NR328/NR 328 Exam 2 V2 | Pediatric Nursing Q&A
with Rationale | Chamberlain University
1. A nurse is caring for an infant with Tetralogy of Fallot who suddenly becomes cyanotic and
dyspneic. Which action should the nurse perform first?
A. Administer 100% oxygen via face mask
B. Notify the pediatric cardiologist immediately
C. Prepare for administration of morphine sulfate
D. Place the infant in a knee-chest position
Correct Answer: D
Explanation: Placing the infant in a knee-chest position increases systemic vascular
resistance, which helps reduce the right-to-left shunt. This maneuver improves pulmonary
blood flow and is the priority intervention for a hypercyanotic spell. Once the infant is
positioned, oxygen and medications can be administered as secondary steps.
2. A 4-week-old infant is brought to the clinic with a history of non-bilious projectile vomiting.
The nurse notes an olive-shaped mass in the right upper quadrant. Which condition is most
likely?
A. Hypertrophic pyloric stenosis
B. Hirschsprung disease
C. Intussusception
,D. Gastroesophageal reflux
Correct Answer: A
Explanation: Hypertrophic pyloric stenosis is characterized by the narrowing of the
pyloric canal, which leads to gastric outlet obstruction. Projectile vomiting and a palpable
olive-shaped mass are classic clinical findings for this condition. These symptoms typically
manifest between 2 to 8 weeks of age as the hypertrophy progresses.
3. A newborn is suspected of having Hirschsprung disease. Which finding should the nurse
expect to observe during the assessment?
A. Visible peristaltic waves across the abdomen
B. Currant jelly-like stools containing blood and mucus
C. Failure to pass meconium within the first 24 to 48 hours
D. A scaphoid abdomen with respiratory distress
Correct Answer: C
Explanation: Hirschsprung disease is a congenital anomaly where ganglion cells are
absent in part of the colon. This lack of innervation prevents peristalsis and leads to a
functional obstruction. The hallmark sign in neonates is the failure to pass meconium
within the first 48 hours of life.
4. The nurse is educating a parent of a child with Intussusception. Which description of the
stool should the nurse include?
A. Currant jelly-like stools
, B. Greasy, frothy, and bulky stools
C. Hard, pebble-like stools
D. Ribbon-like and foul-smelling stools
Correct Answer: A
Explanation: Intussusception occurs when one segment of the bowel telescopes into
another, causing obstruction and ischemia. This leads to the leakage of blood and mucus
into the intestinal lumen. The resulting stools are characteristically described as currant
jelly-like in appearance.
5. A child is admitted with Nephrotic Syndrome. Which clinical manifestation should the
nurse prioritize during the physical assessment?
A. Gross hematuria and hypertension
B. Weight loss and increased appetite
C. Generalized edema and severe proteinuria
D. Elevated serum creatinine and high fever
Correct Answer: C
Explanation: Nephrotic syndrome is characterized by massive proteinuria, which leads to
hypoalbuminemia and subsequent generalized edema. Parents often report that the child’s
clothes or shoes feel tight due to fluid retention. Management focuses on reducing edema
and restoring protein balance through corticosteroids and diet.
with Rationale | Chamberlain University
1. A nurse is caring for an infant with Tetralogy of Fallot who suddenly becomes cyanotic and
dyspneic. Which action should the nurse perform first?
A. Administer 100% oxygen via face mask
B. Notify the pediatric cardiologist immediately
C. Prepare for administration of morphine sulfate
D. Place the infant in a knee-chest position
Correct Answer: D
Explanation: Placing the infant in a knee-chest position increases systemic vascular
resistance, which helps reduce the right-to-left shunt. This maneuver improves pulmonary
blood flow and is the priority intervention for a hypercyanotic spell. Once the infant is
positioned, oxygen and medications can be administered as secondary steps.
2. A 4-week-old infant is brought to the clinic with a history of non-bilious projectile vomiting.
The nurse notes an olive-shaped mass in the right upper quadrant. Which condition is most
likely?
A. Hypertrophic pyloric stenosis
B. Hirschsprung disease
C. Intussusception
,D. Gastroesophageal reflux
Correct Answer: A
Explanation: Hypertrophic pyloric stenosis is characterized by the narrowing of the
pyloric canal, which leads to gastric outlet obstruction. Projectile vomiting and a palpable
olive-shaped mass are classic clinical findings for this condition. These symptoms typically
manifest between 2 to 8 weeks of age as the hypertrophy progresses.
3. A newborn is suspected of having Hirschsprung disease. Which finding should the nurse
expect to observe during the assessment?
A. Visible peristaltic waves across the abdomen
B. Currant jelly-like stools containing blood and mucus
C. Failure to pass meconium within the first 24 to 48 hours
D. A scaphoid abdomen with respiratory distress
Correct Answer: C
Explanation: Hirschsprung disease is a congenital anomaly where ganglion cells are
absent in part of the colon. This lack of innervation prevents peristalsis and leads to a
functional obstruction. The hallmark sign in neonates is the failure to pass meconium
within the first 48 hours of life.
4. The nurse is educating a parent of a child with Intussusception. Which description of the
stool should the nurse include?
A. Currant jelly-like stools
, B. Greasy, frothy, and bulky stools
C. Hard, pebble-like stools
D. Ribbon-like and foul-smelling stools
Correct Answer: A
Explanation: Intussusception occurs when one segment of the bowel telescopes into
another, causing obstruction and ischemia. This leads to the leakage of blood and mucus
into the intestinal lumen. The resulting stools are characteristically described as currant
jelly-like in appearance.
5. A child is admitted with Nephrotic Syndrome. Which clinical manifestation should the
nurse prioritize during the physical assessment?
A. Gross hematuria and hypertension
B. Weight loss and increased appetite
C. Generalized edema and severe proteinuria
D. Elevated serum creatinine and high fever
Correct Answer: C
Explanation: Nephrotic syndrome is characterized by massive proteinuria, which leads to
hypoalbuminemia and subsequent generalized edema. Parents often report that the child’s
clothes or shoes feel tight due to fluid retention. Management focuses on reducing edema
and restoring protein balance through corticosteroids and diet.
