NUR 203/NUR203 Exam 2 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 actions is the highest priority?
A. Obtain a throat culture to identify the causative organism.
B. Prepare the child for immediate surgical intervention.
C. Administer oral fluids to prevent dehydration.
D. Maintain a patent airway and monitor respiratory status.
Correct Answer: D
Explanation: In a child with epiglottitis, maintaining a patent airway is the absolute
priority due to the risk of sudden respiratory occlusion. The nurse should avoid any
invasive procedures in the throat, such as using a tongue blade, which could trigger
laryngospasm. Monitoring oxygen saturation and respiratory effort is essential for early
detection of deterioration.
2. Which clinical manifestation should a nurse expect to see in a child with Tetralogy of Fallot
experiencing a hypercyanotic (‘tet’) spell?
A. Profound cyanosis and tachypnea.
B. Bradycardia and hypertension.
C. Lowered heart rate and peripheral edema.
,D. Flushed skin and bounding pulses.
Correct Answer: A
Explanation: Hypercyanotic spells are characterized by sudden, deep cyanosis and rapid,
labored breathing. These spells occur when there is an acute decrease in pulmonary blood
flow and an increase in right-to-left shunting. Placing the child in a knee-chest position is
the primary nursing intervention to improve systemic vascular resistance.
3. A school-age child with cystic fibrosis is being educated on nutritional needs. What should
the nurse include in the teaching?
A. Low-fat, low-sodium diet to prevent metabolic complications.
B. High-protein, high-calorie diet with pancreatic enzyme replacement.
C. Pancreatic enzymes administered only before the largest meal of the day.
D. Restriction of fat-soluble vitamins to prevent toxicity.
Correct Answer: B
Explanation: Children with cystic fibrosis require a high-protein, high-calorie diet to
support growth and compensate for malabsorption. Pancreatic enzymes must be taken
with every meal and snack to facilitate the digestion of fats and proteins. Fat-soluble
vitamin supplements (A, D, E, and K) are also necessary because they are poorly absorbed
without supplementation.
,4. A nurse is assessing an infant with suspected pyloric stenosis. Which finding is most
characteristic of this condition?
A. Bile-stained emesis occurring after every feeding.
B. Ribbon-like, foul-smelling stools.
C. Projectile, non-bilious vomiting after feedings.
D. Currant jelly-like stools containing blood and mucus.
Correct Answer: C
Explanation: Projectile, non-bilious vomiting is the hallmark sign of hypertrophic pyloric
stenosis, usually appearing between 2 to 8 weeks of age. The vomiting occurs because the
thickened pyloric muscle prevents gastric contents from entering the duodenum. An olive-
shaped mass may also be palpable in the right upper quadrant of the abdomen.
5. A child is admitted with a diagnosis of intussusception. Which clinical finding is the nurse
most likely to document?
A. Projectile vomiting and metabolic alkalosis.
B. Sudden onset of abdominal pain and currant jelly stools.
C. Painless rectal bleeding and abdominal distension.
D. Chronic constipation and ribbon-like stools.
Correct Answer: B
, Explanation: Intussusception involves the telescoping of one portion of the intestine into
another, leading to obstruction and ischemia. The classic triad of symptoms includes
sudden abdominal pain, a palpable sausage-shaped mass, and ‘currant jelly’ stools mixed
with blood and mucus. Early recognition and treatment with an air or barium enema are
crucial to prevent bowel necrosis.
6. The nurse is providing discharge teaching to the parents of a child with a
ventriculoperitoneal (VP) shunt. Which symptom should the nurse instruct the parents to
report immediately?
A. Vomiting, irritability, and a bulging fontanel.
B. Increased appetite and weight gain.
C. Mild lethargy after a long afternoon nap.
D. Sleeping through the night for 8 hours.
Correct Answer: A
Explanation: Vomiting, irritability, and a bulging fontanel are classic signs of increased
intracranial pressure (ICP), which may indicate a shunt malfunction or infection. It is
critical for parents to monitor for neurological changes such as decreased level of
consciousness or sunsetting eyes. Prompt medical evaluation is necessary to prevent
permanent brain damage or death.
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 actions is the highest priority?
A. Obtain a throat culture to identify the causative organism.
B. Prepare the child for immediate surgical intervention.
C. Administer oral fluids to prevent dehydration.
D. Maintain a patent airway and monitor respiratory status.
Correct Answer: D
Explanation: In a child with epiglottitis, maintaining a patent airway is the absolute
priority due to the risk of sudden respiratory occlusion. The nurse should avoid any
invasive procedures in the throat, such as using a tongue blade, which could trigger
laryngospasm. Monitoring oxygen saturation and respiratory effort is essential for early
detection of deterioration.
2. Which clinical manifestation should a nurse expect to see in a child with Tetralogy of Fallot
experiencing a hypercyanotic (‘tet’) spell?
A. Profound cyanosis and tachypnea.
B. Bradycardia and hypertension.
C. Lowered heart rate and peripheral edema.
,D. Flushed skin and bounding pulses.
Correct Answer: A
Explanation: Hypercyanotic spells are characterized by sudden, deep cyanosis and rapid,
labored breathing. These spells occur when there is an acute decrease in pulmonary blood
flow and an increase in right-to-left shunting. Placing the child in a knee-chest position is
the primary nursing intervention to improve systemic vascular resistance.
3. A school-age child with cystic fibrosis is being educated on nutritional needs. What should
the nurse include in the teaching?
A. Low-fat, low-sodium diet to prevent metabolic complications.
B. High-protein, high-calorie diet with pancreatic enzyme replacement.
C. Pancreatic enzymes administered only before the largest meal of the day.
D. Restriction of fat-soluble vitamins to prevent toxicity.
Correct Answer: B
Explanation: Children with cystic fibrosis require a high-protein, high-calorie diet to
support growth and compensate for malabsorption. Pancreatic enzymes must be taken
with every meal and snack to facilitate the digestion of fats and proteins. Fat-soluble
vitamin supplements (A, D, E, and K) are also necessary because they are poorly absorbed
without supplementation.
,4. A nurse is assessing an infant with suspected pyloric stenosis. Which finding is most
characteristic of this condition?
A. Bile-stained emesis occurring after every feeding.
B. Ribbon-like, foul-smelling stools.
C. Projectile, non-bilious vomiting after feedings.
D. Currant jelly-like stools containing blood and mucus.
Correct Answer: C
Explanation: Projectile, non-bilious vomiting is the hallmark sign of hypertrophic pyloric
stenosis, usually appearing between 2 to 8 weeks of age. The vomiting occurs because the
thickened pyloric muscle prevents gastric contents from entering the duodenum. An olive-
shaped mass may also be palpable in the right upper quadrant of the abdomen.
5. A child is admitted with a diagnosis of intussusception. Which clinical finding is the nurse
most likely to document?
A. Projectile vomiting and metabolic alkalosis.
B. Sudden onset of abdominal pain and currant jelly stools.
C. Painless rectal bleeding and abdominal distension.
D. Chronic constipation and ribbon-like stools.
Correct Answer: B
, Explanation: Intussusception involves the telescoping of one portion of the intestine into
another, leading to obstruction and ischemia. The classic triad of symptoms includes
sudden abdominal pain, a palpable sausage-shaped mass, and ‘currant jelly’ stools mixed
with blood and mucus. Early recognition and treatment with an air or barium enema are
crucial to prevent bowel necrosis.
6. The nurse is providing discharge teaching to the parents of a child with a
ventriculoperitoneal (VP) shunt. Which symptom should the nurse instruct the parents to
report immediately?
A. Vomiting, irritability, and a bulging fontanel.
B. Increased appetite and weight gain.
C. Mild lethargy after a long afternoon nap.
D. Sleeping through the night for 8 hours.
Correct Answer: A
Explanation: Vomiting, irritability, and a bulging fontanel are classic signs of increased
intracranial pressure (ICP), which may indicate a shunt malfunction or infection. It is
critical for parents to monitor for neurological changes such as decreased level of
consciousness or sunsetting eyes. Prompt medical evaluation is necessary to prevent
permanent brain damage or death.
