NUR 203/NUR203 Final Exam V3 | Pediatric
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a 2-year-old child during a well-child visit. Which developmental task,
according to Erikson, should the nurse expect the child to be working on?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Initiative vs. Guilt
D. Industry vs. Inferiority
Correct Answer: B
Explanation: According to Erikson, toddlers aged 1 to 3 years are in the stage of Autonomy
vs. Shame and Doubt. During this time, children are learning to exercise their will and do
things for themselves, or they will doubt their abilities. The nurse should support this
developmental milestone by encouraging independent choices when safe and appropriate.
2. A 4-year-old child is admitted with a diagnosis of acute epiglottitis. Which nursing
intervention is the highest priority?
A. Obtain a throat culture immediately.
B. Maintain a patent airway and keep the child calm.
C. Apply warm compresses to the neck.
D. Administer oral fluids to prevent dehydration.
,Correct Answer: B
Explanation: Acute epiglottitis is a medical emergency that can lead to sudden and
complete airway obstruction. The nurse must prioritize airway maintenance and avoid any
procedures that could agitate the child, such as a throat culture or using a tongue blade.
Keeping the child in a position of comfort, usually sitting upright, is essential for safety.
3. A nurse is caring for an infant with tetralogy of Fallot who suddenly becomes cyanotic and
agitated. Which action should the nurse take first?
A. Administer a dose of morphine sulfate.
B. Start a bolus of intravenous fluids.
C. Place the infant in the knee-chest position.
D. Increase the oxygen flow rate to 10 L/min.
Correct Answer: C
Explanation: The infant is experiencing a hypercyanotic spell, often referred to as a ‘Tet
spell.’ Placing the infant in a knee-chest position increases systemic vascular resistance,
which helps force blood into the pulmonary artery rather than through the ventricular
septal defect. This immediate nursing action improves oxygenation and is the standard first
response for this condition.
4. A school-age child with cystic fibrosis is being educated on the use of pancreatic enzymes.
When should the nurse instruct the child to take these enzymes?
A. Once daily in the morning before school.
, B. Only after high-fat meals.
C. Two hours after eating to aid late digestion.
D. With every meal and every snack.
Correct Answer: D
Explanation: Children with cystic fibrosis have pancreatic insufficiency and require
exogenous enzymes to digest fats, proteins, and carbohydrates. These enzymes must be
taken with every meal and snack to ensure proper nutrient absorption. Consistent
administration is vital to prevent malabsorption syndrome and promote healthy weight
gain.
5. The nurse is assessing a child with suspected pyloric stenosis. Which clinical finding is most
characteristic of this condition?
A. Currant jelly-like stools
B. Projectile vomiting after feedings
C. Ribbon-like, foul-smelling stools
D. Increased appetite with weight gain
Correct Answer: B
Explanation: Projectile vomiting is the hallmark sign of hypertrophic pyloric stenosis due
to the gastric outlet obstruction. This usually occurs shortly after feeding and does not
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a 2-year-old child during a well-child visit. Which developmental task,
according to Erikson, should the nurse expect the child to be working on?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Initiative vs. Guilt
D. Industry vs. Inferiority
Correct Answer: B
Explanation: According to Erikson, toddlers aged 1 to 3 years are in the stage of Autonomy
vs. Shame and Doubt. During this time, children are learning to exercise their will and do
things for themselves, or they will doubt their abilities. The nurse should support this
developmental milestone by encouraging independent choices when safe and appropriate.
2. A 4-year-old child is admitted with a diagnosis of acute epiglottitis. Which nursing
intervention is the highest priority?
A. Obtain a throat culture immediately.
B. Maintain a patent airway and keep the child calm.
C. Apply warm compresses to the neck.
D. Administer oral fluids to prevent dehydration.
,Correct Answer: B
Explanation: Acute epiglottitis is a medical emergency that can lead to sudden and
complete airway obstruction. The nurse must prioritize airway maintenance and avoid any
procedures that could agitate the child, such as a throat culture or using a tongue blade.
Keeping the child in a position of comfort, usually sitting upright, is essential for safety.
3. A nurse is caring for an infant with tetralogy of Fallot who suddenly becomes cyanotic and
agitated. Which action should the nurse take first?
A. Administer a dose of morphine sulfate.
B. Start a bolus of intravenous fluids.
C. Place the infant in the knee-chest position.
D. Increase the oxygen flow rate to 10 L/min.
Correct Answer: C
Explanation: The infant is experiencing a hypercyanotic spell, often referred to as a ‘Tet
spell.’ Placing the infant in a knee-chest position increases systemic vascular resistance,
which helps force blood into the pulmonary artery rather than through the ventricular
septal defect. This immediate nursing action improves oxygenation and is the standard first
response for this condition.
4. A school-age child with cystic fibrosis is being educated on the use of pancreatic enzymes.
When should the nurse instruct the child to take these enzymes?
A. Once daily in the morning before school.
, B. Only after high-fat meals.
C. Two hours after eating to aid late digestion.
D. With every meal and every snack.
Correct Answer: D
Explanation: Children with cystic fibrosis have pancreatic insufficiency and require
exogenous enzymes to digest fats, proteins, and carbohydrates. These enzymes must be
taken with every meal and snack to ensure proper nutrient absorption. Consistent
administration is vital to prevent malabsorption syndrome and promote healthy weight
gain.
5. The nurse is assessing a child with suspected pyloric stenosis. Which clinical finding is most
characteristic of this condition?
A. Currant jelly-like stools
B. Projectile vomiting after feedings
C. Ribbon-like, foul-smelling stools
D. Increased appetite with weight gain
Correct Answer: B
Explanation: Projectile vomiting is the hallmark sign of hypertrophic pyloric stenosis due
to the gastric outlet obstruction. This usually occurs shortly after feeding and does not
