PNR 204/PNR204 Final Exam V3 | Pediatric
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a 4-year-old child who has been diagnosed with acute epiglottitis.
Which of the following clinical findings should the nurse prioritize as the most critical?
A. A harsh, barking cough
B. Low-grade fever and malaise
C. Drooling and difficulty swallowing
D. Wheezing on expiration
Correct Answer: C
Explanation: Drooling and dysphagia are hallmark signs of acute epiglottitis because the
child is unable to swallow saliva due to severe laryngeal obstruction. This condition is a
medical emergency that can lead to rapid respiratory failure if not managed immediately.
The nurse must avoid examining the throat with a tongue depressor to prevent a complete
airway occlusion.
2. According to Erikson’s stages of psychosocial development, which task should a nurse
expect a 9-year-old child to be working toward?
A. Developing a sense of autonomy
B. Mastering a sense of industry
C. Establishing a sense of identity
,D. Forming a sense of initiative
Correct Answer: B
Explanation: School-age children, typically ages 6 to 12, are in the Industry vs. Inferiority
stage of development. During this time, children focus on mastering new skills and
completing tasks to build self-esteem. Failure to achieve success in these areas can lead to
feelings of inadequacy or inferiority compared to their peers.
3. A nurse is caring for an infant who has Tetralogy of Fallot and experiences a hypercyanotic
spell (Tet spell). Which action should the nurse take first?
A. Place the infant in a knee-chest position
B. Administer 100% oxygen via face mask
C. Prepare for immediate administration of morphine
D. Obtain an arterial blood gas sample
Correct Answer: A
Explanation: The knee-chest position is the priority intervention because it increases
systemic vascular resistance and decreases the right-to-left shunt. This maneuver improves
pulmonary blood flow and increases oxygen saturation during a hypercyanotic episode.
Oxygen and medications may follow, but physical positioning provides the most rapid
relief.
, 4. A nurse is teaching the parents of a child with cystic fibrosis about chest physiotherapy
(CPT). Which of the following instructions should be included?
A. Perform CPT 30 minutes before or 2 hours after meals.
B. Perform CPT immediately after the child eats a meal.
C. Limit fluid intake during the day to prevent mucus buildup.
D. CPT is only necessary when the child has an active infection.
Correct Answer: A
Explanation: Chest physiotherapy should be scheduled away from meal times to reduce
the risk of vomiting and aspiration. Performing it before meals or at least two hours after
helps clear the airway of thick secretions more effectively. Routine CPT is essential for
cystic fibrosis management even when the child is asymptomatic to prevent pulmonary
complications.
5. A 2-year-old child is brought to the clinic for a routine check-up. The nurse notes the child
has not yet received the Measles, Mumps, and Rubella (MMR) vaccine. Which statement is
correct regarding this vaccine?
A. This is an inactivated vaccine and requires four doses.
B. The vaccine is contraindicated if the child has a mild cold.
C. MMR should only be given to children who are over 4 years old.
D. The first dose is typically given between 12 and 15 months of age.
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a 4-year-old child who has been diagnosed with acute epiglottitis.
Which of the following clinical findings should the nurse prioritize as the most critical?
A. A harsh, barking cough
B. Low-grade fever and malaise
C. Drooling and difficulty swallowing
D. Wheezing on expiration
Correct Answer: C
Explanation: Drooling and dysphagia are hallmark signs of acute epiglottitis because the
child is unable to swallow saliva due to severe laryngeal obstruction. This condition is a
medical emergency that can lead to rapid respiratory failure if not managed immediately.
The nurse must avoid examining the throat with a tongue depressor to prevent a complete
airway occlusion.
2. According to Erikson’s stages of psychosocial development, which task should a nurse
expect a 9-year-old child to be working toward?
A. Developing a sense of autonomy
B. Mastering a sense of industry
C. Establishing a sense of identity
,D. Forming a sense of initiative
Correct Answer: B
Explanation: School-age children, typically ages 6 to 12, are in the Industry vs. Inferiority
stage of development. During this time, children focus on mastering new skills and
completing tasks to build self-esteem. Failure to achieve success in these areas can lead to
feelings of inadequacy or inferiority compared to their peers.
3. A nurse is caring for an infant who has Tetralogy of Fallot and experiences a hypercyanotic
spell (Tet spell). Which action should the nurse take first?
A. Place the infant in a knee-chest position
B. Administer 100% oxygen via face mask
C. Prepare for immediate administration of morphine
D. Obtain an arterial blood gas sample
Correct Answer: A
Explanation: The knee-chest position is the priority intervention because it increases
systemic vascular resistance and decreases the right-to-left shunt. This maneuver improves
pulmonary blood flow and increases oxygen saturation during a hypercyanotic episode.
Oxygen and medications may follow, but physical positioning provides the most rapid
relief.
, 4. A nurse is teaching the parents of a child with cystic fibrosis about chest physiotherapy
(CPT). Which of the following instructions should be included?
A. Perform CPT 30 minutes before or 2 hours after meals.
B. Perform CPT immediately after the child eats a meal.
C. Limit fluid intake during the day to prevent mucus buildup.
D. CPT is only necessary when the child has an active infection.
Correct Answer: A
Explanation: Chest physiotherapy should be scheduled away from meal times to reduce
the risk of vomiting and aspiration. Performing it before meals or at least two hours after
helps clear the airway of thick secretions more effectively. Routine CPT is essential for
cystic fibrosis management even when the child is asymptomatic to prevent pulmonary
complications.
5. A 2-year-old child is brought to the clinic for a routine check-up. The nurse notes the child
has not yet received the Measles, Mumps, and Rubella (MMR) vaccine. Which statement is
correct regarding this vaccine?
A. This is an inactivated vaccine and requires four doses.
B. The vaccine is contraindicated if the child has a mild cold.
C. MMR should only be given to children who are over 4 years old.
D. The first dose is typically given between 12 and 15 months of age.
