NUR 2633/NUR2633 Exam 4 V1 | Maternal
Child Health Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a 4-week-old infant who presents with projectile vomiting after
feedings and a palpable olive-shaped mass in the right upper quadrant. Which condition
should the nurse suspect?
A. Intussusception
B. Hypertrophic Pyloric Stenosis
C. Hirschsprung’s Disease
D. Gastroesophageal Reflux
Correct Answer: B
Rationale: Hypertrophic pyloric stenosis is characterized by the thickening of the pyloric
sphincter, leading to obstruction. The classic clinical manifestations include non-bilious
projectile vomiting and a palpable olive-like mass in the epigastrium. Surgical intervention
via pyloromyotomy is the definitive treatment for this condition.
2. A toddler is admitted to the pediatric unit with a diagnosis of Laryngotracheobronchitis
(Croup). Which of the following nursing interventions is the highest priority?
A. Maintaining a patent airway and monitoring respiratory status
B. Administering oral antibiotics as prescribed
,C. Providing a high-calorie diet for growth
D. Encouraging vigorous physical activity to clear secretions
Correct Answer: A
Rationale: Laryngotracheobronchitis causes inflammation and narrowing of the upper
airway, leading to inspiratory stridor and a barking cough. Maintaining airway patency is
the most critical intervention to prevent respiratory failure. The nurse must monitor for
signs of increased respiratory distress, such as retractions and nasal flaring.
3. Which of the following findings is most characteristic of a child diagnosed with Tetralogy of
Fallot during a ‘tet spell’?
A. Sudden cyanosis and hyperpnea
B. Hypotonia and decreased deep tendon reflexes
C. Hypertension and bradycardia
D. Localized edema in the lower extremities
Correct Answer: A
Rationale: A ‘tet spell’ or hypercyanotic spell occurs when there is an acute decrease in
pulmonary blood flow. This results in sudden cyanosis, respiratory distress, and potential
loss of consciousness. The nurse should place the child in a knee-chest position to increase
systemic vascular resistance and improve oxygenation.
, 4. A nurse is caring for a newborn receiving phototherapy for hyperbilirubinemia. Which
action should the nurse include in the plan of care?
A. Apply lotion to the skin to prevent drying
B. Keep the infant dressed in a full onesie
C. Limit fluid intake to prevent overhydration
D. Cover the infant’s eyes with protective shields
Correct Answer: D
Rationale: Protective eye shields are essential during phototherapy to prevent retinal
damage from high-intensity light. The nurse must also ensure maximum skin exposure, so
the infant should only wear a diaper. Hydration is critical as phototherapy increases
insensible water loss, so fluids should be encouraged.
5. A school-age child with Cystic Fibrosis is being discharged. Which dietary recommendation
is most appropriate for this patient?
A. Low-fat, low-sodium diet
B. Fluid-restricted diet
C. High-calorie, high-protein diet
D. Vegan diet with no fat soluble vitamins
Correct Answer: C
Child Health Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a 4-week-old infant who presents with projectile vomiting after
feedings and a palpable olive-shaped mass in the right upper quadrant. Which condition
should the nurse suspect?
A. Intussusception
B. Hypertrophic Pyloric Stenosis
C. Hirschsprung’s Disease
D. Gastroesophageal Reflux
Correct Answer: B
Rationale: Hypertrophic pyloric stenosis is characterized by the thickening of the pyloric
sphincter, leading to obstruction. The classic clinical manifestations include non-bilious
projectile vomiting and a palpable olive-like mass in the epigastrium. Surgical intervention
via pyloromyotomy is the definitive treatment for this condition.
2. A toddler is admitted to the pediatric unit with a diagnosis of Laryngotracheobronchitis
(Croup). Which of the following nursing interventions is the highest priority?
A. Maintaining a patent airway and monitoring respiratory status
B. Administering oral antibiotics as prescribed
,C. Providing a high-calorie diet for growth
D. Encouraging vigorous physical activity to clear secretions
Correct Answer: A
Rationale: Laryngotracheobronchitis causes inflammation and narrowing of the upper
airway, leading to inspiratory stridor and a barking cough. Maintaining airway patency is
the most critical intervention to prevent respiratory failure. The nurse must monitor for
signs of increased respiratory distress, such as retractions and nasal flaring.
3. Which of the following findings is most characteristic of a child diagnosed with Tetralogy of
Fallot during a ‘tet spell’?
A. Sudden cyanosis and hyperpnea
B. Hypotonia and decreased deep tendon reflexes
C. Hypertension and bradycardia
D. Localized edema in the lower extremities
Correct Answer: A
Rationale: A ‘tet spell’ or hypercyanotic spell occurs when there is an acute decrease in
pulmonary blood flow. This results in sudden cyanosis, respiratory distress, and potential
loss of consciousness. The nurse should place the child in a knee-chest position to increase
systemic vascular resistance and improve oxygenation.
, 4. A nurse is caring for a newborn receiving phototherapy for hyperbilirubinemia. Which
action should the nurse include in the plan of care?
A. Apply lotion to the skin to prevent drying
B. Keep the infant dressed in a full onesie
C. Limit fluid intake to prevent overhydration
D. Cover the infant’s eyes with protective shields
Correct Answer: D
Rationale: Protective eye shields are essential during phototherapy to prevent retinal
damage from high-intensity light. The nurse must also ensure maximum skin exposure, so
the infant should only wear a diaper. Hydration is critical as phototherapy increases
insensible water loss, so fluids should be encouraged.
5. A school-age child with Cystic Fibrosis is being discharged. Which dietary recommendation
is most appropriate for this patient?
A. Low-fat, low-sodium diet
B. Fluid-restricted diet
C. High-calorie, high-protein diet
D. Vegan diet with no fat soluble vitamins
Correct Answer: C
