NR327/NR 327 Exam 4 V1 | Maternal Child Nursing
Q&A with Rationale | Chamberlain University
1. A nurse is providing discharge teaching to the parents of a child with Cystic Fibrosis. Which
instruction regarding pancreatic enzyme administration should the nurse include?
A. Administer enzymes once daily in the morning before breakfast.
B. Mix the enzymes with hot oatmeal to ensure the child eats it all.
C. Give enzymes with all meals and snacks to aid digestion.
D. Provide enzymes only if the child has a high-fat meal.
Correct Answer: C
Explanation: Pancreatic enzymes are essential for children with Cystic Fibrosis because
their pancreatic ducts are often blocked by thick mucus. These enzymes must be taken with
every meal and snack to facilitate the absorption of fats, proteins, and carbohydrates.
Without these enzymes, the child will experience malabsorption and steatorrhea, which
can lead to failure to thrive.
2. Which clinical manifestation should a nurse expect to find in a 4-week-old infant diagnosed
with hypertrophic 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. Abdominal distention and ribbon-like stools.
Correct Answer: C
Explanation: Hypertrophic pyloric stenosis is characterized by the thickening of the
pyloric sphincter, which creates an outlet obstruction. This leads to progressive, non-
bilious projectile vomiting as the stomach attempts to push food through the narrowed
opening. After vomiting, infants are typically hungry and eager to feed again because the
stomach is empty.
3. A nurse is assessing a 2-year-old child for a suspected intussusception. Which of the
following findings is a classic sign of this condition?
A. Perianal itching that increases during the night.
B. Sausage-shaped mass in the upper right quadrant.
C. Pain in the lower right quadrant with rebound tenderness.
D. Steatorrhea and foul-smelling, bulky stools.
Correct Answer: B
Explanation: Intussusception occurs when one segment of the bowel telescopes into
another, leading to obstruction and vascular compromise. A sausage-shaped mass is often
palpable in the right upper quadrant during physical examination. This condition is also
frequently associated with sudden abdominal pain and ‘currant jelly’ stools.
, 4. A child is admitted with a diagnosis of acute post-streptococcal glomerulonephritis
(APSGN). Which assessment finding is the nurse most likely to observe?
A. Periorbital edema and tea-colored urine.
B. Hypotension and clear, pale yellow urine.
C. Profuse watery diarrhea and high-grade fever.
D. Polyuria and increased appetite with weight loss.
Correct Answer: A
Explanation: APSGN typically manifests 1 to 2 weeks after a streptococcal infection of the
throat or skin. The child often presents with periorbital edema due to fluid retention and
tea-colored or ‘cola’ colored urine due to hematuria. Hypertension and oliguria are also
common clinical features during the acute phase of the disease.
5. The nurse is caring for a 6-month-old infant with Tetralogy of Fallot who suddenly becomes
cyanotic and dyspneic. Which action should the nurse take first?
A. Administer a dose of morphine sulfate intramuscularly.
B. Prepare the infant for an emergency cardiac catheterization.
C. Place the infant in the knee-chest position.
D. Start a high-flow oxygen mask at 10 liters per minute.
Correct Answer: C
Q&A with Rationale | Chamberlain University
1. A nurse is providing discharge teaching to the parents of a child with Cystic Fibrosis. Which
instruction regarding pancreatic enzyme administration should the nurse include?
A. Administer enzymes once daily in the morning before breakfast.
B. Mix the enzymes with hot oatmeal to ensure the child eats it all.
C. Give enzymes with all meals and snacks to aid digestion.
D. Provide enzymes only if the child has a high-fat meal.
Correct Answer: C
Explanation: Pancreatic enzymes are essential for children with Cystic Fibrosis because
their pancreatic ducts are often blocked by thick mucus. These enzymes must be taken with
every meal and snack to facilitate the absorption of fats, proteins, and carbohydrates.
Without these enzymes, the child will experience malabsorption and steatorrhea, which
can lead to failure to thrive.
2. Which clinical manifestation should a nurse expect to find in a 4-week-old infant diagnosed
with hypertrophic 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. Abdominal distention and ribbon-like stools.
Correct Answer: C
Explanation: Hypertrophic pyloric stenosis is characterized by the thickening of the
pyloric sphincter, which creates an outlet obstruction. This leads to progressive, non-
bilious projectile vomiting as the stomach attempts to push food through the narrowed
opening. After vomiting, infants are typically hungry and eager to feed again because the
stomach is empty.
3. A nurse is assessing a 2-year-old child for a suspected intussusception. Which of the
following findings is a classic sign of this condition?
A. Perianal itching that increases during the night.
B. Sausage-shaped mass in the upper right quadrant.
C. Pain in the lower right quadrant with rebound tenderness.
D. Steatorrhea and foul-smelling, bulky stools.
Correct Answer: B
Explanation: Intussusception occurs when one segment of the bowel telescopes into
another, leading to obstruction and vascular compromise. A sausage-shaped mass is often
palpable in the right upper quadrant during physical examination. This condition is also
frequently associated with sudden abdominal pain and ‘currant jelly’ stools.
, 4. A child is admitted with a diagnosis of acute post-streptococcal glomerulonephritis
(APSGN). Which assessment finding is the nurse most likely to observe?
A. Periorbital edema and tea-colored urine.
B. Hypotension and clear, pale yellow urine.
C. Profuse watery diarrhea and high-grade fever.
D. Polyuria and increased appetite with weight loss.
Correct Answer: A
Explanation: APSGN typically manifests 1 to 2 weeks after a streptococcal infection of the
throat or skin. The child often presents with periorbital edema due to fluid retention and
tea-colored or ‘cola’ colored urine due to hematuria. Hypertension and oliguria are also
common clinical features during the acute phase of the disease.
5. The nurse is caring for a 6-month-old infant with Tetralogy of Fallot who suddenly becomes
cyanotic and dyspneic. Which action should the nurse take first?
A. Administer a dose of morphine sulfate intramuscularly.
B. Prepare the infant for an emergency cardiac catheterization.
C. Place the infant in the knee-chest position.
D. Start a high-flow oxygen mask at 10 liters per minute.
Correct Answer: C
