PNR 204/PNR204 Exam 4 V3 | Pediatric Nursing
Q&A with Rationale | Fortis College
1. A nurse is providing discharge teaching to the parents of a child newly diagnosed with
Cystic Fibrosis. Which dietary modification should the nurse emphasize?
A. Restricting fluids to prevent pulmonary congestion.
B. A low-fat, low-sodium diet.
C. A diet high in protein and calories.
D. A gluten-free, low-carbohydrate diet.
Correct Answer: C
Explanation: Children with Cystic Fibrosis require a high-protein, high-calorie diet to
compensate for the malabsorption of nutrients caused by pancreatic insufficiency.
Pancreatic enzymes must also be administered with every meal and snack to ensure proper
digestion. Failure to provide adequate nutrition can lead to significant growth delays and
increased susceptibility to respiratory infections.
2. A child with Tetralogy of Fallot is experiencing a ‘Tet spell’ (hypercyanotic episode). Which
action should the nurse take first?
A. Administer 100% oxygen via mask.
B. Place the child in a knee-chest position.
C. Prepare for immediate intravenous morphine administration.
,D. Notify the healthcare provider immediately.
Correct Answer: B
Explanation: The knee-chest position is the priority action because it increases systemic
vascular resistance, which helps reduce the right-to-left shunting of blood. By forcing more
blood into the pulmonary artery, oxygenation levels can improve rapidly. Once the child is
positioned, supplemental oxygen and pharmacological interventions can be initiated as
needed.
3. The nurse is assessing a 4-year-old child for suspected epiglottitis. Which of the following
assessment findings is considered a medical emergency?
A. A barking, brassy cough.
B. High fever and drooling.
C. Generalized wheezing upon expiration.
D. Low-grade fever and rhinorrhea.
Correct Answer: B
Explanation: Epiglottitis is a life-threatening bacterial infection that causes rapid swelling
of the epiglottis, potentially obstructing the airway. The ‘four Ds’ of epiglottitis include
drooling, dysphagia, dysphonia, and distressed inspiratory efforts. The nurse should never
use a tongue blade to examine the throat in these patients, as it may trigger complete
airway closure.
,4. A nurse is caring for a school-aged child with Type 1 Diabetes Mellitus who reports feeling
shaky and dizzy. What is the nurse’s priority action?
A. Administer the scheduled dose of regular insulin.
B. Provide a high-fat snack to stabilize blood sugar.
C. Check the child’s blood glucose level.
D. Encourage the child to lie down and rest.
Correct Answer: C
Explanation: The child is exhibiting classic signs of hypoglycemia, which require
immediate verification via blood glucose monitoring. If hypoglycemia is confirmed, the
nurse should follow the 15-15 rule by providing 15 grams of fast-acting carbohydrates.
Ignoring these symptoms or providing insulin could lead to severe neurological
compromise or coma.
5. Which of the following clinical manifestations is most characteristic of a child with Pyloric
Stenosis?
A. Currant jelly-like stools.
B. Chronic constipation and abdominal distention.
C. Bile-stained emesis.
D. Projectile vomiting after feedings.
Correct Answer: D
, Explanation: Pyloric stenosis involves hypertrophy of the pyloric sphincter, leading to an
obstruction of the gastric outlet. This typically results in non-bilious projectile vomiting in
infants between 2 and 8 weeks of age. An olive-shaped mass may also be palpable in the
right upper quadrant during the physical examination.
6. A nurse is reviewing the lab results of a child with Nephrotic Syndrome. Which finding
should the nurse expect?
A. Gross hematuria and hypertension.
B. Decreased specific gravity and polyuria.
C. Elevated serum potassium and low sodium.
D. Massive proteinuria and hypoalbuminemia.
Correct Answer: D
Explanation: Nephrotic syndrome is characterized by increased glomerular permeability
to protein, leading to massive proteinuria. This loss of protein results in hypoalbuminemia,
which causes a shift of fluid from the intravascular space to the interstitial space, creating
severe edema. Management typically involves corticosteroid therapy and sodium
restriction.
7. When assessing a child for possible scoliosis, the nurse should instruct the child to perform
which maneuver?
A. Stand on one foot with eyes closed.
B. Perform a deep squat while keeping the back straight.
Q&A with Rationale | Fortis College
1. A nurse is providing discharge teaching to the parents of a child newly diagnosed with
Cystic Fibrosis. Which dietary modification should the nurse emphasize?
A. Restricting fluids to prevent pulmonary congestion.
B. A low-fat, low-sodium diet.
C. A diet high in protein and calories.
D. A gluten-free, low-carbohydrate diet.
Correct Answer: C
Explanation: Children with Cystic Fibrosis require a high-protein, high-calorie diet to
compensate for the malabsorption of nutrients caused by pancreatic insufficiency.
Pancreatic enzymes must also be administered with every meal and snack to ensure proper
digestion. Failure to provide adequate nutrition can lead to significant growth delays and
increased susceptibility to respiratory infections.
2. A child with Tetralogy of Fallot is experiencing a ‘Tet spell’ (hypercyanotic episode). Which
action should the nurse take first?
A. Administer 100% oxygen via mask.
B. Place the child in a knee-chest position.
C. Prepare for immediate intravenous morphine administration.
,D. Notify the healthcare provider immediately.
Correct Answer: B
Explanation: The knee-chest position is the priority action because it increases systemic
vascular resistance, which helps reduce the right-to-left shunting of blood. By forcing more
blood into the pulmonary artery, oxygenation levels can improve rapidly. Once the child is
positioned, supplemental oxygen and pharmacological interventions can be initiated as
needed.
3. The nurse is assessing a 4-year-old child for suspected epiglottitis. Which of the following
assessment findings is considered a medical emergency?
A. A barking, brassy cough.
B. High fever and drooling.
C. Generalized wheezing upon expiration.
D. Low-grade fever and rhinorrhea.
Correct Answer: B
Explanation: Epiglottitis is a life-threatening bacterial infection that causes rapid swelling
of the epiglottis, potentially obstructing the airway. The ‘four Ds’ of epiglottitis include
drooling, dysphagia, dysphonia, and distressed inspiratory efforts. The nurse should never
use a tongue blade to examine the throat in these patients, as it may trigger complete
airway closure.
,4. A nurse is caring for a school-aged child with Type 1 Diabetes Mellitus who reports feeling
shaky and dizzy. What is the nurse’s priority action?
A. Administer the scheduled dose of regular insulin.
B. Provide a high-fat snack to stabilize blood sugar.
C. Check the child’s blood glucose level.
D. Encourage the child to lie down and rest.
Correct Answer: C
Explanation: The child is exhibiting classic signs of hypoglycemia, which require
immediate verification via blood glucose monitoring. If hypoglycemia is confirmed, the
nurse should follow the 15-15 rule by providing 15 grams of fast-acting carbohydrates.
Ignoring these symptoms or providing insulin could lead to severe neurological
compromise or coma.
5. Which of the following clinical manifestations is most characteristic of a child with Pyloric
Stenosis?
A. Currant jelly-like stools.
B. Chronic constipation and abdominal distention.
C. Bile-stained emesis.
D. Projectile vomiting after feedings.
Correct Answer: D
, Explanation: Pyloric stenosis involves hypertrophy of the pyloric sphincter, leading to an
obstruction of the gastric outlet. This typically results in non-bilious projectile vomiting in
infants between 2 and 8 weeks of age. An olive-shaped mass may also be palpable in the
right upper quadrant during the physical examination.
6. A nurse is reviewing the lab results of a child with Nephrotic Syndrome. Which finding
should the nurse expect?
A. Gross hematuria and hypertension.
B. Decreased specific gravity and polyuria.
C. Elevated serum potassium and low sodium.
D. Massive proteinuria and hypoalbuminemia.
Correct Answer: D
Explanation: Nephrotic syndrome is characterized by increased glomerular permeability
to protein, leading to massive proteinuria. This loss of protein results in hypoalbuminemia,
which causes a shift of fluid from the intravascular space to the interstitial space, creating
severe edema. Management typically involves corticosteroid therapy and sodium
restriction.
7. When assessing a child for possible scoliosis, the nurse should instruct the child to perform
which maneuver?
A. Stand on one foot with eyes closed.
B. Perform a deep squat while keeping the back straight.
