NUR 231 Exam 4 Actual Exam V3 | NUR 231 Childbearing & Child
Caring Family (NUR231 Exam 4) | Galen College of Nursing
1. A nurse is assessing a 4-year-old child with suspected epiglottitis. Which clinical
manifestation should the nurse prioritize as a sign of imminent airway obstruction?
A. Drooling, dysphonia, and distress
B. Barking cough and afebrile state
C. Bilateral wheezing and productive cough
D. Nasal congestion and sore throat
Answer: A
Rationale: Epiglottitis is a pediatric emergency characterized by the four Ds: Drooling,
Dysphagia, Dysphonia, and Distressed inspiratory efforts. This condition involves severe
inflammation of the epiglottis which can lead to sudden, total airway occlusion. The nurse
must avoid examining the throat with a tongue depressor to prevent triggering a fatal
laryngospasm.
2. An infant is diagnosed with Tetralogy of Fallot and experiences a hypercyanotic (tet) spell
during a blood draw. Which immediate action should the nurse take?
A. Place the infant in a knee-chest position
B. Administer high-flow oxygen via nasal cannula
C. Prepare for immediate endotracheal intubation
D. Administer a bolus of intravenous fluids
Answer: A
Rationale: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt across the ventricular septal defect. This maneuver improves
pulmonary blood flow and increases oxygenation during a hypercyanotic spell. Following
this position change, the nurse should provide supplemental oxygen and may administer
morphine to reduce infundibular spasms.
3. A 10-year-old child is hospitalized with Acute Post-Streptococcal Glomerulonephritis
(APSGN). Which assessment finding requires immediate notification of the healthcare
provider?
A. Blood pressure of 152/96 mmHg
B. Periorbital edema that is worse in the morning
C. Tea-colored or smoky urine
,D. A weight gain of 1 pound over 24 hours
Answer: A
Rationale: Hypertension is a significant complication of APSGN and can lead to
hypertensive encephalopathy or seizures if left untreated. While tea-colored urine and
periorbital edema are classic signs of the disease, they are expected rather than emergent.
The nurse must monitor blood pressure frequently and report significant elevations to
initiate antihypertensive therapy.
4. A nurse is providing discharge teaching to the parents of a toddler newly diagnosed with
Celiac Disease. Which food choice indicates a need for further teaching?
A. Corn tortillas with grilled chicken
B. Rice cakes with peanut butter
C. Oatmeal cookies made with traditional oats
D. Fresh fruit salad and yogurt
Answer: C
Rationale: Celiac disease requires a lifelong gluten-free diet, which means avoiding wheat,
barley, rye, and frequently oats due to cross-contamination. Traditional oats often contain
gluten unless specifically labeled as certified gluten-free. Educating the family on reading
labels for hidden gluten sources is essential for preventing intestinal damage and
malabsorption.
5. A 2-month-old infant is admitted with Hirschsprung disease. Which stool characteristic
should the nurse expect to document in the patient record?
A. Currant jelly-like stools containing blood and mucus
B. Ribbon-like, foul-smelling stools
C. Large, oily, pale-colored stools
D. Hard, marble-like pellets
Answer: B
Rationale: Hirschsprung disease is characterized by an absence of ganglion cells in the
distal colon, leading to a functional obstruction. This results in the passage of ribbon-like,
foul-smelling stools as the stool passes through the narrowed segment. Currant jelly stools
are indicative of intussusception, while oily stools (steatorrhea) are associated with cystic
fibrosis.
6. A nurse is evaluating the developmental progress of an 18-month-old child. According to
Erikson, which behavior indicates successful achievement of the current developmental task?
A. The child shares toys willingly with other children.
, B. The child follows complex two-step instructions consistently.
C. The child plays cooperatively in a small group.
D. The child says ‘No’ frequently and attempts to dress themselves.
Answer: D
Rationale: Toddlers (ages 1-3) are in the stage of Autonomy vs. Shame and Doubt. The use
of ‘negativism’ (saying no) and the desire for independence in self-care are hallmarks of
developing autonomy. Successful completion of this stage results in a child who is confident
in their ability to survive in the world.
7. A child with Cystic Fibrosis (CF) is prescribed pancrelipase. Which instruction should the
nurse provide to the parents regarding medication administration?
A. Administer the enzymes once daily in the morning.
B. Mix the enzyme beads with hot oatmeal or applesauce.
C. Give the enzymes with every meal and snack.
D. Ensure the child chews the capsules thoroughly.
Answer: C
Rationale: Pancreatic enzymes are necessary for the digestion of fats and proteins in
children with CF and must be taken with all food intake. The enzymes should not be
chewed or crushed as they are enteric-coated to survive the stomach acid. If the child
cannot swallow capsules, they can be opened and sprinkled on a small amount of acidic
food like applesauce, but not hot foods which can deactivate the enzymes.
8. A nurse is caring for a 6-year-old child following a tonsillectomy. Which assessment finding
is the most sensitive indicator of postoperative hemorrhage?
A. Bright red emesis of 10 mL
B. A report of a ‘scratchy’ throat
C. Frequent swallowing or throat clearing
D. A heart rate of 95 beats per minute
Answer: C
Rationale: Frequent swallowing or clearing of the throat is a classic sign of bleeding from
the surgical site in the posterior pharynx. This occurs as the child swallows the blood
trickling down the throat, often while sleeping. The nurse must maintain a high index of
suspicion for hemorrhage during the first 24 hours and again 7-10 days post-op when the
scabs slough off.
Caring Family (NUR231 Exam 4) | Galen College of Nursing
1. A nurse is assessing a 4-year-old child with suspected epiglottitis. Which clinical
manifestation should the nurse prioritize as a sign of imminent airway obstruction?
A. Drooling, dysphonia, and distress
B. Barking cough and afebrile state
C. Bilateral wheezing and productive cough
D. Nasal congestion and sore throat
Answer: A
Rationale: Epiglottitis is a pediatric emergency characterized by the four Ds: Drooling,
Dysphagia, Dysphonia, and Distressed inspiratory efforts. This condition involves severe
inflammation of the epiglottis which can lead to sudden, total airway occlusion. The nurse
must avoid examining the throat with a tongue depressor to prevent triggering a fatal
laryngospasm.
2. An infant is diagnosed with Tetralogy of Fallot and experiences a hypercyanotic (tet) spell
during a blood draw. Which immediate action should the nurse take?
A. Place the infant in a knee-chest position
B. Administer high-flow oxygen via nasal cannula
C. Prepare for immediate endotracheal intubation
D. Administer a bolus of intravenous fluids
Answer: A
Rationale: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt across the ventricular septal defect. This maneuver improves
pulmonary blood flow and increases oxygenation during a hypercyanotic spell. Following
this position change, the nurse should provide supplemental oxygen and may administer
morphine to reduce infundibular spasms.
3. A 10-year-old child is hospitalized with Acute Post-Streptococcal Glomerulonephritis
(APSGN). Which assessment finding requires immediate notification of the healthcare
provider?
A. Blood pressure of 152/96 mmHg
B. Periorbital edema that is worse in the morning
C. Tea-colored or smoky urine
,D. A weight gain of 1 pound over 24 hours
Answer: A
Rationale: Hypertension is a significant complication of APSGN and can lead to
hypertensive encephalopathy or seizures if left untreated. While tea-colored urine and
periorbital edema are classic signs of the disease, they are expected rather than emergent.
The nurse must monitor blood pressure frequently and report significant elevations to
initiate antihypertensive therapy.
4. A nurse is providing discharge teaching to the parents of a toddler newly diagnosed with
Celiac Disease. Which food choice indicates a need for further teaching?
A. Corn tortillas with grilled chicken
B. Rice cakes with peanut butter
C. Oatmeal cookies made with traditional oats
D. Fresh fruit salad and yogurt
Answer: C
Rationale: Celiac disease requires a lifelong gluten-free diet, which means avoiding wheat,
barley, rye, and frequently oats due to cross-contamination. Traditional oats often contain
gluten unless specifically labeled as certified gluten-free. Educating the family on reading
labels for hidden gluten sources is essential for preventing intestinal damage and
malabsorption.
5. A 2-month-old infant is admitted with Hirschsprung disease. Which stool characteristic
should the nurse expect to document in the patient record?
A. Currant jelly-like stools containing blood and mucus
B. Ribbon-like, foul-smelling stools
C. Large, oily, pale-colored stools
D. Hard, marble-like pellets
Answer: B
Rationale: Hirschsprung disease is characterized by an absence of ganglion cells in the
distal colon, leading to a functional obstruction. This results in the passage of ribbon-like,
foul-smelling stools as the stool passes through the narrowed segment. Currant jelly stools
are indicative of intussusception, while oily stools (steatorrhea) are associated with cystic
fibrosis.
6. A nurse is evaluating the developmental progress of an 18-month-old child. According to
Erikson, which behavior indicates successful achievement of the current developmental task?
A. The child shares toys willingly with other children.
, B. The child follows complex two-step instructions consistently.
C. The child plays cooperatively in a small group.
D. The child says ‘No’ frequently and attempts to dress themselves.
Answer: D
Rationale: Toddlers (ages 1-3) are in the stage of Autonomy vs. Shame and Doubt. The use
of ‘negativism’ (saying no) and the desire for independence in self-care are hallmarks of
developing autonomy. Successful completion of this stage results in a child who is confident
in their ability to survive in the world.
7. A child with Cystic Fibrosis (CF) is prescribed pancrelipase. Which instruction should the
nurse provide to the parents regarding medication administration?
A. Administer the enzymes once daily in the morning.
B. Mix the enzyme beads with hot oatmeal or applesauce.
C. Give the enzymes with every meal and snack.
D. Ensure the child chews the capsules thoroughly.
Answer: C
Rationale: Pancreatic enzymes are necessary for the digestion of fats and proteins in
children with CF and must be taken with all food intake. The enzymes should not be
chewed or crushed as they are enteric-coated to survive the stomach acid. If the child
cannot swallow capsules, they can be opened and sprinkled on a small amount of acidic
food like applesauce, but not hot foods which can deactivate the enzymes.
8. A nurse is caring for a 6-year-old child following a tonsillectomy. Which assessment finding
is the most sensitive indicator of postoperative hemorrhage?
A. Bright red emesis of 10 mL
B. A report of a ‘scratchy’ throat
C. Frequent swallowing or throat clearing
D. A heart rate of 95 beats per minute
Answer: C
Rationale: Frequent swallowing or clearing of the throat is a classic sign of bleeding from
the surgical site in the posterior pharynx. This occurs as the child swallows the blood
trickling down the throat, often while sleeping. The nurse must maintain a high index of
suspicion for hemorrhage during the first 24 hours and again 7-10 days post-op when the
scabs slough off.
