PNR 204/PNR204 Exam 2 V1 | Pediatric Nursing
Q&A with Rationale | Fortis College
1. A 3-year-old child is admitted to the pediatric unit with suspected epiglottitis. Which of the
following nursing actions is the highest priority?
A. Assess the throat using a tongue blade to check for inflammation.
B. Ensure emergency intubation equipment is readily available at the bedside.
C. Obtain a throat culture to identify the causative organism.
D. Place the child in a supine position to facilitate breathing.
Correct Answer: B
Explanation: Epiglottitis is a medical emergency that can lead to sudden and total airway
obstruction. Attempting to visualize the throat with a tongue blade or swab can trigger
laryngospasm and complete blockage. The nurse’s priority is to maintain airway patency
and ensure that equipment for emergency airway management is immediately accessible.
2. A nurse is providing discharge instructions to the parents of a child with Celiac disease.
Which food choice should the nurse instruct the parents to avoid?
A. Rice cereal
B. Wheat crackers
C. Corn tortillas
D. Fresh strawberries
,Correct Answer: B
Explanation: Celiac disease is a permanent intolerance to gluten, which is found in wheat,
barley, rye, and oats. Wheat crackers contain gluten and will cause damage to the intestinal
mucosa in a patient with this condition. The nurse must teach the family to identify hidden
sources of gluten and substitute them with gluten-free options like rice or corn.
3. When assessing a 4-week-old infant with suspected pyloric stenosis, which clinical
manifestation should the nurse expect to find?
A. Projectile vomiting after feedings
B. Currant jelly-like stools
C. Bile-stained emesis
D. Abdominal distention and ribbon-like stools
Correct Answer: A
Explanation: Hypertrophic pyloric stenosis is characterized by the thickening of the
pyloric sphincter, leading to obstruction. This typically causes non-bilious projectile
vomiting immediately after feeding in infants. An olive-shaped mass may also be palpable
in the right upper quadrant during the physical examination.
4. A nurse is caring for an infant diagnosed with Tetralogy of Fallot who suddenly becomes
cyanotic and agitated. Which action should the nurse take first?
A. Administer 100% oxygen via face mask.
B. Place the infant in the knee-chest position.
, C. Prepare to administer morphine sulfate.
D. Call for the rapid response team.
Correct Answer: B
Explanation: The infant is experiencing a ‘Tet spell’ or hypercyanotic spell, which is
common in Tetralogy of Fallot. Placing the infant in the knee-chest position increases
systemic vascular resistance, which helps reduce the right-to-left shunt and improves
oxygenation. This is the primary non-pharmacological intervention that should be
performed immediately before other treatments.
5. Which lab result is most characteristic of a child with Cystic Fibrosis?
A. Decreased serum sodium levels
B. Elevated serum glucose levels
C. Decreased fecal fat content
D. Elevated sweat chloride concentration
Correct Answer: D
Explanation: The sweat chloride test is the gold standard for diagnosing Cystic Fibrosis
(CF). CF involves a mutation in the CFTR protein, leading to defective chloride transport
and abnormally high levels of salt in sweat. A chloride concentration greater than 60
mEq/L is considered diagnostic for this genetic disorder.
Q&A with Rationale | Fortis College
1. A 3-year-old child is admitted to the pediatric unit with suspected epiglottitis. Which of the
following nursing actions is the highest priority?
A. Assess the throat using a tongue blade to check for inflammation.
B. Ensure emergency intubation equipment is readily available at the bedside.
C. Obtain a throat culture to identify the causative organism.
D. Place the child in a supine position to facilitate breathing.
Correct Answer: B
Explanation: Epiglottitis is a medical emergency that can lead to sudden and total airway
obstruction. Attempting to visualize the throat with a tongue blade or swab can trigger
laryngospasm and complete blockage. The nurse’s priority is to maintain airway patency
and ensure that equipment for emergency airway management is immediately accessible.
2. A nurse is providing discharge instructions to the parents of a child with Celiac disease.
Which food choice should the nurse instruct the parents to avoid?
A. Rice cereal
B. Wheat crackers
C. Corn tortillas
D. Fresh strawberries
,Correct Answer: B
Explanation: Celiac disease is a permanent intolerance to gluten, which is found in wheat,
barley, rye, and oats. Wheat crackers contain gluten and will cause damage to the intestinal
mucosa in a patient with this condition. The nurse must teach the family to identify hidden
sources of gluten and substitute them with gluten-free options like rice or corn.
3. When assessing a 4-week-old infant with suspected pyloric stenosis, which clinical
manifestation should the nurse expect to find?
A. Projectile vomiting after feedings
B. Currant jelly-like stools
C. Bile-stained emesis
D. Abdominal distention and ribbon-like stools
Correct Answer: A
Explanation: Hypertrophic pyloric stenosis is characterized by the thickening of the
pyloric sphincter, leading to obstruction. This typically causes non-bilious projectile
vomiting immediately after feeding in infants. An olive-shaped mass may also be palpable
in the right upper quadrant during the physical examination.
4. A nurse is caring for an infant diagnosed with Tetralogy of Fallot who suddenly becomes
cyanotic and agitated. Which action should the nurse take first?
A. Administer 100% oxygen via face mask.
B. Place the infant in the knee-chest position.
, C. Prepare to administer morphine sulfate.
D. Call for the rapid response team.
Correct Answer: B
Explanation: The infant is experiencing a ‘Tet spell’ or hypercyanotic spell, which is
common in Tetralogy of Fallot. Placing the infant in the knee-chest position increases
systemic vascular resistance, which helps reduce the right-to-left shunt and improves
oxygenation. This is the primary non-pharmacological intervention that should be
performed immediately before other treatments.
5. Which lab result is most characteristic of a child with Cystic Fibrosis?
A. Decreased serum sodium levels
B. Elevated serum glucose levels
C. Decreased fecal fat content
D. Elevated sweat chloride concentration
Correct Answer: D
Explanation: The sweat chloride test is the gold standard for diagnosing Cystic Fibrosis
(CF). CF involves a mutation in the CFTR protein, leading to defective chloride transport
and abnormally high levels of salt in sweat. A chloride concentration greater than 60
mEq/L is considered diagnostic for this genetic disorder.
