Grand Canyon University NSG 434 Exam 2 (pdf) | 2026/2027 |
Pediatric Q&A | Pediatric Nursing
1. A nurse is assessing a 5-year-old child who presents with crampy
abdominal pain, inconsolable crying, drawing knees to the chest, and red
currant jelly-like stools. Which nursing intervention is most appropriate for
this child?
A) Blood transfusion
B) Ambulation to relieve bowel gas
C) Electrolyte replacement to stop cramping
D) Gas enema
Correct Answer: Gas enema
Rationale: These symptoms are classic for intussusception, where the bowel
telescopes into another segment, causing intestinal obstruction. A gas or
barium enema creates pressure to help reduce the intussusception. Normal
brown stool would indicate resolution of the problem.
---
2. A nurse is providing education to an expectant mother about preventing
cleft lip and palate. Which risk factor should the nurse include in the
teaching?
A) Not drinking enough milk during pregnancy
B) Folate deficiency during pregnancy
C) Not enough Vitamin D during pregnancy
D) Having a sibling with a cleft palate
Correct Answer: Folate deficiency during pregnancy
,Rationale: Folic acid (vitamin B9) is essential for healthy cell growth and
development, and deficiency during pregnancy is a risk factor for cleft lip and
palate. Folic acid supplementation before and during early pregnancy helps
reduce the risk of neural tube defects and other congenital anomalies.
---
3. A nurse is assessing an infant with projectile vomiting after feeding. The
nurse palpates a small, hard, movable mass in the right upper quadrant.
Which condition is most consistent with these findings?
A) Pyloric stenosis
B) Celiac disease
C) Omphalocele
D) Biliary atresia
Correct Answer: Pyloric stenosis
Rationale: Pyloric stenosis presents with projectile vomiting and a palpable
"olive-sized" mass in the right upper quadrant, caused by hypertrophy of the
pylorus. This condition typically occurs in infants at 4-6 weeks of age and
requires surgical correction.
---
4. A nurse is caring for a newborn who has not passed meconium within 48
hours of birth and is vomiting bilious contents. Which condition should the
nurse suspect?
A) Pyloric stenosis
B) Hirschsprung disease
C) Intussusception
,D) Gastroesophageal reflux
Correct Answer: Hirschsprung disease
Rationale: Hirschsprung disease is a structural disorder characterized by the
absence of ganglion cells in the bowel, leading to loss of peristalsis. Failure to
pass meconium within 24-48 hours of birth is a classic sign in neonates.
Other manifestations include bilious vomiting, constipation, and ribbon-like
stools.
---
5. A nurse is assessing a child with severe dehydration. Which finding would
the nurse expect?
A) Tears present when crying
B) Weight loss of less than 5% in infants
C) Capillary refill greater than 4 seconds
D) Normal anterior fontanel
Correct Answer: Capillary refill greater than 4 seconds
Rationale: Severe dehydration is characterized by capillary refill greater than
4 seconds, weight loss of more than 10% in infants and 6% in older children,
sunken fontanel, absent tears, and lethargy. Capillary refill is delayed, and
skin may show tenting.
---
, 6. A nurse is caring for a child with acute diarrhea. The nurse understands
that which pathogen is the most common cause of serious gastroenteritis in
children?
A) Escherichia coli
B) Salmonella
C) Rotavirus
D) Shigella
Correct Answer: Rotavirus
Rationale: Rotavirus is the most common cause of serious gastroenteritis
among children, with most children infected at least once by age 5. The virus
is transmitted through the fecal-oral route, making day care centers a high-
risk environment.
---
7. A nurse is caring for a child with ulcerative colitis. Which finding is most
characteristic of this condition?
A) Ribbon-like, foul-smelling stools
B) 10-20 bloody stools per day
C) Projectile vomiting after feeding
D) Red currant jelly-like stools
Correct Answer: 10-20 bloody stools per day
Rationale: Ulcerative colitis is characterized by frequent bloody stools (10-20
per day), abdominal pain, and weight loss. Patients may appear pale and
anemic. Ribbon-like stools are seen in Hirschsprung disease, projectile
vomiting in pyloric stenosis, and currant jelly stools in intussusception.
Pediatric Q&A | Pediatric Nursing
1. A nurse is assessing a 5-year-old child who presents with crampy
abdominal pain, inconsolable crying, drawing knees to the chest, and red
currant jelly-like stools. Which nursing intervention is most appropriate for
this child?
A) Blood transfusion
B) Ambulation to relieve bowel gas
C) Electrolyte replacement to stop cramping
D) Gas enema
Correct Answer: Gas enema
Rationale: These symptoms are classic for intussusception, where the bowel
telescopes into another segment, causing intestinal obstruction. A gas or
barium enema creates pressure to help reduce the intussusception. Normal
brown stool would indicate resolution of the problem.
---
2. A nurse is providing education to an expectant mother about preventing
cleft lip and palate. Which risk factor should the nurse include in the
teaching?
A) Not drinking enough milk during pregnancy
B) Folate deficiency during pregnancy
C) Not enough Vitamin D during pregnancy
D) Having a sibling with a cleft palate
Correct Answer: Folate deficiency during pregnancy
,Rationale: Folic acid (vitamin B9) is essential for healthy cell growth and
development, and deficiency during pregnancy is a risk factor for cleft lip and
palate. Folic acid supplementation before and during early pregnancy helps
reduce the risk of neural tube defects and other congenital anomalies.
---
3. A nurse is assessing an infant with projectile vomiting after feeding. The
nurse palpates a small, hard, movable mass in the right upper quadrant.
Which condition is most consistent with these findings?
A) Pyloric stenosis
B) Celiac disease
C) Omphalocele
D) Biliary atresia
Correct Answer: Pyloric stenosis
Rationale: Pyloric stenosis presents with projectile vomiting and a palpable
"olive-sized" mass in the right upper quadrant, caused by hypertrophy of the
pylorus. This condition typically occurs in infants at 4-6 weeks of age and
requires surgical correction.
---
4. A nurse is caring for a newborn who has not passed meconium within 48
hours of birth and is vomiting bilious contents. Which condition should the
nurse suspect?
A) Pyloric stenosis
B) Hirschsprung disease
C) Intussusception
,D) Gastroesophageal reflux
Correct Answer: Hirschsprung disease
Rationale: Hirschsprung disease is a structural disorder characterized by the
absence of ganglion cells in the bowel, leading to loss of peristalsis. Failure to
pass meconium within 24-48 hours of birth is a classic sign in neonates.
Other manifestations include bilious vomiting, constipation, and ribbon-like
stools.
---
5. A nurse is assessing a child with severe dehydration. Which finding would
the nurse expect?
A) Tears present when crying
B) Weight loss of less than 5% in infants
C) Capillary refill greater than 4 seconds
D) Normal anterior fontanel
Correct Answer: Capillary refill greater than 4 seconds
Rationale: Severe dehydration is characterized by capillary refill greater than
4 seconds, weight loss of more than 10% in infants and 6% in older children,
sunken fontanel, absent tears, and lethargy. Capillary refill is delayed, and
skin may show tenting.
---
, 6. A nurse is caring for a child with acute diarrhea. The nurse understands
that which pathogen is the most common cause of serious gastroenteritis in
children?
A) Escherichia coli
B) Salmonella
C) Rotavirus
D) Shigella
Correct Answer: Rotavirus
Rationale: Rotavirus is the most common cause of serious gastroenteritis
among children, with most children infected at least once by age 5. The virus
is transmitted through the fecal-oral route, making day care centers a high-
risk environment.
---
7. A nurse is caring for a child with ulcerative colitis. Which finding is most
characteristic of this condition?
A) Ribbon-like, foul-smelling stools
B) 10-20 bloody stools per day
C) Projectile vomiting after feeding
D) Red currant jelly-like stools
Correct Answer: 10-20 bloody stools per day
Rationale: Ulcerative colitis is characterized by frequent bloody stools (10-20
per day), abdominal pain, and weight loss. Patients may appear pale and
anemic. Ribbon-like stools are seen in Hirschsprung disease, projectile
vomiting in pyloric stenosis, and currant jelly stools in intussusception.
