PNR 204/PNR204 Exam 4 V1 | Pediatric Nursing
Q&A with Rationale | Fortis College
1. A nurse is caring for an infant with Tetralogy of Fallot who suddenly becomes cyanotic and
dyspneic. Which action should the nurse perform first?
A. Administer 100% oxygen via face mask
B. Obtain an immediate chest X-ray
C. Prepare to administer morphine sulfate
D. Place the infant in a knee-chest position
Correct Answer: D
Explanation: Placing the infant in a knee-chest position increases systemic vascular
resistance, which helps reduce the right-to-left shunt. This is the priority nursing
intervention for a hypercyanotic or ‘Tet’ spell. Oxygen and medication follow after
positioning the patient safely.
2. A school-age child is diagnosed with Hemophilia A. Which medication should the nurse
instruct the parents to avoid?
A. Acetaminophen
B. Ibuprofen
C. Aspirin
D. Amoxicillin
,Correct Answer: C
Explanation: Aspirin inhibits platelet aggregation and can lead to prolonged bleeding in
children with hemophilia. While NSAIDs like ibuprofen should also be used with caution,
aspirin is strictly contraindicated due to its irreversible effect on platelets and risk of
Reye’s syndrome. Acetaminophen is usually the preferred analgesic for these patients.
3. A nurse is assessing a child with suspected Wilms tumor. What is the most important
nursing intervention during the physical examination?
A. Avoid palpating the abdomen
B. Monitor blood pressure frequently
C. Measure abdominal girth every 4 hours
D. Obtain a 24-hour urine collection
Correct Answer: A
Explanation: Palpating the abdomen of a child with Wilms tumor (nephroblastoma) can
cause the encapsulated tumor to rupture and spread cancerous cells into the peritoneal
cavity. A sign should be placed above the bed to alert all staff not to palpate the abdomen.
Hypertension is a common symptom due to increased renin, but safety during physical
assessment is the priority.
4. Which clinical manifestation is a hallmark sign of a child with Coarctation of the Aorta?
A. Clubbing of the fingernails
B. Profound cyanosis at birth
, C. A continuous machinery-like murmur
D. Bounding upper pulses and weak femoral pulses
Correct Answer: D
Explanation: Coarctation of the aorta involves narrowing of the lumen of the aorta,
typically near the ductus arteriosus. This results in high blood pressure and bounding
pulses in the upper extremities and low blood pressure with weak or absent pulses in the
lower extremities. Clubbing is more characteristic of chronic cyanotic defects like Tetralogy
of Fallot.
5. A nurse is teaching the parents of a toddler with Iron Deficiency Anemia about liquid iron
supplements. Which instruction should be included?
A. Give the medication with a glass of milk
B. Administer the medication using a straw or dropper
C. Mix the medication with the child’s cereal
D. Wait one hour after the dose before giving orange juice
Correct Answer: B
Explanation: Liquid iron supplements can cause temporary staining of the teeth, so they
should be administered through a straw or a dropper directed toward the back of the
mouth. Giving iron with Vitamin C, such as orange juice, actually enhances absorption. Iron
should not be given with milk as calcium interferes with its absorption.
Q&A with Rationale | Fortis College
1. A nurse is caring for an infant with Tetralogy of Fallot who suddenly becomes cyanotic and
dyspneic. Which action should the nurse perform first?
A. Administer 100% oxygen via face mask
B. Obtain an immediate chest X-ray
C. Prepare to administer morphine sulfate
D. Place the infant in a knee-chest position
Correct Answer: D
Explanation: Placing the infant in a knee-chest position increases systemic vascular
resistance, which helps reduce the right-to-left shunt. This is the priority nursing
intervention for a hypercyanotic or ‘Tet’ spell. Oxygen and medication follow after
positioning the patient safely.
2. A school-age child is diagnosed with Hemophilia A. Which medication should the nurse
instruct the parents to avoid?
A. Acetaminophen
B. Ibuprofen
C. Aspirin
D. Amoxicillin
,Correct Answer: C
Explanation: Aspirin inhibits platelet aggregation and can lead to prolonged bleeding in
children with hemophilia. While NSAIDs like ibuprofen should also be used with caution,
aspirin is strictly contraindicated due to its irreversible effect on platelets and risk of
Reye’s syndrome. Acetaminophen is usually the preferred analgesic for these patients.
3. A nurse is assessing a child with suspected Wilms tumor. What is the most important
nursing intervention during the physical examination?
A. Avoid palpating the abdomen
B. Monitor blood pressure frequently
C. Measure abdominal girth every 4 hours
D. Obtain a 24-hour urine collection
Correct Answer: A
Explanation: Palpating the abdomen of a child with Wilms tumor (nephroblastoma) can
cause the encapsulated tumor to rupture and spread cancerous cells into the peritoneal
cavity. A sign should be placed above the bed to alert all staff not to palpate the abdomen.
Hypertension is a common symptom due to increased renin, but safety during physical
assessment is the priority.
4. Which clinical manifestation is a hallmark sign of a child with Coarctation of the Aorta?
A. Clubbing of the fingernails
B. Profound cyanosis at birth
, C. A continuous machinery-like murmur
D. Bounding upper pulses and weak femoral pulses
Correct Answer: D
Explanation: Coarctation of the aorta involves narrowing of the lumen of the aorta,
typically near the ductus arteriosus. This results in high blood pressure and bounding
pulses in the upper extremities and low blood pressure with weak or absent pulses in the
lower extremities. Clubbing is more characteristic of chronic cyanotic defects like Tetralogy
of Fallot.
5. A nurse is teaching the parents of a toddler with Iron Deficiency Anemia about liquid iron
supplements. Which instruction should be included?
A. Give the medication with a glass of milk
B. Administer the medication using a straw or dropper
C. Mix the medication with the child’s cereal
D. Wait one hour after the dose before giving orange juice
Correct Answer: B
Explanation: Liquid iron supplements can cause temporary staining of the teeth, so they
should be administered through a straw or a dropper directed toward the back of the
mouth. Giving iron with Vitamin C, such as orange juice, actually enhances absorption. Iron
should not be given with milk as calcium interferes with its absorption.
