NUR 230 Exam 4 V2 | NUR 230 The
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 4) | Galen
College of Nursing
1. A nurse is caring for a 4-year-old child with Cystic Fibrosis. Which of the following should
the nurse implement as a priority for chest physiotherapy (CPT)?
A. Perform CPT immediately after the child eats a meal.
B. Restrict fluid intake during the day of the procedure.
C. Administer a cough suppressant before starting the CPT session.
D. Schedule CPT sessions at least 1 hour before or 2 hours after meals.
Answer: D
Rationale: Scheduling chest physiotherapy (CPT) away from meal times is crucial to
prevent vomiting and aspiration in the pediatric patient. CPT uses percussion and vibration
to mobilize thick secretions characteristic of Cystic Fibrosis. Performing this procedure
when the stomach is empty ensures better tolerance and safety for the child.
2. An infant with Tetralogy of Fallot experiences a hypercyanotic ‘Tet’ spell. Which action
should the nurse take first?
A. Administer morphine sulfate intravenously.
B. Place the infant in the knee-chest position.
,C. Obtain an arterial blood gas (ABG) sample.
D. Apply high-flow oxygen via a simple face mask.
Answer: B
Rationale: The knee-chest position is the immediate priority because it increases systemic
vascular resistance and reduces the right-to-left shunt. This physical maneuver helps
redirect blood flow into the pulmonary artery to improve oxygenation. While oxygen and
morphine are often used, positioning is the fastest non-invasive intervention to stabilize
the infant.
3. Which clinical manifestation is most characteristic of a child diagnosed with Pyloric
Stenosis?
A. Currant jelly-like stools containing blood and mucus.
B. Bile-stained emesis occurring after every feeding.
C. Projectile vomiting followed by immediate hunger.
D. Severe abdominal distension and ribbon-like stools.
Answer: C
Rationale: Projectile vomiting is the hallmark sign of pyloric stenosis due to the muscular
hypertrophy of the pyloric sphincter. Infants often remain hungry immediately after
vomiting because the food never reached the duodenum for absorption. The nurse may
also palpate an olive-shaped mass in the right upper quadrant during physical assessment.
, 4. A school-age child is admitted with a diagnosis of Acute Post-streptococcal
Glomerulonephritis (APSGN). Which assessment finding should the nurse expect?
A. Hypotension and clear, pale urine.
B. Increased appetite and weight loss.
C. Massive proteinuria and low serum cholesterol.
D. Periorbital edema and tea-colored urine.
Answer: D
Rationale: APSGN typically presents with periorbital edema and dark, tea-colored or
smoky urine due to hematuria. This condition follows a recent streptococcal infection,
which triggers an immune response that damages the glomeruli. Nurses must monitor
blood pressure closely as hypertension is a common and potentially dangerous
complication of this disorder.
5. The nurse is monitoring a toddler with Croup (Laryngotracheobronchitis). Which finding
indicates that the child’s condition is worsening?
A. Increased restlessness and subcostal retractions.
B. Inspiratory stridor heard only when the child is crying.
C. A barking, brassy cough heard mainly at night.
D. A temperature of 100.4 F (38 C) taken rectally.
Answer: A
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 4) | Galen
College of Nursing
1. A nurse is caring for a 4-year-old child with Cystic Fibrosis. Which of the following should
the nurse implement as a priority for chest physiotherapy (CPT)?
A. Perform CPT immediately after the child eats a meal.
B. Restrict fluid intake during the day of the procedure.
C. Administer a cough suppressant before starting the CPT session.
D. Schedule CPT sessions at least 1 hour before or 2 hours after meals.
Answer: D
Rationale: Scheduling chest physiotherapy (CPT) away from meal times is crucial to
prevent vomiting and aspiration in the pediatric patient. CPT uses percussion and vibration
to mobilize thick secretions characteristic of Cystic Fibrosis. Performing this procedure
when the stomach is empty ensures better tolerance and safety for the child.
2. An infant with Tetralogy of Fallot experiences a hypercyanotic ‘Tet’ spell. Which action
should the nurse take first?
A. Administer morphine sulfate intravenously.
B. Place the infant in the knee-chest position.
,C. Obtain an arterial blood gas (ABG) sample.
D. Apply high-flow oxygen via a simple face mask.
Answer: B
Rationale: The knee-chest position is the immediate priority because it increases systemic
vascular resistance and reduces the right-to-left shunt. This physical maneuver helps
redirect blood flow into the pulmonary artery to improve oxygenation. While oxygen and
morphine are often used, positioning is the fastest non-invasive intervention to stabilize
the infant.
3. Which clinical manifestation is most characteristic of a child diagnosed with Pyloric
Stenosis?
A. Currant jelly-like stools containing blood and mucus.
B. Bile-stained emesis occurring after every feeding.
C. Projectile vomiting followed by immediate hunger.
D. Severe abdominal distension and ribbon-like stools.
Answer: C
Rationale: Projectile vomiting is the hallmark sign of pyloric stenosis due to the muscular
hypertrophy of the pyloric sphincter. Infants often remain hungry immediately after
vomiting because the food never reached the duodenum for absorption. The nurse may
also palpate an olive-shaped mass in the right upper quadrant during physical assessment.
, 4. A school-age child is admitted with a diagnosis of Acute Post-streptococcal
Glomerulonephritis (APSGN). Which assessment finding should the nurse expect?
A. Hypotension and clear, pale urine.
B. Increased appetite and weight loss.
C. Massive proteinuria and low serum cholesterol.
D. Periorbital edema and tea-colored urine.
Answer: D
Rationale: APSGN typically presents with periorbital edema and dark, tea-colored or
smoky urine due to hematuria. This condition follows a recent streptococcal infection,
which triggers an immune response that damages the glomeruli. Nurses must monitor
blood pressure closely as hypertension is a common and potentially dangerous
complication of this disorder.
5. The nurse is monitoring a toddler with Croup (Laryngotracheobronchitis). Which finding
indicates that the child’s condition is worsening?
A. Increased restlessness and subcostal retractions.
B. Inspiratory stridor heard only when the child is crying.
C. A barking, brassy cough heard mainly at night.
D. A temperature of 100.4 F (38 C) taken rectally.
Answer: A
