GASTROINTESTINAL DISORDERS OF
THE CHILD NCLEX TEST QUESTIONS
WITH CORRECT DETAILED ANSWERS
A mother and 7 month old infant present to the pediatric clinic. The infant appears
developmentally appropriate and healthy, but the mother tells you that she is
exacerbated. She says yesterday her infant had been incessantly crying with vomiting
and jelly-like stool. But now is fine. What is the nurse's first action?
A) Determine prenatal status of the mother and child
B) Prepare the child for immediate surgery
C) Palpate the stomach for a mass
D) Administer barium enema - Answer-Answer: C. Page 725. ADPIE. The nurse would
further assess the child. The nurse suspects this child to possibly have intussusception.
A "sausage-like" mass in the upper mid-abdomen is a hallmark sign of intussusception.
It may not be present at this time, but it would be important to assess for this finding. A
barium enema is often used to treat this disorder. Surgery can also be used. The
prenatal status of the mother/child would not be a priority assessment.
You are the awesome nursing teacher with a huge class of 80 students. Yikes. Anyway,
in pediatric clinical, you ask the students to differentiate omphalocele and gastroschisis.
Which statement, if made by a student, indicates that they were smart and knew the
right answer?
A) The contents of the omphacele contain organs such as the bladder and uterus while
gastroschisis contains pieces of the digestive tract
B) With omphacele, the organs are covered with a protective sheath while with
gastroschisis the organs protruding from the abdomen are exposed completely.
C) In gastroschisis, parts of the intestines protrude through in a sac from the umbilicus
while in omphacele, they can protrude from anywhere in the abdominal wall.
D) Both disorders consist of portions of the digestive tract protruding out of a
dysfunctional abdominal wall, gastroschisis also contains portions of the biliary tract -
Answer-Answer: B. See page 711.
When planning care for the infant diagnosed with cleft lip and palate, which action would
the nurse take in relation to the priority nursing diagnosis for this child?
A) Prevent the baby from vigorously crying
B) Burp the baby well throughout feedings
C) Temporarily refrain from having the baby breastfeed
D) Encourage mother to use false palate covering when feeding baby - Answer-Answer:
D. A false palate covering will help prevent the baby from aspirating while breastfeeding
by providing a covering for the cleft palate. Adaptive nipples can also be used for this
purpose. Burping the baby would be important to include in the plan of care, but would
not be for the priority nursing diagnosis of risk for aspiration. It would not be necessary
, to have the baby refrain from breastfeeding. Preventing the baby from vigorously crying
would be important postoperatively to prevent sutures from ripping.
The nurse is caring for the child with cleft lip and palate. Which of the following does the
nurse understand as a complication of this disorder? Select all that apply:
A) Heart malformation
B) Otitis media
C) Altered dentation
D) Speech impediments
E) Encopresis - Answer-Answer: B, C, and D. These are complications that can occur
with cleft lip and palate. Others include feeding difficulties, aspiration, and hearing loss
(related to ear infections). Page 707.
You are taking care of an infant who has come back from having cleft lip and palate
repair. The nurse would include all of the following in the plan of care except:
A) Use of pacifier to prevent vigorous crying
B) Holding, cuddling and rocking of infant
C) Arm restraints or mummy restraint
D) Placing infant in the supine position - Answer-Answer: A. It would be important to
protect the palate operative site by avoiding putting items in the mouth that might disrupt
the sutures such as suction catheters, spoons, straws, pacifiers, or plastic syringes. It
would be important to keep the infant from rubbing the surgical sight. To prevent this the
infant will be placed in the supine or side-lying position and arm restraints are often
used. Holding, cuddling and rocking the infant can help soothe and comfort the infant
after surgery.
The nurse understands that the young child is at a greater risk of developing fluid loss
than an adult because of which of the following? Select all that apply:
A) Greater body surface area
B) Thinner skin
C) Renal immaturity
D) Higher likelihood of febrile illness
E) Higher basic metabolic rate - Answer-Answer: A, C, D, and E. (pages 695-696)
A pediatric nurse is assessing a 2-month-old child who has been vomiting for the past
48 hours with accompanying fever of 100.7. The nurse recognizes that which of the
following does not represent dehydration in an infant?
1) 3-5 wet diapers a day for the past 2 days
2) Lack of tears when crying
3) Puffiness of the skin
4) Pale oral mucosa - Answer-Answer: 3)
Tenting of the skin may be seen in a child who is dehydrated. The oral mucosa should
be pink and moist, tears should be present when the 2-month-old cries, and a 2-month-
old should produce 6-8 wet diapers daily.
THE CHILD NCLEX TEST QUESTIONS
WITH CORRECT DETAILED ANSWERS
A mother and 7 month old infant present to the pediatric clinic. The infant appears
developmentally appropriate and healthy, but the mother tells you that she is
exacerbated. She says yesterday her infant had been incessantly crying with vomiting
and jelly-like stool. But now is fine. What is the nurse's first action?
A) Determine prenatal status of the mother and child
B) Prepare the child for immediate surgery
C) Palpate the stomach for a mass
D) Administer barium enema - Answer-Answer: C. Page 725. ADPIE. The nurse would
further assess the child. The nurse suspects this child to possibly have intussusception.
A "sausage-like" mass in the upper mid-abdomen is a hallmark sign of intussusception.
It may not be present at this time, but it would be important to assess for this finding. A
barium enema is often used to treat this disorder. Surgery can also be used. The
prenatal status of the mother/child would not be a priority assessment.
You are the awesome nursing teacher with a huge class of 80 students. Yikes. Anyway,
in pediatric clinical, you ask the students to differentiate omphalocele and gastroschisis.
Which statement, if made by a student, indicates that they were smart and knew the
right answer?
A) The contents of the omphacele contain organs such as the bladder and uterus while
gastroschisis contains pieces of the digestive tract
B) With omphacele, the organs are covered with a protective sheath while with
gastroschisis the organs protruding from the abdomen are exposed completely.
C) In gastroschisis, parts of the intestines protrude through in a sac from the umbilicus
while in omphacele, they can protrude from anywhere in the abdominal wall.
D) Both disorders consist of portions of the digestive tract protruding out of a
dysfunctional abdominal wall, gastroschisis also contains portions of the biliary tract -
Answer-Answer: B. See page 711.
When planning care for the infant diagnosed with cleft lip and palate, which action would
the nurse take in relation to the priority nursing diagnosis for this child?
A) Prevent the baby from vigorously crying
B) Burp the baby well throughout feedings
C) Temporarily refrain from having the baby breastfeed
D) Encourage mother to use false palate covering when feeding baby - Answer-Answer:
D. A false palate covering will help prevent the baby from aspirating while breastfeeding
by providing a covering for the cleft palate. Adaptive nipples can also be used for this
purpose. Burping the baby would be important to include in the plan of care, but would
not be for the priority nursing diagnosis of risk for aspiration. It would not be necessary
, to have the baby refrain from breastfeeding. Preventing the baby from vigorously crying
would be important postoperatively to prevent sutures from ripping.
The nurse is caring for the child with cleft lip and palate. Which of the following does the
nurse understand as a complication of this disorder? Select all that apply:
A) Heart malformation
B) Otitis media
C) Altered dentation
D) Speech impediments
E) Encopresis - Answer-Answer: B, C, and D. These are complications that can occur
with cleft lip and palate. Others include feeding difficulties, aspiration, and hearing loss
(related to ear infections). Page 707.
You are taking care of an infant who has come back from having cleft lip and palate
repair. The nurse would include all of the following in the plan of care except:
A) Use of pacifier to prevent vigorous crying
B) Holding, cuddling and rocking of infant
C) Arm restraints or mummy restraint
D) Placing infant in the supine position - Answer-Answer: A. It would be important to
protect the palate operative site by avoiding putting items in the mouth that might disrupt
the sutures such as suction catheters, spoons, straws, pacifiers, or plastic syringes. It
would be important to keep the infant from rubbing the surgical sight. To prevent this the
infant will be placed in the supine or side-lying position and arm restraints are often
used. Holding, cuddling and rocking the infant can help soothe and comfort the infant
after surgery.
The nurse understands that the young child is at a greater risk of developing fluid loss
than an adult because of which of the following? Select all that apply:
A) Greater body surface area
B) Thinner skin
C) Renal immaturity
D) Higher likelihood of febrile illness
E) Higher basic metabolic rate - Answer-Answer: A, C, D, and E. (pages 695-696)
A pediatric nurse is assessing a 2-month-old child who has been vomiting for the past
48 hours with accompanying fever of 100.7. The nurse recognizes that which of the
following does not represent dehydration in an infant?
1) 3-5 wet diapers a day for the past 2 days
2) Lack of tears when crying
3) Puffiness of the skin
4) Pale oral mucosa - Answer-Answer: 3)
Tenting of the skin may be seen in a child who is dehydrated. The oral mucosa should
be pink and moist, tears should be present when the 2-month-old cries, and a 2-month-
old should produce 6-8 wet diapers daily.
