NUR 2633/NUR2633 Exam 3 V3 | Maternal Child
Health Nursing Q&A with Rationale | Rasmussen
University
1. A 3-year-old child is admitted with a diagnosis of epiglottitis. Which nursing action should
the nurse prioritize during the initial assessment?
A. Obtain a throat culture to identify the causative organism.
B. Examine the throat using a tongue blade to check for edema.
C. Encourage the child to lie flat to facilitate easier breathing.
D. Prepare for immediate tracheal intubation if respiratory distress increases.
Correct Answer: D
Explanation: Epiglottitis is a life-threatening medical emergency that can cause sudden
airway obstruction. The nurse must avoid using a tongue blade or throat culture as this can
trigger a laryngospasm. Immediate access to emergency airway equipment is the highest
priority for these patients.
2. A nurse is caring for an infant with Tetralogy of Fallot who begins to cry and becomes
cyanotic. Which action should the nurse take first?
A. Administer 100% oxygen via a face mask.
B. Place the infant in a knee-chest position.
C. Administer a dose of morphine sulfate intravenously.
,D. Prepare for emergency cardiac catheterization.
B. Place the infant in a knee-chest position.
Correct Answer: B
Explanation: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt in Tetralogy of Fallot. This maneuver improves pulmonary
blood flow and increases oxygen saturation during a ‘tet spell.’ Following this, oxygen and
morphine may be administered as secondary interventions.
3. A school-age child with cystic fibrosis is being discharged. What information should the
nurse include in the teaching regarding pancreatic enzyme replacement?
A. Enzymes should be taken once daily in the morning.
B. Enzymes must be taken with every meal and snack.
C. Enzymes are only necessary when consuming high-fat meals.
D. Enzymes should be withheld if the child has a bowel movement.
Correct Answer: B
Explanation: Children with cystic fibrosis require pancreatic enzymes to digest proteins,
fats, and carbohydrates due to pancreatic insufficiency. These enzymes must be taken with
every meal and snack to ensure proper nutrient absorption. The effectiveness of the dose is
monitored by the consistency and frequency of the child’s stools.
, 4. A nurse is assessing a newborn with suspected pyloric stenosis. Which clinical
manifestation is most characteristic of this condition?
A. Biliary-stained emesis after feedings.
B. Projectile vomiting followed by immediate hunger.
C. Currant jelly-like stools containing blood and mucus.
D. Visible peristaltic waves in the lower abdomen.
Correct Answer: B
Explanation: Hypertrophic pyloric stenosis typically presents with non-biliary projectile
vomiting that occurs shortly after feeding. The infant remains hungry and eager to eat
again despite the vomiting episodes. An olive-shaped mass may also be palpable in the
right upper quadrant during the physical exam.
5. A 10-year-old child is diagnosed with acute glomerulonephritis. Which finding should the
nurse expect to see in the child’s medical history?
A. A recent history of a urinary tract infection.
B. A recent episode of streptococcal pharyngitis.
C. A history of chronic renal insufficiency.
D. Previous diagnosis of vesicoureteral reflux.
Correct Answer: B
Health Nursing Q&A with Rationale | Rasmussen
University
1. A 3-year-old child is admitted with a diagnosis of epiglottitis. Which nursing action should
the nurse prioritize during the initial assessment?
A. Obtain a throat culture to identify the causative organism.
B. Examine the throat using a tongue blade to check for edema.
C. Encourage the child to lie flat to facilitate easier breathing.
D. Prepare for immediate tracheal intubation if respiratory distress increases.
Correct Answer: D
Explanation: Epiglottitis is a life-threatening medical emergency that can cause sudden
airway obstruction. The nurse must avoid using a tongue blade or throat culture as this can
trigger a laryngospasm. Immediate access to emergency airway equipment is the highest
priority for these patients.
2. A nurse is caring for an infant with Tetralogy of Fallot who begins to cry and becomes
cyanotic. Which action should the nurse take first?
A. Administer 100% oxygen via a face mask.
B. Place the infant in a knee-chest position.
C. Administer a dose of morphine sulfate intravenously.
,D. Prepare for emergency cardiac catheterization.
B. Place the infant in a knee-chest position.
Correct Answer: B
Explanation: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt in Tetralogy of Fallot. This maneuver improves pulmonary
blood flow and increases oxygen saturation during a ‘tet spell.’ Following this, oxygen and
morphine may be administered as secondary interventions.
3. A school-age child with cystic fibrosis is being discharged. What information should the
nurse include in the teaching regarding pancreatic enzyme replacement?
A. Enzymes should be taken once daily in the morning.
B. Enzymes must be taken with every meal and snack.
C. Enzymes are only necessary when consuming high-fat meals.
D. Enzymes should be withheld if the child has a bowel movement.
Correct Answer: B
Explanation: Children with cystic fibrosis require pancreatic enzymes to digest proteins,
fats, and carbohydrates due to pancreatic insufficiency. These enzymes must be taken with
every meal and snack to ensure proper nutrient absorption. The effectiveness of the dose is
monitored by the consistency and frequency of the child’s stools.
, 4. A nurse is assessing a newborn with suspected pyloric stenosis. Which clinical
manifestation is most characteristic of this condition?
A. Biliary-stained emesis after feedings.
B. Projectile vomiting followed by immediate hunger.
C. Currant jelly-like stools containing blood and mucus.
D. Visible peristaltic waves in the lower abdomen.
Correct Answer: B
Explanation: Hypertrophic pyloric stenosis typically presents with non-biliary projectile
vomiting that occurs shortly after feeding. The infant remains hungry and eager to eat
again despite the vomiting episodes. An olive-shaped mass may also be palpable in the
right upper quadrant during the physical exam.
5. A 10-year-old child is diagnosed with acute glomerulonephritis. Which finding should the
nurse expect to see in the child’s medical history?
A. A recent history of a urinary tract infection.
B. A recent episode of streptococcal pharyngitis.
C. A history of chronic renal insufficiency.
D. Previous diagnosis of vesicoureteral reflux.
Correct Answer: B
