Chapter 43: The Child with a
Gastrointestinal Alteration McKinney:
Evolve Resources for Maternal-Child
Nursing, 5th Edition Test Bank
Questions with Complete Answers.
What is the best response by the nurse to a mother asking about the cause of her infant's
bilateral cleft lip?
a. "Did you use alcohol during your pregnancy?"
b. "Does anyone in your family have a cleft lip or palate?"
c. "This defect is associated with intrauterine infection during the second trimester."
d. "The prevalent of cleft lip is higher in Caucasians." - Answer ANS: B
Cleft lip and palate result from embryonic failure resulting from multiple genetic and
environmental factors. A genetic pattern or familial risk seems to exist. Tobacco during
pregnancy (not drinking) has been associated with bilateral cleft lip. The defect occurred at
approximately 6 to 8 weeks of gestation. Second-trimester intrauterine infection is not a known
cause of bilateral cleft lip. The prevalence of cleft lip and palate is higher in Asian and Native
American populations.
PTS: 1 DIF: Cognitive Level: Application/Application
The nurse is caring for a neonate with a suspected tracheoesophageal fistula (TEF). Nursing care
should include which of the following?
a. Elevating the head but give nothing by mouth
b. Elevating the head for feedings
c. Feeding glucose water only
d. Avoiding suction unless infant is cyanotic - Answer ANS: A
When a newborn is suspected of having TEF, the most desirable position is supine with the head
elevated on an incline plane of at least 30 degrees. It is imperative that any source of aspiration
be removed at once; oral feedings are withheld. Feedings should not be given to infants
suspected of having TEF. The oral pharynx should be kept clear of secretion by oral suctioning.
This is to avoid cyanosis that is usually the result of laryngospasm caused by overflow of saliva
into the larynx.
, a. Teach parents to position the infant on the left side.
b. Reinforce the parents' knowledge of the infant's developmental needs.
c. Teach the parents how to do infant cardiopulmonary resuscitation (CPR).
d. Have the parents keep an accurate record of intake and output. - Answer ANS: C
Risk of aspiration is a priority nursing diagnosis for the infant with gastroesophageal reflux. The
parents must be taught infant CPR. Correct positioning minimizes aspiration. The correct
position for the infant is supine for sleeping unless the risk of aspiration is great. Knowledge of
developmental needs should be included in discharge planning for all hospitalized infants, but it
is not the most important in this case. Keeping a record of intake and output is not a priority
and may not be necessary.
PTS: 1 DIF: Cognitive Level: Application/Applying
What is an appropriate statement for the nurse to make to parents of a child who has had a
barium enema to correct an intussusception?
a. "I will call the physician when the baby passes his first stool."
b. "I am going to dilate the anal sphincter with a gloved finger to help the baby pass the
barium."
c. "Your baby can't have anything to eat or drink until bowel function returns."
d. "Add cereal to the baby's formula to help him pass the barium." - Answer ANS: C
Post procedure, the child is kept NPO until bowel function returns. The physician does not need
to be notified when the infant passes the first stool. Dilating the anal sphincter is not
appropriate for the child after a barium enema.
PTS: 1 DIF: Cognitive Level: Application/Applying
Which nursing diagnosis has the highest priority for the toddler with celiac disease?
a. Disturbed Body Image related to chronic constipation
b. Risk for Disproportionate Growth related to obesity
c. Excess Fluid Volume related to celiac crisis
d. Imbalanced Nutrition: Less than Body Requirements related to malabsorption - Answer
ANS: D
Imbalanced Nutrition: Less than Body Requirements is the highest priority nursing diagnosis
because celiac disease causes gluten enteropathy, a malabsorption condition. A psychosocial
diagnosis (Disturbed Body Image) would not take priority over a physical diagnosis. Celiac
Gastrointestinal Alteration McKinney:
Evolve Resources for Maternal-Child
Nursing, 5th Edition Test Bank
Questions with Complete Answers.
What is the best response by the nurse to a mother asking about the cause of her infant's
bilateral cleft lip?
a. "Did you use alcohol during your pregnancy?"
b. "Does anyone in your family have a cleft lip or palate?"
c. "This defect is associated with intrauterine infection during the second trimester."
d. "The prevalent of cleft lip is higher in Caucasians." - Answer ANS: B
Cleft lip and palate result from embryonic failure resulting from multiple genetic and
environmental factors. A genetic pattern or familial risk seems to exist. Tobacco during
pregnancy (not drinking) has been associated with bilateral cleft lip. The defect occurred at
approximately 6 to 8 weeks of gestation. Second-trimester intrauterine infection is not a known
cause of bilateral cleft lip. The prevalence of cleft lip and palate is higher in Asian and Native
American populations.
PTS: 1 DIF: Cognitive Level: Application/Application
The nurse is caring for a neonate with a suspected tracheoesophageal fistula (TEF). Nursing care
should include which of the following?
a. Elevating the head but give nothing by mouth
b. Elevating the head for feedings
c. Feeding glucose water only
d. Avoiding suction unless infant is cyanotic - Answer ANS: A
When a newborn is suspected of having TEF, the most desirable position is supine with the head
elevated on an incline plane of at least 30 degrees. It is imperative that any source of aspiration
be removed at once; oral feedings are withheld. Feedings should not be given to infants
suspected of having TEF. The oral pharynx should be kept clear of secretion by oral suctioning.
This is to avoid cyanosis that is usually the result of laryngospasm caused by overflow of saliva
into the larynx.
, a. Teach parents to position the infant on the left side.
b. Reinforce the parents' knowledge of the infant's developmental needs.
c. Teach the parents how to do infant cardiopulmonary resuscitation (CPR).
d. Have the parents keep an accurate record of intake and output. - Answer ANS: C
Risk of aspiration is a priority nursing diagnosis for the infant with gastroesophageal reflux. The
parents must be taught infant CPR. Correct positioning minimizes aspiration. The correct
position for the infant is supine for sleeping unless the risk of aspiration is great. Knowledge of
developmental needs should be included in discharge planning for all hospitalized infants, but it
is not the most important in this case. Keeping a record of intake and output is not a priority
and may not be necessary.
PTS: 1 DIF: Cognitive Level: Application/Applying
What is an appropriate statement for the nurse to make to parents of a child who has had a
barium enema to correct an intussusception?
a. "I will call the physician when the baby passes his first stool."
b. "I am going to dilate the anal sphincter with a gloved finger to help the baby pass the
barium."
c. "Your baby can't have anything to eat or drink until bowel function returns."
d. "Add cereal to the baby's formula to help him pass the barium." - Answer ANS: C
Post procedure, the child is kept NPO until bowel function returns. The physician does not need
to be notified when the infant passes the first stool. Dilating the anal sphincter is not
appropriate for the child after a barium enema.
PTS: 1 DIF: Cognitive Level: Application/Applying
Which nursing diagnosis has the highest priority for the toddler with celiac disease?
a. Disturbed Body Image related to chronic constipation
b. Risk for Disproportionate Growth related to obesity
c. Excess Fluid Volume related to celiac crisis
d. Imbalanced Nutrition: Less than Body Requirements related to malabsorption - Answer
ANS: D
Imbalanced Nutrition: Less than Body Requirements is the highest priority nursing diagnosis
because celiac disease causes gluten enteropathy, a malabsorption condition. A psychosocial
diagnosis (Disturbed Body Image) would not take priority over a physical diagnosis. Celiac
