PNR 204/PNR204 Exam 3 V1 | Pediatric Nursing
Q&A with Rationale | Fortis College
1. A nurse is caring for a 4-year-old child diagnosed with Epiglottitis. Which of the following
nursing interventions is the highest priority?
A. Obtaining a throat culture to identify the causative organism.
B. Maintaining a patent airway and avoiding the use of a tongue blade.
C. Administering a dose of oral antibiotics as prescribed.
D. Encouraging the child to lie flat to ease breathing efforts.
Correct Answer: B
Explanation: Epiglottitis is a medical emergency that can lead to sudden and complete
airway obstruction. Using a tongue blade or performing a throat culture can trigger
laryngospasm, which is life-threatening. The priority is to keep the child calm and ensure
emergency airway equipment is readily available at the bedside.
2. A child with Tetralogy of Fallot (TOF) experiences a hypercyanotic spell (Tet spell). Which
action should the nurse take first?
A. Administer 100% oxygen via a face mask.
B. Prepare the child for an emergency cardiac catheterization.
C. Administer a dose of IV morphine sulfate.
D. Place the child in the knee-chest position.
,Correct Answer: D
Explanation: Placing the child in a knee-chest position increases systemic vascular
resistance and reduces the right-to-left shunt. This maneuver improves pulmonary blood
flow and increases oxygen saturation during a hypercyanotic spell. While oxygen and
morphine are used, positioning is the immediate non-invasive first step to take.
3. When teaching the parents of a child with Cystic Fibrosis about pancreatic enzyme
replacement, the nurse should include which instruction?
A. Enzymes should be given once daily in the morning.
B. Skip the dose if the child is having a small snack like an apple.
C. Crush the enzyme beads to ensure better absorption in the stomach.
D. Administer the enzymes with every meal and snack.
Correct Answer: D
Explanation: Children with Cystic Fibrosis have pancreatic insufficiency and require
exogenous enzymes to digest fats, proteins, and carbohydrates. These enzymes must be
taken with every meal and snack to prevent malabsorption and steatorrhea. The beads
should never be crushed or chewed as they are enteric-coated to survive stomach acid.
4. A 2-month-old infant is admitted with suspected Pyloric Stenosis. Which clinical
manifestation should the nurse expect to observe?
A. Chronic diarrhea and abdominal distention.
B. Currant jelly-like stools containing blood and mucus.
, C. Projectile vomiting followed by immediate hunger.
D. Severe bile-stained emesis after every feeding.
Correct Answer: C
Explanation: Hypertrophic pyloric stenosis causes an obstruction at the outlet of the
stomach, leading to characteristic non-bilious projectile vomiting. After vomiting, the infant
is typically very hungry and eager to feed again because the stomach has emptied. An olive-
shaped mass may also be palpable in the right upper quadrant of the abdomen.
5. A child is diagnosed with Nephrotic Syndrome. Which of the following is a classic clinical
manifestation of this condition?
A. Massive proteinuria and generalized edema.
B. Gross hematuria and hypertension.
C. Elevated blood urea nitrogen (BUN) and low cholesterol.
D. Increased urinary output and weight loss.
Correct Answer: A
Explanation: Nephrotic Syndrome is characterized by increased glomerular permeability
to protein, leading to massive proteinuria. This loss of albumin reduces osmotic pressure,
resulting in severe generalized edema (anasarca) and hypoalbuminemia. Hyperlipidemia is
also a common finding as the liver increases lipid production in response to low protein
levels.
Q&A with Rationale | Fortis College
1. A nurse is caring for a 4-year-old child diagnosed with Epiglottitis. Which of the following
nursing interventions is the highest priority?
A. Obtaining a throat culture to identify the causative organism.
B. Maintaining a patent airway and avoiding the use of a tongue blade.
C. Administering a dose of oral antibiotics as prescribed.
D. Encouraging the child to lie flat to ease breathing efforts.
Correct Answer: B
Explanation: Epiglottitis is a medical emergency that can lead to sudden and complete
airway obstruction. Using a tongue blade or performing a throat culture can trigger
laryngospasm, which is life-threatening. The priority is to keep the child calm and ensure
emergency airway equipment is readily available at the bedside.
2. A child with Tetralogy of Fallot (TOF) experiences a hypercyanotic spell (Tet spell). Which
action should the nurse take first?
A. Administer 100% oxygen via a face mask.
B. Prepare the child for an emergency cardiac catheterization.
C. Administer a dose of IV morphine sulfate.
D. Place the child in the knee-chest position.
,Correct Answer: D
Explanation: Placing the child in a knee-chest position increases systemic vascular
resistance and reduces the right-to-left shunt. This maneuver improves pulmonary blood
flow and increases oxygen saturation during a hypercyanotic spell. While oxygen and
morphine are used, positioning is the immediate non-invasive first step to take.
3. When teaching the parents of a child with Cystic Fibrosis about pancreatic enzyme
replacement, the nurse should include which instruction?
A. Enzymes should be given once daily in the morning.
B. Skip the dose if the child is having a small snack like an apple.
C. Crush the enzyme beads to ensure better absorption in the stomach.
D. Administer the enzymes with every meal and snack.
Correct Answer: D
Explanation: Children with Cystic Fibrosis have pancreatic insufficiency and require
exogenous enzymes to digest fats, proteins, and carbohydrates. These enzymes must be
taken with every meal and snack to prevent malabsorption and steatorrhea. The beads
should never be crushed or chewed as they are enteric-coated to survive stomach acid.
4. A 2-month-old infant is admitted with suspected Pyloric Stenosis. Which clinical
manifestation should the nurse expect to observe?
A. Chronic diarrhea and abdominal distention.
B. Currant jelly-like stools containing blood and mucus.
, C. Projectile vomiting followed by immediate hunger.
D. Severe bile-stained emesis after every feeding.
Correct Answer: C
Explanation: Hypertrophic pyloric stenosis causes an obstruction at the outlet of the
stomach, leading to characteristic non-bilious projectile vomiting. After vomiting, the infant
is typically very hungry and eager to feed again because the stomach has emptied. An olive-
shaped mass may also be palpable in the right upper quadrant of the abdomen.
5. A child is diagnosed with Nephrotic Syndrome. Which of the following is a classic clinical
manifestation of this condition?
A. Massive proteinuria and generalized edema.
B. Gross hematuria and hypertension.
C. Elevated blood urea nitrogen (BUN) and low cholesterol.
D. Increased urinary output and weight loss.
Correct Answer: A
Explanation: Nephrotic Syndrome is characterized by increased glomerular permeability
to protein, leading to massive proteinuria. This loss of albumin reduces osmotic pressure,
resulting in severe generalized edema (anasarca) and hypoalbuminemia. Hyperlipidemia is
also a common finding as the liver increases lipid production in response to low protein
levels.
