NR328/NR 328 Exam 2 V3 | Pediatric Nursing Q&A
with Rationale | Chamberlain University
1. A nurse is caring for an infant with Tetralogy of Fallot who suddenly becomes cyanotic and
dyspneic. Which action should the nurse perform first?
A. Administer 100% oxygen via blow-by
B. Prepare to administer morphine sulfate
C. Place the infant in a knee-chest position
D. Notify the pediatric cardiologist immediately
Correct Answer: C
Explanation: The knee-chest position is the priority intervention for a hypercyanotic or
‘tet’ spell because it increases systemic vascular resistance. This increased resistance
reduces the right-to-left shunt across the ventricular septal defect, thereby improving
pulmonary blood flow. After positioning, the nurse should then provide oxygen and
consider medication as ordered by the provider.
2. A 4-year-old child is admitted with a diagnosis of epiglottitis. Which nursing intervention is
contraindicated?
A. Maintaining the child in an upright position
B. Visualizing the throat with a tongue depressor
C. Monitoring oxygen saturation via pulse oximetry
,D. Ensuring emergency intubation equipment is at the bedside
Correct Answer: B
Explanation: Attempting to visualize the throat or obtain a throat culture can trigger a
laryngospasm in a child with epiglottitis, leading to immediate airway obstruction. The
primary goal is to keep the child calm and avoid any invasive procedures until the airway is
stabilized. Management focuses on airway maintenance and antibiotic therapy in a
controlled environment.
3. The nurse is assessing a child with a suspected ventricular septal defect (VSD). Which
clinical manifestation is most characteristic of this condition?
A. Weak femoral pulses
B. A loud, harsh holosystolic murmur at the left lower sternal border
C. Cyanosis that increases with crying
D. A machinery-like murmur heard throughout the cardiac cycle
Correct Answer: B
Explanation: A ventricular septal defect (VSD) typically presents with a loud, harsh
holosystolic murmur due to the high-pressure left-to-right shunting of blood. Small defects
may be asymptomatic, while larger ones can lead to heart failure and poor growth. This
condition is the most common congenital heart defect observed in pediatric patients.
, 4. A child is prescribed Pancrelipase for Cystic Fibrosis management. When should the nurse
instruct the parents to administer this medication?
A. With every meal and every snack
B. Once daily in the morning before breakfast
C. Only when the child has a high-fat meal
D. Two hours after eating to maximize absorption
Correct Answer: A
Explanation: Pancreatic enzymes must be taken with all meals and snacks to ensure the
digestion and absorption of fats, proteins, and carbohydrates. In Cystic Fibrosis, the
pancreatic ducts are blocked by thick mucus, preventing natural enzymes from reaching
the duodenum. Consistent administration is essential to prevent malabsorption and
steatorrhea.
5. Which assessment finding in a 2-year-old child with heart failure should the nurse report to
the provider immediately?
A. A weight gain of 1 pound in 24 hours
B. Heart rate of 110 beats per minute while resting
C. Respiratory rate of 28 breaths per minute
D. Increased appetite during the morning feed
Correct Answer: A
with Rationale | Chamberlain University
1. A nurse is caring for an infant with Tetralogy of Fallot who suddenly becomes cyanotic and
dyspneic. Which action should the nurse perform first?
A. Administer 100% oxygen via blow-by
B. Prepare to administer morphine sulfate
C. Place the infant in a knee-chest position
D. Notify the pediatric cardiologist immediately
Correct Answer: C
Explanation: The knee-chest position is the priority intervention for a hypercyanotic or
‘tet’ spell because it increases systemic vascular resistance. This increased resistance
reduces the right-to-left shunt across the ventricular septal defect, thereby improving
pulmonary blood flow. After positioning, the nurse should then provide oxygen and
consider medication as ordered by the provider.
2. A 4-year-old child is admitted with a diagnosis of epiglottitis. Which nursing intervention is
contraindicated?
A. Maintaining the child in an upright position
B. Visualizing the throat with a tongue depressor
C. Monitoring oxygen saturation via pulse oximetry
,D. Ensuring emergency intubation equipment is at the bedside
Correct Answer: B
Explanation: Attempting to visualize the throat or obtain a throat culture can trigger a
laryngospasm in a child with epiglottitis, leading to immediate airway obstruction. The
primary goal is to keep the child calm and avoid any invasive procedures until the airway is
stabilized. Management focuses on airway maintenance and antibiotic therapy in a
controlled environment.
3. The nurse is assessing a child with a suspected ventricular septal defect (VSD). Which
clinical manifestation is most characteristic of this condition?
A. Weak femoral pulses
B. A loud, harsh holosystolic murmur at the left lower sternal border
C. Cyanosis that increases with crying
D. A machinery-like murmur heard throughout the cardiac cycle
Correct Answer: B
Explanation: A ventricular septal defect (VSD) typically presents with a loud, harsh
holosystolic murmur due to the high-pressure left-to-right shunting of blood. Small defects
may be asymptomatic, while larger ones can lead to heart failure and poor growth. This
condition is the most common congenital heart defect observed in pediatric patients.
, 4. A child is prescribed Pancrelipase for Cystic Fibrosis management. When should the nurse
instruct the parents to administer this medication?
A. With every meal and every snack
B. Once daily in the morning before breakfast
C. Only when the child has a high-fat meal
D. Two hours after eating to maximize absorption
Correct Answer: A
Explanation: Pancreatic enzymes must be taken with all meals and snacks to ensure the
digestion and absorption of fats, proteins, and carbohydrates. In Cystic Fibrosis, the
pancreatic ducts are blocked by thick mucus, preventing natural enzymes from reaching
the duodenum. Consistent administration is essential to prevent malabsorption and
steatorrhea.
5. Which assessment finding in a 2-year-old child with heart failure should the nurse report to
the provider immediately?
A. A weight gain of 1 pound in 24 hours
B. Heart rate of 110 beats per minute while resting
C. Respiratory rate of 28 breaths per minute
D. Increased appetite during the morning feed
Correct Answer: A
