|Rationales
1. A nurse is caring for an infant with suspected Pyloric Stenosis. Which clinical
manifestation is most characteristic of this condition?
A. Currant jelly-like stools
B. Projectile vomiting after feeding
C. Ribbon-like foul-smelling stools
D. Severe periumbilical pain
Answer: B
Rationale: Projectile vomiting after feeding is the classic sign of hypertrophic pyloric
stenosis due to the obstructed gastric outlet.
2. When assessing a child with Tetralogy of Fallot who is having a hypercyanotic
(‘tet’) spell, what should be the nurse’s first action?
A. Administer 100% oxygen via mask
B. Administer morphine sulfate intravenously
C. Place the child in a knee-chest position
D. Prepare for immediate endotracheal intubation
Answer: C
Rationale: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt and improves pulmonary blood flow.
,3. A child is admitted with Acute Glomerulonephritis (AGN). Which historical
finding is most significant to this diagnosis?
A. Frequent urinary tract infections
B. A recent history of a streptococcal infection
C. A family history of polycystic kidney disease
D. Exposure to lead-based paint
Answer: B
Rationale: AGN is often a post-infectious complication following a Group A beta-hemolytic
streptococcal infection of the throat or skin.
4. What is the primary goal of treatment for a child with Sickle Cell Anemia
during a vaso-occlusive crisis?
A. To increase the hemoglobin level to normal
B. To promote adequate hydration and pain management
C. To prevent the spread of infection to others
D. To restrict fluids to prevent heart failure
Answer: B
Rationale: Hydration reduces blood viscosity to prevent further sickling, and aggressive
pain management is necessary for the severe pain of ischemia.
5. A nurse is providing discharge education to parents of a child with Celiac
Disease. Which food should be excluded from the child’s diet?
A. Fresh fruits and vegetables
B. Rice and corn cereals
C. Wheat bread and crackers
D. Plain poultry and meats
Answer: C
Rationale: Celiac disease requires a lifelong gluten-free diet, which means avoiding wheat,
barley, and rye.
, 6. Which assessment finding is a hallmark sign of Intussusception?
A. Persistent dry cough
B. Stools mixed with blood and mucus (‘currant jelly’)
C. Painless scrotal swelling
D. Extreme hyperactivity
Answer: B
Rationale: Intussusception involves the telescoping of the bowel, which leads to ischemia
and the characteristic currant jelly stools.
7. A 2-year-old is suspected of having Epiglottitis. Which action by the nurse is
contraindicated?
A. Maintaining the child in an upright position
B. Placing the child on a cardiac monitor
C. Administering humidified oxygen
D. Using a tongue blade to visualize the throat
Answer: D
Rationale: Visualizing the throat with a tongue blade or swab can trigger laryngospasm
and cause immediate complete airway obstruction in a child with epiglottitis.
8. Which of the following is the priority nursing intervention for a child
hospitalized with a diagnosis of Wilms Tumor?
A. Avoid palpation of the abdomen
B. Perform vigorous abdominal assessments every 4 hours
C. Maintain the child on a high-fiber diet
D. Prepare the child for immediate dialysis
Answer: A
Rationale: Wilms tumor (nephroblastoma) is an encapsulated tumor; palpation can cause
the capsule to rupture and spread cancer cells throughout the abdomen.