NRSG 112 Exam 3 V1 | NRSG 112
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 3) | Ivy Tech
1. A 4-year-old child is brought to the emergency department with a sudden onset of high
fever, drooling, and agitation. The child is sitting in a ‘tripod’ position. Which action should
the nurse take first?
A. Obtain a throat culture to identify the causative organism.
B. Examine the throat using a tongue depressor to visualize the epiglottis.
C. Place the child in a supine position to facilitate breathing.
D. Notify the healthcare provider and prepare for emergency intubation.
Correct Answer: D
These symptoms are classic signs of epiglottitis, which is a life-threatening medical
emergency. Any attempt to visualize the throat or obtain a culture can trigger a
laryngospasm and completely obstruct the airway. The priority is to maintain a patent
airway, keep the child calm, and have emergency intubation equipment readily available.
2. A nurse is caring for an infant who has just undergone a surgical repair for pyloric stenosis.
What is the priority nursing intervention during the immediate postoperative period?
A. Start the infant on full-strength formula immediately.
B. Keep the infant in a flat, supine position for 24 hours.
,C. Maintain IV fluids and monitor for the return of bowel sounds before starting clear
liquids.
D. Apply a tight abdominal binder to protect the incision site.
Correct Answer: C
Postoperative care for pyloromyotomy involves a gradual reintroduction of feeding
starting with clear liquids or glucose water. Monitoring IV fluids is essential to maintain
hydration until oral intake is tolerated. Bowel sounds must be present to ensure the
gastrointestinal tract is functioning before progressing the diet.
3. Which clinical manifestation is most characteristic of a child diagnosed with nephrotic
syndrome?
A. Gross hematuria and hypertension.
B. Massive proteinuria and generalized edema (anasarca).
C. Elevated serum antistreptolysin O (ASO) titer.
D. Increased urine output and weight loss.
Correct Answer: B
Nephrotic syndrome is characterized by increased glomerular permeability to protein,
leading to massive proteinuria. This loss of albumin reduces intravascular oncotic pressure,
causing fluid to shift into the interstitial spaces, resulting in severe edema. Hematuria and
hypertension are more commonly associated with acute glomerulonephritis rather than
nephrotic syndrome.
, 4. A school-age child is admitted with suspected bacterial meningitis. Which nursing action is
the highest priority?
A. Administer the first dose of oral pain medication.
B. Initiate droplet precautions and maintain a quiet, dark environment.
C. Assist the child with range-of-motion exercises to prevent stiffness.
D. Encourage frequent visitors to keep the child’s spirits up.
Correct Answer: B
Bacterial meningitis is highly contagious and requires immediate isolation using droplet
precautions to prevent spread to others. A quiet, dark environment is necessary because
these children are often photophobic and hypersensitive to stimuli. Reducing
environmental triggers helps minimize the risk of seizures and decreases intracranial
pressure.
5. The nurse is providing discharge instructions to the parents of a 2-month-old infant with
developmental dysplasia of the hip (DDH) who is being treated with a Pavlik harness. Which
statement by the parent indicates a need for further teaching?
A. I will take the harness off for at least two hours every day so the baby can kick freely.
B. I will put the diaper on underneath the straps of the harness.
C. I will check the skin under the straps for redness several times a day.
D. I will avoid using lotions or powders under the harness.
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 3) | Ivy Tech
1. A 4-year-old child is brought to the emergency department with a sudden onset of high
fever, drooling, and agitation. The child is sitting in a ‘tripod’ position. Which action should
the nurse take first?
A. Obtain a throat culture to identify the causative organism.
B. Examine the throat using a tongue depressor to visualize the epiglottis.
C. Place the child in a supine position to facilitate breathing.
D. Notify the healthcare provider and prepare for emergency intubation.
Correct Answer: D
These symptoms are classic signs of epiglottitis, which is a life-threatening medical
emergency. Any attempt to visualize the throat or obtain a culture can trigger a
laryngospasm and completely obstruct the airway. The priority is to maintain a patent
airway, keep the child calm, and have emergency intubation equipment readily available.
2. A nurse is caring for an infant who has just undergone a surgical repair for pyloric stenosis.
What is the priority nursing intervention during the immediate postoperative period?
A. Start the infant on full-strength formula immediately.
B. Keep the infant in a flat, supine position for 24 hours.
,C. Maintain IV fluids and monitor for the return of bowel sounds before starting clear
liquids.
D. Apply a tight abdominal binder to protect the incision site.
Correct Answer: C
Postoperative care for pyloromyotomy involves a gradual reintroduction of feeding
starting with clear liquids or glucose water. Monitoring IV fluids is essential to maintain
hydration until oral intake is tolerated. Bowel sounds must be present to ensure the
gastrointestinal tract is functioning before progressing the diet.
3. Which clinical manifestation is most characteristic of a child diagnosed with nephrotic
syndrome?
A. Gross hematuria and hypertension.
B. Massive proteinuria and generalized edema (anasarca).
C. Elevated serum antistreptolysin O (ASO) titer.
D. Increased urine output and weight loss.
Correct Answer: B
Nephrotic syndrome is characterized by increased glomerular permeability to protein,
leading to massive proteinuria. This loss of albumin reduces intravascular oncotic pressure,
causing fluid to shift into the interstitial spaces, resulting in severe edema. Hematuria and
hypertension are more commonly associated with acute glomerulonephritis rather than
nephrotic syndrome.
, 4. A school-age child is admitted with suspected bacterial meningitis. Which nursing action is
the highest priority?
A. Administer the first dose of oral pain medication.
B. Initiate droplet precautions and maintain a quiet, dark environment.
C. Assist the child with range-of-motion exercises to prevent stiffness.
D. Encourage frequent visitors to keep the child’s spirits up.
Correct Answer: B
Bacterial meningitis is highly contagious and requires immediate isolation using droplet
precautions to prevent spread to others. A quiet, dark environment is necessary because
these children are often photophobic and hypersensitive to stimuli. Reducing
environmental triggers helps minimize the risk of seizures and decreases intracranial
pressure.
5. The nurse is providing discharge instructions to the parents of a 2-month-old infant with
developmental dysplasia of the hip (DDH) who is being treated with a Pavlik harness. Which
statement by the parent indicates a need for further teaching?
A. I will take the harness off for at least two hours every day so the baby can kick freely.
B. I will put the diaper on underneath the straps of the harness.
C. I will check the skin under the straps for redness several times a day.
D. I will avoid using lotions or powders under the harness.
