NUR 203/NUR203 Exam 4 V3 | Pediatric Nursing
Q&A with Rationale | Fortis College
1. An infant with Tetralogy of Fallot (TOF) becomes acutely cyanotic and hyperpneic during a
crying episode. Which action should the nurse perform first?
A. Administer 100% oxygen via face mask
B. Prepare a dose of Morphine Sulfate
C. Place the infant in the knee-chest position
D. Notify the pediatric cardiologist immediately
Correct Answer: C
Explanation: The knee-chest position increases systemic vascular resistance, which helps
to reduce the right-to-left shunt through the ventricular septal defect. This maneuver
improves pulmonary blood flow and oxygenation during a hypercyanotic or ‘tet’ spell. It is
the immediate priority intervention to stabilize the infant before secondary treatments like
oxygen or medication are administered.
2. A nurse is preparing to administer Digoxin to a 6-month-old infant. The nurse should
withhold the dose and notify the provider if the apical pulse is below which threshold?
A. 90 beats per minute
B. 110 beats per minute
C. 70 beats per minute
,D. 60 beats per minute
Correct Answer: A
Explanation: In infants, Digoxin is typically withheld if the apical heart rate is less than 90
beats per minute. For older children, the common threshold is 70 beats per minute, while
for adults it is 60 beats per minute. The nurse must auscultate the apical pulse for a full
minute to ensure accuracy before administration of this potent cardiac glycoside.
3. A child is diagnosed with Kawasaki Disease and is in the acute phase. Which medication
does the nurse expect to be ordered to prevent coronary artery aneurysm?
A. Warfarin and Heparin
B. Prednisone and Ibuprofen
C. Intravenous Immunoglobulin (IVIG) and high-dose Aspirin
D. Acetaminophen and Amoxicillin
Correct Answer: C
Explanation: IVIG is administered in high doses to reduce the inflammatory response and
the risk of coronary artery abnormalities. High-dose Aspirin is used for its anti-
inflammatory and anti-platelet properties during the acute phase. This combined therapy is
the gold standard for managing Kawasaki Disease to prevent long-term cardiac
complications.
, 4. Which clinical manifestation is a hallmark sign of Coarctation of the Aorta in a pediatric
patient?
A. A loud, machine-like murmur heard throughout the cardiac cycle
B. Cyanosis that increases with crying or feeding
C. Bounding peripheral pulses in all four extremities
D. Higher blood pressure in the upper extremities compared to the lower extremities
Correct Answer: D
Explanation: Coarctation of the Aorta involves a narrowing near the ductus arteriosus,
which restricts blood flow to the lower body. This results in hypertension in the arms and
hypotension or weak pulses in the legs. Nurses must perform four-point blood pressure
checks to identify this disparity as part of a comprehensive cardiac assessment.
5. A 2-year-old is suspected of having Laryngotracheobronchitis (Croup). Which sound does
the nurse expect to hear during the physical assessment?
A. Inspiratory stridor and a barking cough
B. Expiratory wheezing
C. Fine crackles at the lung bases
D. Silent chest with no audible air movement
Correct Answer: A
Q&A with Rationale | Fortis College
1. An infant with Tetralogy of Fallot (TOF) becomes acutely cyanotic and hyperpneic during a
crying episode. Which action should the nurse perform first?
A. Administer 100% oxygen via face mask
B. Prepare a dose of Morphine Sulfate
C. Place the infant in the knee-chest position
D. Notify the pediatric cardiologist immediately
Correct Answer: C
Explanation: The knee-chest position increases systemic vascular resistance, which helps
to reduce the right-to-left shunt through the ventricular septal defect. This maneuver
improves pulmonary blood flow and oxygenation during a hypercyanotic or ‘tet’ spell. It is
the immediate priority intervention to stabilize the infant before secondary treatments like
oxygen or medication are administered.
2. A nurse is preparing to administer Digoxin to a 6-month-old infant. The nurse should
withhold the dose and notify the provider if the apical pulse is below which threshold?
A. 90 beats per minute
B. 110 beats per minute
C. 70 beats per minute
,D. 60 beats per minute
Correct Answer: A
Explanation: In infants, Digoxin is typically withheld if the apical heart rate is less than 90
beats per minute. For older children, the common threshold is 70 beats per minute, while
for adults it is 60 beats per minute. The nurse must auscultate the apical pulse for a full
minute to ensure accuracy before administration of this potent cardiac glycoside.
3. A child is diagnosed with Kawasaki Disease and is in the acute phase. Which medication
does the nurse expect to be ordered to prevent coronary artery aneurysm?
A. Warfarin and Heparin
B. Prednisone and Ibuprofen
C. Intravenous Immunoglobulin (IVIG) and high-dose Aspirin
D. Acetaminophen and Amoxicillin
Correct Answer: C
Explanation: IVIG is administered in high doses to reduce the inflammatory response and
the risk of coronary artery abnormalities. High-dose Aspirin is used for its anti-
inflammatory and anti-platelet properties during the acute phase. This combined therapy is
the gold standard for managing Kawasaki Disease to prevent long-term cardiac
complications.
, 4. Which clinical manifestation is a hallmark sign of Coarctation of the Aorta in a pediatric
patient?
A. A loud, machine-like murmur heard throughout the cardiac cycle
B. Cyanosis that increases with crying or feeding
C. Bounding peripheral pulses in all four extremities
D. Higher blood pressure in the upper extremities compared to the lower extremities
Correct Answer: D
Explanation: Coarctation of the Aorta involves a narrowing near the ductus arteriosus,
which restricts blood flow to the lower body. This results in hypertension in the arms and
hypotension or weak pulses in the legs. Nurses must perform four-point blood pressure
checks to identify this disparity as part of a comprehensive cardiac assessment.
5. A 2-year-old is suspected of having Laryngotracheobronchitis (Croup). Which sound does
the nurse expect to hear during the physical assessment?
A. Inspiratory stridor and a barking cough
B. Expiratory wheezing
C. Fine crackles at the lung bases
D. Silent chest with no audible air movement
Correct Answer: A
