Chapter 39: Alterations of Renal and Urinary Tract Function in Children

MULTIPLE CHOICE
1. The functional kidney is associated with which embryonic organ?
a. Metanephros
c. Pronephros
b. Mesonephros
d. Endonephros
ANS: A

The functional kidney is associated with the metanephros. The kidney develops from three
sets of structures: the pronephros (nonfunctional by the end of the embryonic period),
mesonephros (nonfunctional), and metanephros (the functional kidney). Endonephros is not
relevant to this process.
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REF: Pages 1376-1377 | Figure 39-1

2. When does urine formation and excretion begin?

a. At birth
c. By 6 months gestation
b. By 3 months gestation
d. By 8 months gestation
ANS: B

Urine formation and excretion begin by the third month of gestation.

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REF: Page 1377

3. Compared with an adult, an infant has a greater content of extracellular fluid, as well as a

greater rate of fluid exchange. What effect does this have on the fluid balance of a child
compared with that of an adult?
a. Edema development is less of a problem.
b. Overhydration is not difficult to manage.
c. Daily fluid requirements are greater.
d. The control of dehydration is more difficult.
ANS: D

An infant not only has a greater content of extracellular fluid, but infants also have a greater
rate of fluid exchange. The adult takes in and excretes approximately 2000 ml of water daily,
representing 5% of the total body fluid and 14% of the extracellular fluid. In contrast, the
infants daily exchange of 600 to 700 ml of water represents 290% of the total body fluid or
nearly 50% of the extracellular volume, making control of dehydration and overhydration
more difficult. This fact makes the other options incorrect.
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REF: Page 1378

4. What term is used to identify the condition that exists when the urethral meatus is located on

the undersurface of the penis?

a. Hypospadias
b. Epispadias

c. Hyperspadias
d. Chordee

ANS: A

Hypospadias is a congenital condition in which the urethral meatus is located on the ventral
side or undersurface of the penis. This is the only term used for this condition.

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REF: Page 1378

5. What initiates inflammation in acute poststreptococcal glomerulonephritis?

a. Lysosomal enzymes
b. Endotoxins from Streptococcus
c. Immune complexes
d. Immunoglobulin E (IgE)mediated response
ANS: C

The immune complexes initiate inflammation and glomerular injury in acute poststreptococcal
glomerulonephritis. Antigen-antibody complexes are deposited in the glomerulus, or the
antigen may be trapped within the glomerulus and immune complexes formed in situ. The
other options are not involved in initiating inflammation in this situation.
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REF: Page 1381

6. Acute glomerulonephritis (AGN) may be accompanied by a positive throat or skin culture for

which bacteria?
a. Staphylococcus aureus
b. Streptococcus

c. Pseudomonas aeruginosa
d. Haemophilus

ANS: B

AGN may be accompanied by a positive throat or skin culture for Streptococcus. AGN is not
associated with any of the other options.
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REF: Page 1382

7. What is the cause of smoky, brown-colored urine resulting from acute poststreptococcal

glomerulonephritis?
a. Presence of red blood cells
b. Presence of urobilinogen

c. Slough from the collecting tubules

d. Protein in the urine

ANS: A

The urine is usually smoky brown or cola-colored because of the presence of red blood cells.
The other options are not correct statements regarding this condition.
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REF: Pages 1381-1382

8. In immunoglobulin G (IgG) nephropathies such as glomerulonephritis, IgG is deposited in

which location?
Juxtamedullary nephrons
Glomerulus basement membranes
Mesangium of the glomerular capillaries
Parietal epithelium

a.
b.
c.
d.

ANS: B

Glomerulonephritis develops with the deposition of antigen-antibody complexes (IgG,

immunoglobulin A [IgA], and C3 complement) in the glomerulus, or the antigen may be
trapped within the glomerulus and immune complexes formed in situ. Immunofluorescence
microscopy shows lumpy deposits of IgG and C3 complement on the glomerular basement
membrane (see Figure 39-5). When considering IgG nephropathies, the only location of the
IgG immunoglobulins is the correct option.
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REF: Page 1381

9. What is the pathophysiologic process responsible for the autoimmune disorder of hemolytic-

uremic syndrome (HUS)?

a. Immunoglobulin A (IgA) coats erythrocytes that are destroyed by the spleen, and

remnants are excreted through the kidneys.

b. Verotoxin from Escherichia coli is absorbed from the intestines and damages

erythrocytes and endothelial cells.

c. Endotoxins from E. coli block the erythropoietin produced by the kidneys, which

reduces the number of erythrocytes produced by the bone marrow.

d. Failure of the nephron to filter urea increases the blood urea nitrogen, which binds

to erythrocytes that are subsequently destroyed by the spleen.

ANS: B

In HUS, verotoxin from E. coli is absorbed from the intestines, the glomerular arterioles
become swollen, and these narrowed vessels damage erythrocytes as they pass through. HUS
is responsible for causing a cascade of effects, including lysis of glomerular capillary
endothelial cells. The other options are not relevant.
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REF: Page 1383

10. What is the first indication of nephrotic syndrome in children?

a. Periorbital edema
c. Frothy urine
b. Scrotal or labial edema
d. Ascites
ANS: A

Onset of nephritic syndrome is insidious, with periorbital edema as the first sign of the
disorder. None of the other options represent the first indication of nephritic syndrome in
children.
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REF: Page 1384

11. Bacteria gain access to the female urinary tract by which means?
a. Systemic blood that is filtered through the kidney
b. Bacteria traveling from the lymph adjacent to the bladder and kidneys
c. Bacteria ascending the urethra into the bladder
d. Colonization of the bladder when urine is static
ANS: C

Urinary tract infections (UTIs) in girls occur as a result of perineal bacteria, especially
Escherichia coli, ascending the urethra. None of the other options represent the means by
which bacteria gain access to the female urinary tract.
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REF: Page 1386

12. What causes vesicoureteral reflux to occur in children?

a. Children do not ask for help in urinating in a timely manner, and urine is forced up

into the ureters.

b. The submucosal segment of a childs ureter is short, making the antireflux

mechanism inefficient.
c. The trigone lying between the opening to the ureters and the urethra is

underdeveloped in children.
d. As the bladder fills in infants and children, it pulls the smooth lining of the

transitional epithelium away from the ureters, making the reflux valves ineffective.
ANS: B

Although reflux is considered abnormal at any age, the shortness of the submucosal segment
of the ureter during infancy and childhood renders the antireflux mechanism relatively
inefficient and delicate. The other options are not considered reasons for this reflux.
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REF: Page 1387

13. What is the mechanism for developing Wilms tumor?

a. The development of a Wilms tumor involves tumor-suppressor genes located on

chromosome 11.
b. Development involves an autosomal dominant inherited disorder involving the Y
chromosome.
c. Wilms tumor is an autoimmune disorder.
d. The development of a Wilms tumor is a congenital anomaly.
ANS: A

Wilms tumorsuppressor genes WT1 and WT 2 are located on chromosome 11. The other
options are not considered relevant to the development of a Wilms tumor.
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REF: Pages 1385-1386

14. Which anomaly is often associated with Wilms tumor?

a. Renal anaplasia
c. Anemia
b. Aniridia
d. Hypothyroidism
ANS: B

Aniridia (lack of an iris in the eye) is an anomaly often associated with Wilms tumor.
Approximately 10% of children who have Wilms tumor also have a loss of other important
genes and therefore have a number of congenital anomalies. The other anomalies listed are not
associated with a Wilms tumor.
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REF: Pages 1385-1386

15. Which statement is false about the causes of enuresis?

a. A maturational lag may cause enuresis.
b. Enuresis may be related to increased light sleep.
c. Obstructive sleep apnea may be a symptom of enuresis.
d. Excessive nocturnal levels of vasopressin may cause enuresis.
ANS: D

Children who do not have the normal nocturnal elevation of vasopressin produce a higher
volume of urine with a lower osmolality. The other options are accurate statements regarding
enuresis.
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REF: Pages 1388-1389

16. When does an individual have their full complement of renal nephrons?
a. At birth
c. At puberty
b. At 6 months of age
d. Between the ages 18 and 21 years
ANS: A

All the nephrons are present at birth, and their number does not increase as the kidney grows
and matures.
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REF: Pages 1376-1377

MULTIPLE RESPONSE
17. Which statements are true regarding the narrow chemical safety margin that infants

demonstrate? (Select all that apply.)

a. The immaturity of tubules may diminish the response to antidiuretic hormone
b.
c.
d.
e.

(ADH).
An immature tubular transport capacity impairs the excretion of potassium.
An immature tubular transport capacity impairs the reabsorption of bicarbonate.
The immaturity of tubules may diminish the response to aldosterone.
The safety margin begins to expand after 2 years of age.

ANS: A, B, C, E

Because of a high hydrogen ion concentration, a limited ability to regulate the internal
environment, and a lowered osmotic pressure, the infants renal system has a narrow chemical
safety margin. The immaturity and smaller surface area of the tubules also may diminish the
water reabsorption response to ADH. An immature tubular transport capacity means that the
ability to excrete a potassium load, reabsorb bicarbonate, or buffer hydrogen with ammonia
does not become efficient until approximately 2 years of age.
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REF: Page 1378

18. The excretion of urea is low in infants because of which feature? (Select all that apply.)
a. Medullary nephrons with comparatively short loops at this stage of development
b. Immature tubular transport capacity, impairing the excretion of urea
c. High anabolic state
d. Dilute urine as a result of the immaturity of an infants glomeruli
e. Available protein used for physical growth
ANS: C, E

Urea excretion is low in infants primarily because infants are in a high anabolic state and use
their protein for growth. The other options are not involved in their low urea excretion.
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REF: Page 1378

19. Which factors are involved in the development of hypospadias? (Select all that apply.)

a.
b.
c.
d.
e.

Disruption in male hormones, including testosterone

Mutation of gene HP-1 (chromosome 16)
5-reductase mutations
Hormones administered for in vitro fertilization
Advanced maternal age

ANS: A, C, D, E

The cause of hypospadias is multifactorial and related to disruptions in male hormones,

including testosterone biosynthesis defects, 5-reductase mutations, hormones administered
for in vitro fertilization, advanced maternal age, and other environmental factors. A mutation
of gene HP-1 (chromosome 16) is not relevant.
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REF: Page 1378

20. Which cells of the inflammatory process are found in acute poststreptococcal

glomerulonephritis? (Select all that apply.)

a. Immunoglobulin G (IgG)
b. Immunoglobulin A (IgA)
c. Complement C3
d. Immunoglobulin E (IgE)
e. Immune complexes
ANS: A, B, C, E

Antigen-antibody complexes of IgG, IgA, and C3 complement are deposited in the

glomerulus, or the antigen may be trapped within the glomerulus and immune complexes
formed in situ. IgE is not relevant to this situation.
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REF: Page 1381

21. Which symptoms are considered part of the nephrotic syndrome in children? (Select all that

apply.)
Proteinuria
Pyuria
Hyperlipidemia
Edema
Hypoalbuminemia

a.
b.
c.
d.
e.

ANS: A, C, D, E

Nephrotic syndrome is a term used to describe a symptom complex characterized by

proteinuria, hypoalbuminemia, hyperlipidemia, and edema. Pyuria is not observed in this
condition.
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REF: Page 1383

22. Which statements are true regarding hemolytic uremic syndrome (HUS)? (Select all that

apply.)
Microangiopathic hemolytic anemia characterizes HUS.
Thrombocytopenia is a comorbid condition.
Wilms tumors are often the trigger for HUS.
HUS is the most common community-acquired cause of acute renal failure in
young children.

a.
b.
c.
d.

e. HUS is chronic in nature.

ANS: A, B, D

HUS is an acute disorder characterized by microangiopathic hemolytic anemia and

thrombocytopenia and is the most common community-acquired cause of acute renal failure
in young children. Wilms tumors are not necessarily associated with this disorder.
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REF: Pages 1382-1383

23. What problems are commonly associated with the diagnosis of horseshoe kidneys? (Select all

that apply.)
Hydronephrosis
Nephritis
Infection
Kidney stones
Pyuria

a.
b.
c.
d.
e.

ANS: A, C, D

Approximately one-third of individuals with horseshoe kidneys are asymptomatic, and the
most common problems are hydronephrosis, infection, and stone formation. Nephritis and
pyuria are not associated with this diagnosis.
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REF: Page 1378

24. Which structural anomalies are associated with urinary tract malformations? (Select all that

apply.)
a. Low-set ears
b. Prune-belly syndrome
c. Broad-bridged nose
d. Imperforate anus
e. Malformed lips
ANS: A, B, D

Structural anomalies that are associated with urinary tract malformations include low-set,
malformed ears; absent abdominal muscles (prune-belly syndrome); and imperforate anus or
genital deviation. Anomalies of the either the nose or the lips are not generally associated with
urinary tract malformations.
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REF: Page 1378

MATCHING

Match the kidney disorder with the corresponding descriptions.

______ A. Hemolytic-uremic syndrome
______ B. Henoch-Schnlein purpura nephritis
______ C. Renal dysplasia
______ D. Ureteropelvic junction obstruction
______ E. Polycystic kidney disease
25. Is usually the result of abnormal differentiation of the renal tissues.
26. Is an autosomal dominant inherited disorder.

27. Fibrin-rich thrombi can be found throughout the microcirculation.

28. Is the most common cause of hydronephrosis in neonates.
29. Immunoglobulin A (IgA) nephropathy causes inflammation to glomerular blood vessels.
25. ANS: C
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REF: Page 1380
MSC: Renal dysplasia usually results from abnormal differentiation of the renal tissues.
26. ANS: E
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REF: Page 1381
MSC: Polycystic kidney disease is an autosomal dominant inherited disorder that occurs in
approximately 1 in 1000 live births.
27. ANS: A
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REF: Pages 1382-1383
MSC: Hemolytic-uremic syndrome (HUS) results in fibrin-rich thrombi found throughout the
microcirculation.
28. ANS: D
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REF: Page 1380
MSC: Ureteropelvic junction obstruction is the most common cause of hydronephrosis in neonates.
29. ANS: B
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REF: Page 1382
MSC: Henoch-Schnlein purpura nephritis, also known as anaphylactoid purpura, is an IgA
nephropathy that affects the glomerular blood vessels, causing inflammation and damage to the vessel
wall.