NRSG 112 Exam 4 V3 | NRSG 112 Maternal-Child
Nursing | Actual Q&A with Rationale (NRSG112
Exam 4) | Ivy Tech
1. A nurse is caring for a 3-year-old child who presents with a sudden onset of a high fever,
muffled voice, and is sitting in a ‘tripod’ position. What is the priority nursing action?
A. Obtain a throat culture to identify the pathogen.
B. Administer an antipyretic to reduce the child’s fever.
C. Examine the throat using a tongue blade for swelling.
D. Notify the healthcare provider and prepare for emergency intubation.
E. Encourage the child to lie down to conserve energy.
Correct Answer: D
Explanation: The child is exhibiting classic signs of epiglottitis, which is a medical
emergency that can lead to sudden airway obstruction. Assessing the throat with a tongue
blade or swab can trigger a laryngospasm and complete airway closure. The priority is to
maintain airway patency by keeping the child calm and preparing for advanced airway
management by the provider.
2. Which clinical manifestation should the nurse expect to find in an infant diagnosed with
Tetralogy of Fallot?
A. Cyanosis and ‘tet spells’ during crying or feeding.
,B. Bounding pulses in the upper extremities.
C. Increased pulmonary blood flow on X-ray.
D. Normal oxygen saturation levels.
Correct Answer: A
Explanation: Tetralogy of Fallot is a cyanotic heart defect involving four specific
abnormalities that result in decreased pulmonary blood flow. During periods of stress, such
as crying or feeding, the infant may experience a sudden drop in oxygenation known as a
‘tet spell.’ Placing the infant in a knee-chest position is a standard nursing intervention to
increase systemic vascular resistance and improve oxygenation.
3. A child is admitted with a diagnosis of Intussusception. Which characteristic of the child’s
stool should the nurse anticipate documenting?
A. Stools that resemble currant jelly.
B. Ribbon-like and foul-smelling stools.
C. Steatorrhea or fatty, bulky stools.
D. Hard, marble-like stools.
Correct Answer: A
Explanation: Intussusception occurs when one portion of the bowel telescopes into
another, leading to inflammation and obstruction. The classic finding is stool mixed with
, blood and mucus, often described as ‘currant jelly’ stools. This condition requires prompt
intervention, often starting with an air or saline enema to reduce the telescoping bowel.
4. The nurse is educating the parents of a child newly diagnosed with Sickle Cell Anemia.
What is the most important instruction to prevent a vaso-occlusive crisis?
A. Apply cold compresses to painful joints.
B. Maintain adequate hydration throughout the day.
C. Restrict the child’s protein intake.
D. Limit all forms of physical activity.
Correct Answer: B
Explanation: Hydration is critical in sickle cell anemia to prevent the sickling of red blood
cells and subsequent clumping that blocks blood flow. Dehydration increases blood
viscosity, which triggers or worsens a vaso-occlusive crisis. Parents should also be taught
to avoid high altitudes and extreme cold, which can also trigger sickling.
5. A 6-year-old child is hospitalized with Acute Post-Streptococcal Glomerulonephritis
(APSGN). Which assessment finding is most characteristic of this condition?
A. Periorbital edema and tea-colored urine.
B. Hypotension and bradycardia.
C. Profuse watery diarrhea.
D. Generalized rash and pruritus.
Nursing | Actual Q&A with Rationale (NRSG112
Exam 4) | Ivy Tech
1. A nurse is caring for a 3-year-old child who presents with a sudden onset of a high fever,
muffled voice, and is sitting in a ‘tripod’ position. What is the priority nursing action?
A. Obtain a throat culture to identify the pathogen.
B. Administer an antipyretic to reduce the child’s fever.
C. Examine the throat using a tongue blade for swelling.
D. Notify the healthcare provider and prepare for emergency intubation.
E. Encourage the child to lie down to conserve energy.
Correct Answer: D
Explanation: The child is exhibiting classic signs of epiglottitis, which is a medical
emergency that can lead to sudden airway obstruction. Assessing the throat with a tongue
blade or swab can trigger a laryngospasm and complete airway closure. The priority is to
maintain airway patency by keeping the child calm and preparing for advanced airway
management by the provider.
2. Which clinical manifestation should the nurse expect to find in an infant diagnosed with
Tetralogy of Fallot?
A. Cyanosis and ‘tet spells’ during crying or feeding.
,B. Bounding pulses in the upper extremities.
C. Increased pulmonary blood flow on X-ray.
D. Normal oxygen saturation levels.
Correct Answer: A
Explanation: Tetralogy of Fallot is a cyanotic heart defect involving four specific
abnormalities that result in decreased pulmonary blood flow. During periods of stress, such
as crying or feeding, the infant may experience a sudden drop in oxygenation known as a
‘tet spell.’ Placing the infant in a knee-chest position is a standard nursing intervention to
increase systemic vascular resistance and improve oxygenation.
3. A child is admitted with a diagnosis of Intussusception. Which characteristic of the child’s
stool should the nurse anticipate documenting?
A. Stools that resemble currant jelly.
B. Ribbon-like and foul-smelling stools.
C. Steatorrhea or fatty, bulky stools.
D. Hard, marble-like stools.
Correct Answer: A
Explanation: Intussusception occurs when one portion of the bowel telescopes into
another, leading to inflammation and obstruction. The classic finding is stool mixed with
, blood and mucus, often described as ‘currant jelly’ stools. This condition requires prompt
intervention, often starting with an air or saline enema to reduce the telescoping bowel.
4. The nurse is educating the parents of a child newly diagnosed with Sickle Cell Anemia.
What is the most important instruction to prevent a vaso-occlusive crisis?
A. Apply cold compresses to painful joints.
B. Maintain adequate hydration throughout the day.
C. Restrict the child’s protein intake.
D. Limit all forms of physical activity.
Correct Answer: B
Explanation: Hydration is critical in sickle cell anemia to prevent the sickling of red blood
cells and subsequent clumping that blocks blood flow. Dehydration increases blood
viscosity, which triggers or worsens a vaso-occlusive crisis. Parents should also be taught
to avoid high altitudes and extreme cold, which can also trigger sickling.
5. A 6-year-old child is hospitalized with Acute Post-Streptococcal Glomerulonephritis
(APSGN). Which assessment finding is most characteristic of this condition?
A. Periorbital edema and tea-colored urine.
B. Hypotension and bradycardia.
C. Profuse watery diarrhea.
D. Generalized rash and pruritus.
