PNR 204/PNR204 Exam 2 V2 | Pediatric Nursing
Q&A with Rationale | Fortis College
1. A nurse is assessing a 4-year-old child who has epiglottitis. Which of the following findings
should the nurse expect?
A. Barking cough
B. Low-grade fever
C. Drooling
D. Dry, hacking cough
Correct Answer: C
Explanation: Drooling is a classic sign of epiglottitis due to the inability to swallow
because of severe throat pain and swelling. The child often assumes a tripod position to
facilitate breathing. This is a medical emergency that requires immediate intervention to
maintain airway patency.
2. A nurse is caring for an infant who has hypertrophic pyloric stenosis. Which of the
following clinical manifestations should the nurse expect?
A. Projectile vomiting
B. Currant jelly stools
C. Biliary vomiting
D. Ribbon-like stools
,Correct Answer: A
Explanation: Projectile vomiting is a hallmark sign of pyloric stenosis caused by the
thickening of the pyloric sphincter. This vomiting typically occurs shortly after feeding and
does not contain bile. An olive-shaped mass may also be palpable in the right upper
quadrant of the abdomen.
3. A nurse is caring for a toddler who has a diagnosis of Tetralogy of Fallot. The child suddenly
becomes cyanotic and dyspneic. Which of the following actions should the nurse take first?
A. Place the child in a knee-chest position
B. Administer oxygen via face mask
C. Administer morphine sulfate intravenously
D. Call for the rapid response team
Correct Answer: A
Explanation: The knee-chest position is the priority action for a ‘tet spell’ to increase
systemic vascular resistance. This maneuver helps force more blood into the pulmonary
artery to improve oxygenation. After positioning, the nurse should then provide oxygen
and call the provider as necessary.
4. A nurse is providing teaching to the parents of a child with cystic fibrosis about pancreatic
enzyme replacement. Which of the following instructions should the nurse include?
A. Administer the enzymes once daily in the morning
B. Dissolve the enzymes in a glass of warm milk
, C. Give the enzymes with all meals and snacks
D. Administer the enzymes 2 hours after meals
Correct Answer: C
Explanation: Pancreatic enzymes must be administered with all meals and snacks to assist
in the digestion and absorption of fats, proteins, and carbohydrates. Because children with
cystic fibrosis lack these enzymes, they are at risk for malabsorption and malnutrition. The
dosage is adjusted based on the child’s growth and the number of stools per day.
5. A nurse is assessing a child who has intussusception. Which of the following findings is
characteristic of this condition?
A. Steatorrhea
B. Stools resembling currant jelly
C. Painless rectal bleeding
D. Hard, marble-like stools
Correct Answer: B
Explanation: Stools that resemble currant jelly, consisting of blood and mucus, are a
classic finding in intussusception. This occurs when a portion of the intestine telescopes
into another, causing inflammation and ischemia. The child typically experiences sudden,
severe abdominal pain that causes them to scream and draw their knees to their chest.
Q&A with Rationale | Fortis College
1. A nurse is assessing a 4-year-old child who has epiglottitis. Which of the following findings
should the nurse expect?
A. Barking cough
B. Low-grade fever
C. Drooling
D. Dry, hacking cough
Correct Answer: C
Explanation: Drooling is a classic sign of epiglottitis due to the inability to swallow
because of severe throat pain and swelling. The child often assumes a tripod position to
facilitate breathing. This is a medical emergency that requires immediate intervention to
maintain airway patency.
2. A nurse is caring for an infant who has hypertrophic pyloric stenosis. Which of the
following clinical manifestations should the nurse expect?
A. Projectile vomiting
B. Currant jelly stools
C. Biliary vomiting
D. Ribbon-like stools
,Correct Answer: A
Explanation: Projectile vomiting is a hallmark sign of pyloric stenosis caused by the
thickening of the pyloric sphincter. This vomiting typically occurs shortly after feeding and
does not contain bile. An olive-shaped mass may also be palpable in the right upper
quadrant of the abdomen.
3. A nurse is caring for a toddler who has a diagnosis of Tetralogy of Fallot. The child suddenly
becomes cyanotic and dyspneic. Which of the following actions should the nurse take first?
A. Place the child in a knee-chest position
B. Administer oxygen via face mask
C. Administer morphine sulfate intravenously
D. Call for the rapid response team
Correct Answer: A
Explanation: The knee-chest position is the priority action for a ‘tet spell’ to increase
systemic vascular resistance. This maneuver helps force more blood into the pulmonary
artery to improve oxygenation. After positioning, the nurse should then provide oxygen
and call the provider as necessary.
4. A nurse is providing teaching to the parents of a child with cystic fibrosis about pancreatic
enzyme replacement. Which of the following instructions should the nurse include?
A. Administer the enzymes once daily in the morning
B. Dissolve the enzymes in a glass of warm milk
, C. Give the enzymes with all meals and snacks
D. Administer the enzymes 2 hours after meals
Correct Answer: C
Explanation: Pancreatic enzymes must be administered with all meals and snacks to assist
in the digestion and absorption of fats, proteins, and carbohydrates. Because children with
cystic fibrosis lack these enzymes, they are at risk for malabsorption and malnutrition. The
dosage is adjusted based on the child’s growth and the number of stools per day.
5. A nurse is assessing a child who has intussusception. Which of the following findings is
characteristic of this condition?
A. Steatorrhea
B. Stools resembling currant jelly
C. Painless rectal bleeding
D. Hard, marble-like stools
Correct Answer: B
Explanation: Stools that resemble currant jelly, consisting of blood and mucus, are a
classic finding in intussusception. This occurs when a portion of the intestine telescopes
into another, causing inflammation and ischemia. The child typically experiences sudden,
severe abdominal pain that causes them to scream and draw their knees to their chest.
