NUR 203/NUR203 Exam 2 V1 | Pediatric Nursing
Q&A with Rationale | Fortis College
1. A 3-year-old child is brought to the emergency department with a high fever, muffled
voice, and is sitting in a ‘tripod’ position. What is the nurse’s immediate priority action?
A. Inspect the posterior pharynx for inflammation.
B. Prepare for emergency airway management.
C. Obtain a stat throat culture to identify the pathogen.
D. Administer an oral antipyretic for the fever.
Correct Answer: B
Explanation: The clinical presentation is classic for acute epiglottitis, which is a life-
threatening pediatric emergency. Attempting to visualize the throat with a tongue blade or
performing a culture can trigger a laryngospasm and complete airway obstruction. The
nurse must prioritize keeping the child calm and preparing for intubation or tracheostomy.
2. When planning care for a child with Tetralogy of Fallot, the nurse understands that ‘Tet
spells’ are best managed by which position?
A. High Fowler’s position
B. Knee-chest position
C. Supine with legs elevated
D. Prone with a pillow under the chest
,Correct Answer: B
Explanation: The knee-chest position increases systemic vascular resistance and reduces
the right-to-left shunt across the ventricular septal defect. This helps increase pulmonary
blood flow and improve oxygenation during a hypercyanotic spell. It is the immediate
nursing intervention required for a child exhibiting acute cyanosis and distress.
3. A nurse is providing discharge teaching for a child newly diagnosed with Cystic Fibrosis.
Which instruction regarding pancreatic enzyme replacement is correct?
A. Enzymes should be taken with every meal and snack.
B. Administer enzymes once daily in the morning.
C. Skip the enzymes if the child is having a loose stool.
D. Crush the enzyme beads to facilitate easier swallowing.
Correct Answer: A
Explanation: Pancreatic enzymes are essential for the digestion of fats and proteins in
children with Cystic Fibrosis. These enzymes must be taken with all meals and snacks to
ensure proper nutrient absorption. The beads should not be crushed as they are enteric-
coated to prevent degradation by stomach acid.
4. A 6-week-old infant is admitted with suspected hypertrophic pyloric stenosis. Which
clinical finding does the nurse expect to assess?
A. Projectile vomiting after feeding
B. Bile-stained emesis
, C. Diarrhea with abdominal distension
D. Currant jelly-like stools
Correct Answer: A
Explanation: Hypertrophic pyloric stenosis is characterized by a thickening of the pyloric
sphincter, leading to obstruction. The classic symptom is non-bilious projectile vomiting
immediately after feeding. Additionally, an olive-shaped mass may be palpated in the right
upper quadrant of the abdomen.
5. The nurse is evaluating a 10-month-old infant for intussusception. Which assessment
finding is most characteristic of this condition?
A. Ribbon-like stools
B. Steatorrhea and foul-smelling stools
C. Absence of bowel movements for 3 days
D. Stools mixed with blood and mucus (currant jelly)
Correct Answer: D
Explanation: Intussusception occurs when one segment of the bowel telescopes into
another, leading to ischemia and mucus production. This results in the classic ‘currant jelly’
stool, which is a hallmark diagnostic sign. The infant often presents with sudden,
intermittent abdominal pain and a sausage-shaped mass in the abdomen.
Q&A with Rationale | Fortis College
1. A 3-year-old child is brought to the emergency department with a high fever, muffled
voice, and is sitting in a ‘tripod’ position. What is the nurse’s immediate priority action?
A. Inspect the posterior pharynx for inflammation.
B. Prepare for emergency airway management.
C. Obtain a stat throat culture to identify the pathogen.
D. Administer an oral antipyretic for the fever.
Correct Answer: B
Explanation: The clinical presentation is classic for acute epiglottitis, which is a life-
threatening pediatric emergency. Attempting to visualize the throat with a tongue blade or
performing a culture can trigger a laryngospasm and complete airway obstruction. The
nurse must prioritize keeping the child calm and preparing for intubation or tracheostomy.
2. When planning care for a child with Tetralogy of Fallot, the nurse understands that ‘Tet
spells’ are best managed by which position?
A. High Fowler’s position
B. Knee-chest position
C. Supine with legs elevated
D. Prone with a pillow under the chest
,Correct Answer: B
Explanation: The knee-chest position increases systemic vascular resistance and reduces
the right-to-left shunt across the ventricular septal defect. This helps increase pulmonary
blood flow and improve oxygenation during a hypercyanotic spell. It is the immediate
nursing intervention required for a child exhibiting acute cyanosis and distress.
3. A nurse is providing discharge teaching for a child newly diagnosed with Cystic Fibrosis.
Which instruction regarding pancreatic enzyme replacement is correct?
A. Enzymes should be taken with every meal and snack.
B. Administer enzymes once daily in the morning.
C. Skip the enzymes if the child is having a loose stool.
D. Crush the enzyme beads to facilitate easier swallowing.
Correct Answer: A
Explanation: Pancreatic enzymes are essential for the digestion of fats and proteins in
children with Cystic Fibrosis. These enzymes must be taken with all meals and snacks to
ensure proper nutrient absorption. The beads should not be crushed as they are enteric-
coated to prevent degradation by stomach acid.
4. A 6-week-old infant is admitted with suspected hypertrophic pyloric stenosis. Which
clinical finding does the nurse expect to assess?
A. Projectile vomiting after feeding
B. Bile-stained emesis
, C. Diarrhea with abdominal distension
D. Currant jelly-like stools
Correct Answer: A
Explanation: Hypertrophic pyloric stenosis is characterized by a thickening of the pyloric
sphincter, leading to obstruction. The classic symptom is non-bilious projectile vomiting
immediately after feeding. Additionally, an olive-shaped mass may be palpated in the right
upper quadrant of the abdomen.
5. The nurse is evaluating a 10-month-old infant for intussusception. Which assessment
finding is most characteristic of this condition?
A. Ribbon-like stools
B. Steatorrhea and foul-smelling stools
C. Absence of bowel movements for 3 days
D. Stools mixed with blood and mucus (currant jelly)
Correct Answer: D
Explanation: Intussusception occurs when one segment of the bowel telescopes into
another, leading to ischemia and mucus production. This results in the classic ‘currant jelly’
stool, which is a hallmark diagnostic sign. The infant often presents with sudden,
intermittent abdominal pain and a sausage-shaped mass in the abdomen.
