NUR 203/NUR203 Exam 3 V3 | Pediatric Nursing
Q&A with Rationale | Fortis College
1. A nurse is caring for a 3-year-old child diagnosed with acute epiglottitis. Which of the
following nursing interventions is the highest priority?
A. Obtaining a throat culture to identify the causative organism
B. Preparing the child for immediate endotracheal intubation or tracheostomy
C. Assessing the child’s throat using a tongue depressor
D. Administering a dose of oral corticosteroids as ordered
Correct Answer: B
Explanation: Acute epiglottitis is a life-threatening medical emergency due to the rapid
progression of airway obstruction. The primary nursing focus is maintaining a patent
airway, and equipment for emergency intubation should be at the bedside. Invasive
procedures like throat cultures or using a tongue depressor are strictly contraindicated
because they can trigger a fatal laryngospasm.
2. A 6-week-old infant is brought to the clinic for frequent vomiting. Which assessment
finding would most strongly suggest a diagnosis of hypertrophic pyloric stenosis?
A. Bilious vomiting occurring after every feeding
B. A history of chronic constipation since birth
C. A palpable olive-shaped mass in the right upper quadrant
,D. Currant jelly-like stools containing blood and mucus
Correct Answer: C
Explanation: Hypertrophic pyloric stenosis is characterized by the thickening of the
pyloric sphincter, which leads to obstruction. The classic clinical finding is a palpable, olive-
shaped mass in the epigastrium or right upper quadrant of the abdomen. This condition
typically presents with non-bilious, projectile vomiting in an infant who remains hungry
despite repeated emesis.
3. A child is admitted with a suspected diagnosis of intussusception. Which clinical
manifestation is considered a classic sign of this condition?
A. Ribbon-like, foul-smelling stools
B. Stools resembling currant jelly
C. Steatorrhea and greasy bowel movements
D. Perinatal weight loss and jaundice
Correct Answer: B
Explanation: Intussusception occurs when one segment of the intestine telescopes into
another, causing obstruction and ischemia. This leads to the leakage of blood and mucus
into the intestinal lumen, creating the characteristic currant jelly stool. Patients also
typically present with sudden, acute abdominal pain and a sausage-shaped mass in the
abdomen.
,4. A nurse is providing care for a child with Tetralogy of Fallot who suddenly develops a
hypercyanotic spell (Tet spell). Which action should the nurse take first?
A. Administer 100% oxygen via a non-rebreather mask
B. Place the child in the knee-chest position
C. Administer an intravenous dose of morphine sulfate
D. Notify the primary healthcare provider immediately
Correct Answer: B
Explanation: The knee-chest position is the initial priority intervention for a
hypercyanotic spell as it increases systemic vascular resistance. This increased resistance
reduces the right-to-left shunt, forcing more blood into the pulmonary artery for
oxygenation. While oxygen and morphine are important subsequent steps, positioning is
the most rapid way to improve pulmonary blood flow.
5. Which of the following instructions should the nurse include when teaching the parents of
a child with cystic fibrosis about pancreatic enzyme replacement?
A. Administer the enzymes twice daily, once in the morning and once at night
B. Give the enzymes with every meal and all snacks throughout the day
C. Mix the enzyme powder with hot formula or warm milk to improve flavor
D. Omit the enzymes if the child is having frequent, loose stools
Correct Answer: B
, Explanation: In cystic fibrosis, pancreatic ducts are blocked by thick mucus, preventing
enzymes from reaching the duodenum. Therefore, enzymes must be taken with all meals
and snacks to ensure the digestion and absorption of fats and proteins. This therapy is
essential for preventing malnutrition and steatorrhea, which are common complications of
the disease.
6. A school-age child with asthma is being discharged with a peak flow meter. What is the
primary purpose of this device?
A. To deliver a metered dose of bronchodilator medication
B. To measure the concentration of carbon dioxide in the blood
C. To monitor the child’s daily respiratory status and predict exacerbations
D. To determine the child’s need for oxygen supplementation
Correct Answer: C
Explanation: A peak flow meter measures the maximum flow of air that can be forcefully
exhaled in one second. By monitoring these values daily, the family can identify trends and
recognize early signs of airway narrowing before symptoms become severe. This allows for
early intervention and adjustments in the asthma action plan to prevent full-blown attacks.
7. A 2-year-old child is diagnosed with Laryngotracheobronchitis (Croup). Which sound would
the nurse expect to hear during the respiratory assessment?
A. Expiratory wheezing throughout all lung fields
B. A barking, seal-like cough and inspiratory stridor
Q&A with Rationale | Fortis College
1. A nurse is caring for a 3-year-old child diagnosed with acute epiglottitis. Which of the
following nursing interventions is the highest priority?
A. Obtaining a throat culture to identify the causative organism
B. Preparing the child for immediate endotracheal intubation or tracheostomy
C. Assessing the child’s throat using a tongue depressor
D. Administering a dose of oral corticosteroids as ordered
Correct Answer: B
Explanation: Acute epiglottitis is a life-threatening medical emergency due to the rapid
progression of airway obstruction. The primary nursing focus is maintaining a patent
airway, and equipment for emergency intubation should be at the bedside. Invasive
procedures like throat cultures or using a tongue depressor are strictly contraindicated
because they can trigger a fatal laryngospasm.
2. A 6-week-old infant is brought to the clinic for frequent vomiting. Which assessment
finding would most strongly suggest a diagnosis of hypertrophic pyloric stenosis?
A. Bilious vomiting occurring after every feeding
B. A history of chronic constipation since birth
C. A palpable olive-shaped mass in the right upper quadrant
,D. Currant jelly-like stools containing blood and mucus
Correct Answer: C
Explanation: Hypertrophic pyloric stenosis is characterized by the thickening of the
pyloric sphincter, which leads to obstruction. The classic clinical finding is a palpable, olive-
shaped mass in the epigastrium or right upper quadrant of the abdomen. This condition
typically presents with non-bilious, projectile vomiting in an infant who remains hungry
despite repeated emesis.
3. A child is admitted with a suspected diagnosis of intussusception. Which clinical
manifestation is considered a classic sign of this condition?
A. Ribbon-like, foul-smelling stools
B. Stools resembling currant jelly
C. Steatorrhea and greasy bowel movements
D. Perinatal weight loss and jaundice
Correct Answer: B
Explanation: Intussusception occurs when one segment of the intestine telescopes into
another, causing obstruction and ischemia. This leads to the leakage of blood and mucus
into the intestinal lumen, creating the characteristic currant jelly stool. Patients also
typically present with sudden, acute abdominal pain and a sausage-shaped mass in the
abdomen.
,4. A nurse is providing care for a child with Tetralogy of Fallot who suddenly develops a
hypercyanotic spell (Tet spell). Which action should the nurse take first?
A. Administer 100% oxygen via a non-rebreather mask
B. Place the child in the knee-chest position
C. Administer an intravenous dose of morphine sulfate
D. Notify the primary healthcare provider immediately
Correct Answer: B
Explanation: The knee-chest position is the initial priority intervention for a
hypercyanotic spell as it increases systemic vascular resistance. This increased resistance
reduces the right-to-left shunt, forcing more blood into the pulmonary artery for
oxygenation. While oxygen and morphine are important subsequent steps, positioning is
the most rapid way to improve pulmonary blood flow.
5. Which of the following instructions should the nurse include when teaching the parents of
a child with cystic fibrosis about pancreatic enzyme replacement?
A. Administer the enzymes twice daily, once in the morning and once at night
B. Give the enzymes with every meal and all snacks throughout the day
C. Mix the enzyme powder with hot formula or warm milk to improve flavor
D. Omit the enzymes if the child is having frequent, loose stools
Correct Answer: B
, Explanation: In cystic fibrosis, pancreatic ducts are blocked by thick mucus, preventing
enzymes from reaching the duodenum. Therefore, enzymes must be taken with all meals
and snacks to ensure the digestion and absorption of fats and proteins. This therapy is
essential for preventing malnutrition and steatorrhea, which are common complications of
the disease.
6. A school-age child with asthma is being discharged with a peak flow meter. What is the
primary purpose of this device?
A. To deliver a metered dose of bronchodilator medication
B. To measure the concentration of carbon dioxide in the blood
C. To monitor the child’s daily respiratory status and predict exacerbations
D. To determine the child’s need for oxygen supplementation
Correct Answer: C
Explanation: A peak flow meter measures the maximum flow of air that can be forcefully
exhaled in one second. By monitoring these values daily, the family can identify trends and
recognize early signs of airway narrowing before symptoms become severe. This allows for
early intervention and adjustments in the asthma action plan to prevent full-blown attacks.
7. A 2-year-old child is diagnosed with Laryngotracheobronchitis (Croup). Which sound would
the nurse expect to hear during the respiratory assessment?
A. Expiratory wheezing throughout all lung fields
B. A barking, seal-like cough and inspiratory stridor
