NUR 2633/NUR2633 Exam 3 V1 | Maternal
Child Health Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a 3-year-old child who is suspected of having epiglottitis. Which of the
following nursing actions is the highest priority?
A. Obtaining a throat culture to identify the causative organism.
B. Starting an IV line for fluid resuscitation and antibiotic therapy.
C. Preparing the child for a lateral neck X-ray to confirm the diagnosis.
D. Visualizing the throat with a tongue depressor to assess for swelling.
Correct Answer: C
Rationale: The nurse should prioritize confirming the diagnosis via a lateral neck X-ray
which will show the ‘thumb sign.’ It is crucial never to visualize the throat or take a culture
using a tongue depressor in a patient with suspected epiglottitis because it can trigger a
fatal laryngospasm. Keeping the child calm and having emergency airway equipment at the
bedside is also essential for safe management.
2. According to Erikson’s stages of psychosocial development, a 2-year-old toddler is in which
stage?
A. Trust vs. Mistrust
B. Initiative vs. Guilt
,C. Autonomy vs. Shame and Doubt
D. Industry vs. Inferiority
Correct Answer: C
Rationale: Toddlers aged 1 to 3 years are in the Autonomy vs. Shame and Doubt stage.
During this period, children strive for independence and control over their physical skills. If
the child is supported in their independence, they develop confidence; otherwise, they may
feel inadequacy and self-doubt.
3. A 6-week-old infant is brought to the clinic with reports of projectile vomiting after
feedings. The nurse notes an olive-shaped mass in the epigastrium. Which condition does the
nurse suspect?
A. Gastroesophageal Reflux Disease (GERD)
B. Intussusception
C. Hirschsprung Disease
D. Hypertrophic Pyloric Stenosis
Correct Answer: D
Rationale: Hypertrophic pyloric stenosis is characterized by projectile vomiting and a
palpable olive-shaped mass in the upper right quadrant. This condition involves the
narrowing of the pyloric sphincter, which blocks food from entering the small intestine.
Surgical intervention, known as a pyloromyotomy, is the standard treatment for this
condition.
, 4. A nurse is providing discharge instructions to the parents of a child with Cystic Fibrosis.
Which instruction regarding pancreatic enzymes is most accurate?
A. Administer the enzymes only if the child has a large meal.
B. Administer enzymes 2 hours after every meal and snack.
C. Mix the enzymes in a bottle of warm milk for easier swallowing.
D. Administer the enzymes with every meal and snack.
Correct Answer: D
Rationale: Children with Cystic Fibrosis require pancreatic enzyme replacement therapy
with all meals and snacks to promote digestion and absorption of nutrients. These enzymes
should not be crushed or chewed, as they are enteric-coated to survive the stomach’s acidic
environment. Failure to provide enzymes consistently results in steatorrhea and poor
weight gain.
5. Which of the following findings is considered a hallmark sign of Intussusception in a
pediatric patient?
A. Ribbon-like, foul-smelling stools
B. Currant jelly-like stools
C. Clay-colored stools
D. Steatorrhea
Correct Answer: B
Child Health Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a 3-year-old child who is suspected of having epiglottitis. Which of the
following nursing actions is the highest priority?
A. Obtaining a throat culture to identify the causative organism.
B. Starting an IV line for fluid resuscitation and antibiotic therapy.
C. Preparing the child for a lateral neck X-ray to confirm the diagnosis.
D. Visualizing the throat with a tongue depressor to assess for swelling.
Correct Answer: C
Rationale: The nurse should prioritize confirming the diagnosis via a lateral neck X-ray
which will show the ‘thumb sign.’ It is crucial never to visualize the throat or take a culture
using a tongue depressor in a patient with suspected epiglottitis because it can trigger a
fatal laryngospasm. Keeping the child calm and having emergency airway equipment at the
bedside is also essential for safe management.
2. According to Erikson’s stages of psychosocial development, a 2-year-old toddler is in which
stage?
A. Trust vs. Mistrust
B. Initiative vs. Guilt
,C. Autonomy vs. Shame and Doubt
D. Industry vs. Inferiority
Correct Answer: C
Rationale: Toddlers aged 1 to 3 years are in the Autonomy vs. Shame and Doubt stage.
During this period, children strive for independence and control over their physical skills. If
the child is supported in their independence, they develop confidence; otherwise, they may
feel inadequacy and self-doubt.
3. A 6-week-old infant is brought to the clinic with reports of projectile vomiting after
feedings. The nurse notes an olive-shaped mass in the epigastrium. Which condition does the
nurse suspect?
A. Gastroesophageal Reflux Disease (GERD)
B. Intussusception
C. Hirschsprung Disease
D. Hypertrophic Pyloric Stenosis
Correct Answer: D
Rationale: Hypertrophic pyloric stenosis is characterized by projectile vomiting and a
palpable olive-shaped mass in the upper right quadrant. This condition involves the
narrowing of the pyloric sphincter, which blocks food from entering the small intestine.
Surgical intervention, known as a pyloromyotomy, is the standard treatment for this
condition.
, 4. A nurse is providing discharge instructions to the parents of a child with Cystic Fibrosis.
Which instruction regarding pancreatic enzymes is most accurate?
A. Administer the enzymes only if the child has a large meal.
B. Administer enzymes 2 hours after every meal and snack.
C. Mix the enzymes in a bottle of warm milk for easier swallowing.
D. Administer the enzymes with every meal and snack.
Correct Answer: D
Rationale: Children with Cystic Fibrosis require pancreatic enzyme replacement therapy
with all meals and snacks to promote digestion and absorption of nutrients. These enzymes
should not be crushed or chewed, as they are enteric-coated to survive the stomach’s acidic
environment. Failure to provide enzymes consistently results in steatorrhea and poor
weight gain.
5. Which of the following findings is considered a hallmark sign of Intussusception in a
pediatric patient?
A. Ribbon-like, foul-smelling stools
B. Currant jelly-like stools
C. Clay-colored stools
D. Steatorrhea
Correct Answer: B
