NR327/NR 327 Exam 4 V2 | Maternal Child Nursing
Q&A with Rationale | Chamberlain University
1. A 4-year-old child is brought to the emergency department with a high fever, drooling, and
an anxious appearance. Which nursing action is the absolute priority?
A. Obtain a throat culture to identify the causative organism.
B. Assess the throat using a tongue blade for visible swelling.
C. Keep the child calm and prepare for emergency airway management.
D. Administer an oral antipyretic to reduce the fever.
Correct Answer: C
Explanation: These symptoms are classic indicators of epiglottitis, which is a medical
emergency. Attempting to visualize the throat or obtain a culture can trigger a
laryngospasm and complete airway obstruction. The primary goal is to maintain airway
patency and minimize stress for the child until the airway is secured.
2. A child is admitted with a vaso-occlusive crisis secondary to Sickle Cell Anemia. Which
intervention should the nurse implement first?
A. Administer high-flow oxygen via a non-rebreather mask.
B. Initiate intravenous fluid replacement and hydration therapy.
C. Apply cold compresses to the painful joints.
D. Administer meperidine for pain management.
,Correct Answer: B
Explanation: Hydration is the priority intervention to reduce blood viscosity and prevent
further sickling of red blood cells. Increasing fluid intake helps to move the sickled cells
through the microvasculature more effectively. Pain management is also critical, but cold
compresses should be avoided as they cause vasoconstriction and worsen the crisis.
3. A nurse is assessing a 3-week-old infant with suspected pyloric stenosis. Which finding
should the nurse expect to observe?
A. Currant jelly-like stools containing mucus and blood.
B. An olive-shaped mass palpated in the right upper quadrant.
C. Bile-stained emesis occurring after every feeding.
D. Visible peristaltic waves moving from right to left.
Correct Answer: B
Explanation: The olive-shaped mass is a hallmark physical finding of hypertrophic pyloric
stenosis. Projectile, non-bilious vomiting is the typical clinical manifestation of this
condition. Peristaltic waves may be visible, but they typically move from left to right across
the epigastrium.
4. A toddler with Tetralogy of Fallot suddenly becomes cyanotic and dyspneic while playing.
What should the nurse do first?
A. Administer 100% oxygen via blow-by.
B. Prepare a dose of intravenous morphine sulfate.
, C. Place the child in the knee-chest position.
D. Begin chest compressions immediately.
Correct Answer: C
Explanation: The knee-chest position increases systemic vascular resistance, which helps
force blood into the pulmonary artery and improves oxygenation during a ‘Tet spell’. This
simple physical maneuver is the first-line treatment for acute cyanotic episodes. After
positioning, oxygen and morphine may be administered to further stabilize the child.
5. A child is diagnosed with Nephrotic Syndrome. Which clinical manifestation should the
nurse anticipate?
A. Gross hematuria and hypertension.
B. Low serum cholesterol and high albumin levels.
C. Weight loss and increased urinary output.
D. Massive proteinuria and generalized edema.
Correct Answer: D
Explanation: Nephrotic Syndrome is characterized by increased glomerular permeability
to protein, leading to massive proteinuria. This results in hypoalbuminemia, which causes a
shift in osmotic pressure and leads to severe edema (anasarca). Treatment often involves
corticosteroids to reduce protein loss in the urine.
Q&A with Rationale | Chamberlain University
1. A 4-year-old child is brought to the emergency department with a high fever, drooling, and
an anxious appearance. Which nursing action is the absolute priority?
A. Obtain a throat culture to identify the causative organism.
B. Assess the throat using a tongue blade for visible swelling.
C. Keep the child calm and prepare for emergency airway management.
D. Administer an oral antipyretic to reduce the fever.
Correct Answer: C
Explanation: These symptoms are classic indicators of epiglottitis, which is a medical
emergency. Attempting to visualize the throat or obtain a culture can trigger a
laryngospasm and complete airway obstruction. The primary goal is to maintain airway
patency and minimize stress for the child until the airway is secured.
2. A child is admitted with a vaso-occlusive crisis secondary to Sickle Cell Anemia. Which
intervention should the nurse implement first?
A. Administer high-flow oxygen via a non-rebreather mask.
B. Initiate intravenous fluid replacement and hydration therapy.
C. Apply cold compresses to the painful joints.
D. Administer meperidine for pain management.
,Correct Answer: B
Explanation: Hydration is the priority intervention to reduce blood viscosity and prevent
further sickling of red blood cells. Increasing fluid intake helps to move the sickled cells
through the microvasculature more effectively. Pain management is also critical, but cold
compresses should be avoided as they cause vasoconstriction and worsen the crisis.
3. A nurse is assessing a 3-week-old infant with suspected pyloric stenosis. Which finding
should the nurse expect to observe?
A. Currant jelly-like stools containing mucus and blood.
B. An olive-shaped mass palpated in the right upper quadrant.
C. Bile-stained emesis occurring after every feeding.
D. Visible peristaltic waves moving from right to left.
Correct Answer: B
Explanation: The olive-shaped mass is a hallmark physical finding of hypertrophic pyloric
stenosis. Projectile, non-bilious vomiting is the typical clinical manifestation of this
condition. Peristaltic waves may be visible, but they typically move from left to right across
the epigastrium.
4. A toddler with Tetralogy of Fallot suddenly becomes cyanotic and dyspneic while playing.
What should the nurse do first?
A. Administer 100% oxygen via blow-by.
B. Prepare a dose of intravenous morphine sulfate.
, C. Place the child in the knee-chest position.
D. Begin chest compressions immediately.
Correct Answer: C
Explanation: The knee-chest position increases systemic vascular resistance, which helps
force blood into the pulmonary artery and improves oxygenation during a ‘Tet spell’. This
simple physical maneuver is the first-line treatment for acute cyanotic episodes. After
positioning, oxygen and morphine may be administered to further stabilize the child.
5. A child is diagnosed with Nephrotic Syndrome. Which clinical manifestation should the
nurse anticipate?
A. Gross hematuria and hypertension.
B. Low serum cholesterol and high albumin levels.
C. Weight loss and increased urinary output.
D. Massive proteinuria and generalized edema.
Correct Answer: D
Explanation: Nephrotic Syndrome is characterized by increased glomerular permeability
to protein, leading to massive proteinuria. This results in hypoalbuminemia, which causes a
shift in osmotic pressure and leads to severe edema (anasarca). Treatment often involves
corticosteroids to reduce protein loss in the urine.
