NUR 203/NUR203 Exam 3 V1 | Pediatric Nursing
Q&A with Rationale | Fortis College
1. A 4-week-old infant is brought to the clinic for projectile vomiting after feedings. The nurse
notes an olive-shaped mass in the right upper quadrant. Which condition is most likely?
A. Intussusception
B. Hypertrophic Pyloric Stenosis
C. Hirschsprung Disease
D. Gastroesophageal Reflux
Correct Answer: B
Explanation: Hypertrophic pyloric stenosis is characterized by the thickening of the
pyloric sphincter, leading to obstruction and projectile vomiting. The ‘olive-shaped mass’ is
a classic pathognomonic finding on physical examination of the abdomen. This condition
typically presents between 3 to 6 weeks of age and requires surgical intervention.
2. A child is admitted with a diagnosis of Intussusception. Which clinical manifestation should
the nurse expect to find in the child’s history?
A. Ribbon-like, foul-smelling stools
B. Persistent constipation
C. Projectile vomiting
D. Currant jelly-like stools
,Correct Answer: D
Explanation: Intussusception occurs when one portion of the intestine telescopes into
another, causing obstruction and ischemia. The classic triad includes abdominal pain, a
sausage-shaped mass, and ‘currant jelly’ stools mixed with blood and mucus. This is a
medical emergency that may be resolved with an air or saline enema.
3. When caring for a child with Nephrotic Syndrome, which primary goal should the nurse
include in the plan of care?
A. Reducing protein intake
B. Increasing sodium intake to manage edema
C. Decreasing urinary excretion of protein
D. Maintaining a high fluid intake
Correct Answer: C
Explanation: Nephrotic syndrome is characterized by massive proteinuria,
hypoalbuminemia, and severe edema. The primary goal of treatment is to reduce the loss of
protein in the urine, often through corticosteroid therapy. Nurses must also monitor fluid
balance and prevent infection in these immunocompromised patients.
4. A school-age child is diagnosed with Acute Glomerulonephritis (AGN). The nurse knows
that this condition is most commonly preceded by which of the following?
A. A urinary tract infection
B. A viral gastrointestinal illness
, C. A streptococcal throat infection
D. An allergic reaction to medication
Correct Answer: C
Explanation: Acute Post-Streptococcal Glomerulonephritis (APSGN) typically follows a
Group A beta-hemolytic streptococcal infection of the throat or skin. The symptoms usually
appear 1 to 2 weeks after the initial infection. Clinical manifestations include hematuria
(tea-colored urine), hypertension, and periorbital edema.
5. A 10-year-old child with Type 1 Diabetes Mellitus presents with shakiness, diaphoresis, and
pallor. What is the nurse’s first action?
A. Administer 15 grams of simple carbohydrates
B. Administer the scheduled dose of insulin
C. Check the child’s blood glucose level
D. Call the healthcare provider immediately
Correct Answer: C
Explanation: When a diabetic patient exhibits signs of hypoglycemia, the first step is to
confirm the blood glucose level if possible. If the glucose is low, the nurse should
immediately follow the 15/15 rule by giving 15g of simple carbs. Safety is a priority, so the
nurse must act quickly to prevent seizure or loss of consciousness.
Q&A with Rationale | Fortis College
1. A 4-week-old infant is brought to the clinic for projectile vomiting after feedings. The nurse
notes an olive-shaped mass in the right upper quadrant. Which condition is most likely?
A. Intussusception
B. Hypertrophic Pyloric Stenosis
C. Hirschsprung Disease
D. Gastroesophageal Reflux
Correct Answer: B
Explanation: Hypertrophic pyloric stenosis is characterized by the thickening of the
pyloric sphincter, leading to obstruction and projectile vomiting. The ‘olive-shaped mass’ is
a classic pathognomonic finding on physical examination of the abdomen. This condition
typically presents between 3 to 6 weeks of age and requires surgical intervention.
2. A child is admitted with a diagnosis of Intussusception. Which clinical manifestation should
the nurse expect to find in the child’s history?
A. Ribbon-like, foul-smelling stools
B. Persistent constipation
C. Projectile vomiting
D. Currant jelly-like stools
,Correct Answer: D
Explanation: Intussusception occurs when one portion of the intestine telescopes into
another, causing obstruction and ischemia. The classic triad includes abdominal pain, a
sausage-shaped mass, and ‘currant jelly’ stools mixed with blood and mucus. This is a
medical emergency that may be resolved with an air or saline enema.
3. When caring for a child with Nephrotic Syndrome, which primary goal should the nurse
include in the plan of care?
A. Reducing protein intake
B. Increasing sodium intake to manage edema
C. Decreasing urinary excretion of protein
D. Maintaining a high fluid intake
Correct Answer: C
Explanation: Nephrotic syndrome is characterized by massive proteinuria,
hypoalbuminemia, and severe edema. The primary goal of treatment is to reduce the loss of
protein in the urine, often through corticosteroid therapy. Nurses must also monitor fluid
balance and prevent infection in these immunocompromised patients.
4. A school-age child is diagnosed with Acute Glomerulonephritis (AGN). The nurse knows
that this condition is most commonly preceded by which of the following?
A. A urinary tract infection
B. A viral gastrointestinal illness
, C. A streptococcal throat infection
D. An allergic reaction to medication
Correct Answer: C
Explanation: Acute Post-Streptococcal Glomerulonephritis (APSGN) typically follows a
Group A beta-hemolytic streptococcal infection of the throat or skin. The symptoms usually
appear 1 to 2 weeks after the initial infection. Clinical manifestations include hematuria
(tea-colored urine), hypertension, and periorbital edema.
5. A 10-year-old child with Type 1 Diabetes Mellitus presents with shakiness, diaphoresis, and
pallor. What is the nurse’s first action?
A. Administer 15 grams of simple carbohydrates
B. Administer the scheduled dose of insulin
C. Check the child’s blood glucose level
D. Call the healthcare provider immediately
Correct Answer: C
Explanation: When a diabetic patient exhibits signs of hypoglycemia, the first step is to
confirm the blood glucose level if possible. If the glucose is low, the nurse should
immediately follow the 15/15 rule by giving 15g of simple carbs. Safety is a priority, so the
nurse must act quickly to prevent seizure or loss of consciousness.
