or Wheat
flour
-Leads to malabsorption problems
-Possible allergies
-Appears 6mo-2 years
Celiac disease: Diagnostic Tests/Nursing Assessment - ANSWERS-Diagnostic Tests:
Serum IGA, Small bowel biopsy, Sweat chloride test to rule out cystic fibrosis
-Assessment/S&S: Distended abdomen,Small buttocks, steatorrhea, inability to absorb
nutrients--FTT
Questions with Correct Answers
Differences in the pediatric GI system - ANSWERS-Decreased resistance to bacterial
and viral infections
-Easily dehydrate
-Increased nutritional needs
-Immature hepatic function
Fluid and Electrolyte imbalance - ANSWERS-Dehydration: Excessive loss of body water
--> Mild,Moderate, and severe
-Increased risk: Less than 2 years of age
Nursing Assessment Findings for dehydration and hypovolemia - ANSWERS-
Dehydration: Extremity,color,urine output,BUN and specific gravity,Mucous
membranes,Lethargy,Turgor,Pulse,Fontanels, Tears
-Hypovolemic Shock: Rapid weak pulse,Mottling,Hypotension, Changes in LOC
Dehydration Nursing Care - ANSWERSAssessment: Monitor, Admin fluids either by PO
or IV, Admin IV potassium
Monitor Lab Values: Serum pH; metabolic acidosis vs alkalosis, Electrolytes:
NA,K,Cl,Ca,Mg, Hct levels, BUN levels and specific gravity
Nursing Care: Vomiting - ANSWERS-Hold PO intake
-Electrolyte enriched drink: Infant break feeding; feed through shorter more frequent
sessions
-Appropriate foods and fluids
-Dehydration nursing care
-Administer medications as ordered by PCP: Zofran, Phenergan, make sure the child is
3 or older
Nursing Care: Diarrhea - ANSWERS-Standard precautions/Transmission-based
-Feed through diarrhea episode
-Children complex carbs: Rice,Potatoes,Wheat,bread,lean meats,yogurt,fruits and
vegetables
-Refer to nursing assessment/care for dehydration
-Rehydrate: Fluids to avoid/Fluids to include: -isotonic (the patient has lost = amounts of
fluids and electrolytes)-hypotonic (the child has lost more electrolytes than fluid) -
Hypertonic (The child lost more fluid than electrolytes)
-Brat diet
-Admin antibiotics if needed
-lactose free diet
,-Educate parent: Avoid antidiarrheal medications,Obtain temperature,appropriate foods
and fluids,know when to call, prevent spread of infection
-collect stool specimens
Nursing Care: Vomiting & Diarrhea - ANSWERS-Educate the parents: Avoid OTC
medications, Appropriate foods and fluids, Preventing the spread of infection
When does the parents need to call the HCP when there child is vomiting or has
diarrhea? - ANSWERS-Bile (green) or blood-tinged (red or brown) vomit
-Any episode of forceful vomiting in a newborn or vomiting that continues for more than
a few hours
-If an infant refuses to eat or drink anything for more than a few hours
-Moderate to severe dehydration: dry mouth, no tears while crying, not urinating in 4-
6hrs (babies) 6-8 (older kids)
-Abdominal pain that is severe, even if it comes and goes
-Bloody bowel movements
-Fever higher than 102 once or fever higher than 101 for more than 3 days
-Behavioral changes, including lethargy or decreased responsiveness
Tracheosophogeal Fistula (TEF)/ Esophageal Atresia Detection - ANSWERSA
congenital anomaly in which the trachea & esophagus are connected or fail to seperate
-During pregnancy: Polyhydramnios or gastric bubble noted on the US
-After birth: Feeding problems (3 c's Coughing,choking,cyanosis),Abdominal
distention,Drooling
TEF and esophageal atresia treatment - ANSWERS-Emergency Surgery to be done
immediately in stages for survival
-G~Tube
Pre-operative nursing care for TEF and esophageal atresia treatment - ANSWERS-
Feeding status prior to surgery
-Removal of secretions
-Positioning for drainage of secretions prior to surgery
-Monitor:For respiratory distress and provide O2 as needed
imperforate anus - ANSWERS-The lower end of GI tract and anus cogentially
malformed
-Nursing Diagnosis: Confirmed by x-ray or MRI
-Treatment: Colostomy,surgery
Imperforate Anus Pre-op Care - ANSWERS-assess appearance of anus;lack of
muscular anus
-Failure of; meconium stool
-Assessment; ( a wink and a stink)
-IVFs
-Feeding status;NPO
, pyloric stenosis - ANSWERS-Narrowing pyloric sphincter (lower end of the stomach)
-Pyloric muscles enlarges
-Prevents stomach from emptying properly may lead to obstruction
-2-->3 weeks old
-First born males
-Genetic predisposition
-Diagnosis
Pyloric stenosis s/s, nursing diagnosis, treatment - ANSWERS-S&S: Projectile
vomiting,weight loss,possible mass,peristaltic
waves,hunger,dehydration,alkalosis,electrolyte loss.
-Nursing Diagnosis: Risk for fluid volume deficit, altered nutrition,risk for injury
-Diagnosis: Ultrasound
-Medical treatment: Pyloromyotomy
Pyloromyotomy: Nursing Care
pre-op and Post-op - ANSWERSPre-op:
-Assess/monitor
-Feedings
-Daily weight
- I & O's
-Electrolytes/Labs
-Replace electrolytes/fluids as ordered
Post-op:
-Increase feeds slowly glucose water at beginning and add formula/breast milk until
feeds 2-3 days later
-Proper positioning: fowlers and on the right side
-Incision site care:REEDA
-Monitor hydration status --> daily weights, I & O's, fontanelles, mucous membranes,
skin turgor
-Pain management
REEDA - ANSWERSredness, edema, ecchymosis, drainage, approximation
Celiac disease/Pathophysiology - ANSWERS-Disease of small intestines
-Can not tolerate foods with gluten or protein portions of: Barley,Rye,Oats, or Wheat
flour
-Leads to malabsorption problems
-Possible allergies
-Appears 6mo-2 years
Celiac disease: Diagnostic Tests/Nursing Assessment - ANSWERS-Diagnostic Tests:
Serum IGA, Small bowel biopsy, Sweat chloride test to rule out cystic fibrosis
-Assessment/S&S: Distended abdomen,Small buttocks, steatorrhea, inability to absorb
nutrients--FTT
