NUR 418 / NUR 415 Exam 4 V3 | NUR 418 /
NUR 415 Nursing Care of the Childbearing
& Childrearing Family | Actual Q&A with
Rationale (NUR418/NUR415 Exam 4) |
Concordia
1. A nurse is caring for a 4-year-old child admitted with a diagnosis of acute epiglottitis.
Which of the following nursing actions are appropriate? (Select All That Apply)
A. Examine the child’s throat using a tongue blade
B. Keep the child in a calm, upright position
C. Monitor oxygen saturation levels continuously
D. Have emergency tracheostomy and intubation equipment at the bedside
E. Administer oral fluids to maintain hydration
F. Allow the child to remain in the caregiver’s lap
Correct Answer: B, C, D, F
Explanation; Assessment of the throat with a tongue blade or swab is strictly
contraindicated in cases of suspected epiglottitis because it can trigger immediate
laryngospasm and complete airway obstruction. The child should be kept in a position of
comfort, often in a parent’s lap, to reduce anxiety and work of breathing. Emergency airway
,equipment must be readily available because the child’s status can deteriorate rapidly into
respiratory arrest.
2. A child is admitted with a suspected diagnosis of intussusception. Which clinical
manifestation should the nurse expect to find during the assessment?
A. Projectile vomiting containing undigested food
B. Ribbon-like, foul-smelling stools
C. Currant jelly-like stools containing blood and mucus
D. Severe, constant pain in the lower left quadrant
Correct Answer: C
Explanation; Intussusception is characterized by the telescoping of one portion of the
intestine into another, which causes inflammation and decreased blood flow. The hallmark
clinical finding is ‘currant jelly’ stools, which result from the leakage of blood and mucus
into the intestinal lumen. The pain associated with intussusception is typically episodic and
colicky rather than constant.
3. A nurse is providing discharge teaching to the parents of a child with cystic fibrosis. Which
information regarding pancreatic enzyme replacement should be included?
A. Enzymes should be administered with all meals and snacks
B. Enzymes should be given once daily in the morning
C. The capsules should be swallowed whole and never opened
,D. Enzymes are only necessary when the child consumes high-fat meals
Correct Answer: A
Explanation; In cystic fibrosis, thick mucus blocks the pancreatic ducts, preventing
digestive enzymes from reaching the duodenum. Pancreatic enzymes must be taken with
every meal and snack to facilitate the absorption of fats, proteins, and carbohydrates. For
younger children, capsules may be opened and the beads sprinkled on acidic foods like
applesauce, but they should never be crushed or chewed.
4. The nurse is evaluating a 2-month-old infant for developmental dysplasia of the hip (DDH).
Which assessment finding is most suggestive of this condition?
A. Symmetrical gluteal folds
B. Apparent shortening of the limb on the affected side
C. Negative Ortolani and Barlow maneuvers
D. Inward rotation of the affected foot
Correct Answer: B
Explanation; Clinical manifestations of developmental dysplasia of the hip include an
apparent shortening of the femur on the affected side, known as the Galeazzi sign.
Additionally, the nurse would expect to see asymmetrical skin folds on the thighs and
gluteal region. The Ortolani and Barlow maneuvers would be positive in an infant with
DDH, indicating hip instability or dislocation.
, 5. A child with Tetralogy of Fallot becomes acutely cyanotic and agitated while crying. Which
action should the nurse perform first?
A. Administer 100% oxygen via face mask
B. Call for the rapid response team
C. Prepare for the administration of morphine sulfate
D. Place the child in the knee-chest position
Correct Answer: D
Explanation; The knee-chest position is the priority intervention for a ‘tet spell’ or
hypercyanotic episode. This position increases systemic vascular resistance, which helps
reduce the right-to-left shunt and improves pulmonary blood flow. Oxygen and morphine
may follow, but the mechanical change in blood flow provided by the knee-chest position is
the immediate first step.
6. A nurse is assessing a 6-year-old child with a diagnosis of Acute Glomerulonephritis. Which
findings are typically associated with this condition? (Select All That Apply)
A. Periorbital edema
B. Massive proteinuria
C. Hypertension
D. Tea-colored or smoky urine
E. Hypotension
NUR 415 Nursing Care of the Childbearing
& Childrearing Family | Actual Q&A with
Rationale (NUR418/NUR415 Exam 4) |
Concordia
1. A nurse is caring for a 4-year-old child admitted with a diagnosis of acute epiglottitis.
Which of the following nursing actions are appropriate? (Select All That Apply)
A. Examine the child’s throat using a tongue blade
B. Keep the child in a calm, upright position
C. Monitor oxygen saturation levels continuously
D. Have emergency tracheostomy and intubation equipment at the bedside
E. Administer oral fluids to maintain hydration
F. Allow the child to remain in the caregiver’s lap
Correct Answer: B, C, D, F
Explanation; Assessment of the throat with a tongue blade or swab is strictly
contraindicated in cases of suspected epiglottitis because it can trigger immediate
laryngospasm and complete airway obstruction. The child should be kept in a position of
comfort, often in a parent’s lap, to reduce anxiety and work of breathing. Emergency airway
,equipment must be readily available because the child’s status can deteriorate rapidly into
respiratory arrest.
2. A child is admitted with a suspected diagnosis of intussusception. Which clinical
manifestation should the nurse expect to find during the assessment?
A. Projectile vomiting containing undigested food
B. Ribbon-like, foul-smelling stools
C. Currant jelly-like stools containing blood and mucus
D. Severe, constant pain in the lower left quadrant
Correct Answer: C
Explanation; Intussusception is characterized by the telescoping of one portion of the
intestine into another, which causes inflammation and decreased blood flow. The hallmark
clinical finding is ‘currant jelly’ stools, which result from the leakage of blood and mucus
into the intestinal lumen. The pain associated with intussusception is typically episodic and
colicky rather than constant.
3. A nurse is providing discharge teaching to the parents of a child with cystic fibrosis. Which
information regarding pancreatic enzyme replacement should be included?
A. Enzymes should be administered with all meals and snacks
B. Enzymes should be given once daily in the morning
C. The capsules should be swallowed whole and never opened
,D. Enzymes are only necessary when the child consumes high-fat meals
Correct Answer: A
Explanation; In cystic fibrosis, thick mucus blocks the pancreatic ducts, preventing
digestive enzymes from reaching the duodenum. Pancreatic enzymes must be taken with
every meal and snack to facilitate the absorption of fats, proteins, and carbohydrates. For
younger children, capsules may be opened and the beads sprinkled on acidic foods like
applesauce, but they should never be crushed or chewed.
4. The nurse is evaluating a 2-month-old infant for developmental dysplasia of the hip (DDH).
Which assessment finding is most suggestive of this condition?
A. Symmetrical gluteal folds
B. Apparent shortening of the limb on the affected side
C. Negative Ortolani and Barlow maneuvers
D. Inward rotation of the affected foot
Correct Answer: B
Explanation; Clinical manifestations of developmental dysplasia of the hip include an
apparent shortening of the femur on the affected side, known as the Galeazzi sign.
Additionally, the nurse would expect to see asymmetrical skin folds on the thighs and
gluteal region. The Ortolani and Barlow maneuvers would be positive in an infant with
DDH, indicating hip instability or dislocation.
, 5. A child with Tetralogy of Fallot becomes acutely cyanotic and agitated while crying. Which
action should the nurse perform first?
A. Administer 100% oxygen via face mask
B. Call for the rapid response team
C. Prepare for the administration of morphine sulfate
D. Place the child in the knee-chest position
Correct Answer: D
Explanation; The knee-chest position is the priority intervention for a ‘tet spell’ or
hypercyanotic episode. This position increases systemic vascular resistance, which helps
reduce the right-to-left shunt and improves pulmonary blood flow. Oxygen and morphine
may follow, but the mechanical change in blood flow provided by the knee-chest position is
the immediate first step.
6. A nurse is assessing a 6-year-old child with a diagnosis of Acute Glomerulonephritis. Which
findings are typically associated with this condition? (Select All That Apply)
A. Periorbital edema
B. Massive proteinuria
C. Hypertension
D. Tea-colored or smoky urine
E. Hypotension
