NUR 203/NUR203 Exam 3 V2 | Pediatric Nursing
Q&A with Rationale | Fortis College
1. A nurse is assessing a 4-week-old infant who has been diagnosed with hypertrophic pyloric
stenosis. Which clinical finding should the nurse expect to observe?
A. Currant jelly-like stools
B. Ribbon-like stools
C. Projectile vomiting after feedings
D. Bile-stained vomitus
Correct Answer: C
Explanation: Projectile vomiting is the classic sign of hypertrophic pyloric stenosis due to
the narrowing of the pyloric sphincter. This vomiting typically occurs shortly after feeding
and does not contain bile because the obstruction is proximal to the ampulla of Vater. The
nurse may also palpate an olive-shaped mass in the right upper quadrant of the abdomen.
2. When caring for a child with intussusception, which of the following stool characteristics is
most indicative of this condition?
A. Stools containing blood and mucus
B. Steatorrhea
C. Hard, marble-like stools
D. Thin, pencil-like stools
,Correct Answer: A
Explanation: Intussusception often results in stools that are described as ‘currant jelly’
because they contain a mixture of blood and mucus. This occurs because the telescoping of
the bowel causes inflammation, edema, and decreased blood flow to the affected area. If the
child passes a normal brown stool, it may indicate that the intussusception has reduced
spontaneously.
3. A child is admitted with a diagnosis of acute glomerulonephritis (AGN). Which of the
following laboratory or clinical findings is most consistent with this diagnosis?
A. Massive proteinuria and hypoalbuminemia
B. Hypotension and bradycardia
C. Low serum creatinine levels
D. Periorbital edema and tea-colored urine
Correct Answer: D
Explanation: Acute glomerulonephritis is frequently characterized by hematuria, which
gives the urine a smoky or tea-colored appearance. Periorbital edema is also a common
early sign due to fluid retention and decreased glomerular filtration. This condition often
follows a recent streptococcal infection, such as strep throat or impetigo.
4. The nurse is providing education to the parents of a child with Nephrotic Syndrome. Which
goal of therapy should the nurse emphasize?
A. Increasing dietary sodium intake
,B. Limiting physical activity to bed rest
C. Reducing excretion of urinary protein
D. Maintaining high fluid intake to flush the kidneys
Correct Answer: C
Explanation: The primary goal in treating Nephrotic Syndrome is to reduce the amount of
protein lost in the urine to resolve the edema. Corticosteroids like prednisone are typically
the first line of treatment to achieve remission and decrease proteinuria. Nurses must also
monitor for signs of infection, as these children are often immunocompromised due to
therapy.
5. Which of the following interventions is a priority for a newborn diagnosed with
Developmental Dysplasia of the Hip (DDH) assigned to a Pavlik harness?
A. Remove the harness for diaper changes and bathing
B. Adjust the straps every 4 hours to ensure a tight fit
C. Check the skin under the straps for redness or irritation
D. Ensure the baby’s legs are kept in an adducted position
Correct Answer: C
Explanation: Skin integrity is a major concern for infants in a Pavlik harness, and parents
should check for redness or skin breakdown at least two to three times a day. The harness
should generally be worn 24 hours a day and should only be removed if specifically
, directed by the provider. The harness is designed to maintain the hips in abduction and
flexion to promote proper acetabular development.
6. A nurse is assessing a 6-year-old with suspected bacterial meningitis. Which physical
assessment finding would support this diagnosis?
A. Positive Brudzinski sign
B. Hypotonia and lethargy
C. Negative Kernig sign
D. Sunken anterior fontanel
Correct Answer: A
Explanation: A positive Brudzinski sign, where the child involuntarily flexes the hips and
knees when the neck is flexed, is a classic indicator of meningeal irritation. In older
children, nuchal rigidity and a positive Kernig sign are also common clinical indicators.
Bacterial meningitis is a medical emergency that requires immediate lumbar puncture and
initiation of antibiotic therapy.
7. A child is diagnosed with Hirschsprung’s disease. The nurse should explain to the parents
that this condition is caused by:
A. A mechanical obstruction of the small intestine
B. Absence of ganglion cells in the distal colon
C. A viral infection of the gastrointestinal tract
Q&A with Rationale | Fortis College
1. A nurse is assessing a 4-week-old infant who has been diagnosed with hypertrophic pyloric
stenosis. Which clinical finding should the nurse expect to observe?
A. Currant jelly-like stools
B. Ribbon-like stools
C. Projectile vomiting after feedings
D. Bile-stained vomitus
Correct Answer: C
Explanation: Projectile vomiting is the classic sign of hypertrophic pyloric stenosis due to
the narrowing of the pyloric sphincter. This vomiting typically occurs shortly after feeding
and does not contain bile because the obstruction is proximal to the ampulla of Vater. The
nurse may also palpate an olive-shaped mass in the right upper quadrant of the abdomen.
2. When caring for a child with intussusception, which of the following stool characteristics is
most indicative of this condition?
A. Stools containing blood and mucus
B. Steatorrhea
C. Hard, marble-like stools
D. Thin, pencil-like stools
,Correct Answer: A
Explanation: Intussusception often results in stools that are described as ‘currant jelly’
because they contain a mixture of blood and mucus. This occurs because the telescoping of
the bowel causes inflammation, edema, and decreased blood flow to the affected area. If the
child passes a normal brown stool, it may indicate that the intussusception has reduced
spontaneously.
3. A child is admitted with a diagnosis of acute glomerulonephritis (AGN). Which of the
following laboratory or clinical findings is most consistent with this diagnosis?
A. Massive proteinuria and hypoalbuminemia
B. Hypotension and bradycardia
C. Low serum creatinine levels
D. Periorbital edema and tea-colored urine
Correct Answer: D
Explanation: Acute glomerulonephritis is frequently characterized by hematuria, which
gives the urine a smoky or tea-colored appearance. Periorbital edema is also a common
early sign due to fluid retention and decreased glomerular filtration. This condition often
follows a recent streptococcal infection, such as strep throat or impetigo.
4. The nurse is providing education to the parents of a child with Nephrotic Syndrome. Which
goal of therapy should the nurse emphasize?
A. Increasing dietary sodium intake
,B. Limiting physical activity to bed rest
C. Reducing excretion of urinary protein
D. Maintaining high fluid intake to flush the kidneys
Correct Answer: C
Explanation: The primary goal in treating Nephrotic Syndrome is to reduce the amount of
protein lost in the urine to resolve the edema. Corticosteroids like prednisone are typically
the first line of treatment to achieve remission and decrease proteinuria. Nurses must also
monitor for signs of infection, as these children are often immunocompromised due to
therapy.
5. Which of the following interventions is a priority for a newborn diagnosed with
Developmental Dysplasia of the Hip (DDH) assigned to a Pavlik harness?
A. Remove the harness for diaper changes and bathing
B. Adjust the straps every 4 hours to ensure a tight fit
C. Check the skin under the straps for redness or irritation
D. Ensure the baby’s legs are kept in an adducted position
Correct Answer: C
Explanation: Skin integrity is a major concern for infants in a Pavlik harness, and parents
should check for redness or skin breakdown at least two to three times a day. The harness
should generally be worn 24 hours a day and should only be removed if specifically
, directed by the provider. The harness is designed to maintain the hips in abduction and
flexion to promote proper acetabular development.
6. A nurse is assessing a 6-year-old with suspected bacterial meningitis. Which physical
assessment finding would support this diagnosis?
A. Positive Brudzinski sign
B. Hypotonia and lethargy
C. Negative Kernig sign
D. Sunken anterior fontanel
Correct Answer: A
Explanation: A positive Brudzinski sign, where the child involuntarily flexes the hips and
knees when the neck is flexed, is a classic indicator of meningeal irritation. In older
children, nuchal rigidity and a positive Kernig sign are also common clinical indicators.
Bacterial meningitis is a medical emergency that requires immediate lumbar puncture and
initiation of antibiotic therapy.
7. A child is diagnosed with Hirschsprung’s disease. The nurse should explain to the parents
that this condition is caused by:
A. A mechanical obstruction of the small intestine
B. Absence of ganglion cells in the distal colon
C. A viral infection of the gastrointestinal tract
