NUR106 | NUR106 Pediatric Nursing Exam 2
Version 2 | Questions with Correct Answers and
Expert Explanation for Each Question | Saint Paul’s
School of Nursing
1. A 9-month-old infant is admitted with diarrhea and vomiting. The nurse notes a
sunken anterior fontanel, dry mucous membranes, and a weight loss of 8%. Which
level of dehydration does this represent?
A. Moderate dehydration
B. Mild dehydration
C. Severe dehydration
D. Critical dehydration
Correct Answer: A
Expert Explanation: Moderate dehydration in infants is typically characterized by a
6% to 9% weight loss. Clinical signs include a sunken fontanel, dry mucous
membranes, and decreased skin turgor. Mild dehydration usually involves less than
5% weight loss and fewer clinical signs. Severe dehydration exceeds 10% weight
loss and often includes signs of shock. Accurate assessment of weight loss is the
most reliable indicator of fluid deficit in pediatric patients.
,2. The nurse is teaching a parent of a toddler with mild dehydration about oral
rehydration therapy (ORT). Which beverage should the nurse instruct the parent to
avoid?
A. Pedialyte
B. Infalyte
C. Rehydralyte
D. Apple juice
Correct Answer: D
Expert Explanation: Clear liquids like apple juice, soda, and sports drinks are high
in sugar and low in electrolytes. The high osmolarity of these drinks can actually
worsen diarrhea via osmotic pull. Oral rehydration solutions (ORS) like Pedialyte
are specifically formulated with the correct balance of sodium and glucose.
Successful ORT helps prevent the need for more invasive intravenous therapy.
Parents should be educated that plain water alone does not replace lost electrolytes
effectively in a dehydrated child.
3. A 4-week-old infant is brought to the clinic for projectile vomiting after every
feeding. The nurse palpates an olive-shaped mass in the right upper quadrant. What is
the most likely diagnosis?
A. Intussusception
,B. Hirschsprung disease
C. Hypertrophic pyloric stenosis
D. Gastroesophageal reflux
Correct Answer: C
Expert Explanation: Hypertrophic pyloric stenosis is characterized by the
thickening of the pyloric sphincter, leading to gastric outlet obstruction. Projectile
vomiting usually begins between the second and fourth weeks of life. The hallmark
physical finding is a hard, olive-shaped mass in the epigastrium to the right of the
midline. This condition often results in metabolic alkalosis due to the loss of gastric
acid through vomiting. Surgical intervention via a pyloromyotomy is the definitive
treatment for this condition.
4. Which clinical manifestation should the nurse expect to find in a child diagnosed
with intussusception?
A. Currant jelly-like stools
B. Ribbon-like stools
C. Projectile vomiting
D. Steatorrhea
Correct Answer: A
, Expert Explanation: Intussusception occurs when one portion of the intestine
telescopes into another, causing obstruction and edema. The classic triad of
symptoms includes abdominal pain, a palpable sausage-shaped mass, and currant
jelly-like stools. These stools contain blood and mucus as a result of intestinal
ischemia and mucosal sloughing. Diagnosis is often confirmed and treated
simultaneously using an air or saline enema. The nurse must monitor for the
passage of normal brown stool, which indicates the intussusception has reduced.
5. A newborn has not passed meconium within the first 48 hours of life. The nurse
suspects Hirschsprung disease. Which pathophysiology underlies this condition?
A. Mechanical obstruction by a fecalith
B. Inflammation of the mucosal layer of the colon
C. Absence of ganglion cells in the distal colon
D. Hypersensitivity to gluten proteins
Correct Answer: C
Expert Explanation: Hirschsprung disease is a congenital anomaly resulting in
inadequate motility of part of the colon. It is caused by the absence of ganglion cells
in the submucosal and myenteric plexuses. This lack of innervation leads to a
functional obstruction and proximal dilation of the colon, known as megacolon.
Newborns typically present with failure to pass meconium and abdominal
Version 2 | Questions with Correct Answers and
Expert Explanation for Each Question | Saint Paul’s
School of Nursing
1. A 9-month-old infant is admitted with diarrhea and vomiting. The nurse notes a
sunken anterior fontanel, dry mucous membranes, and a weight loss of 8%. Which
level of dehydration does this represent?
A. Moderate dehydration
B. Mild dehydration
C. Severe dehydration
D. Critical dehydration
Correct Answer: A
Expert Explanation: Moderate dehydration in infants is typically characterized by a
6% to 9% weight loss. Clinical signs include a sunken fontanel, dry mucous
membranes, and decreased skin turgor. Mild dehydration usually involves less than
5% weight loss and fewer clinical signs. Severe dehydration exceeds 10% weight
loss and often includes signs of shock. Accurate assessment of weight loss is the
most reliable indicator of fluid deficit in pediatric patients.
,2. The nurse is teaching a parent of a toddler with mild dehydration about oral
rehydration therapy (ORT). Which beverage should the nurse instruct the parent to
avoid?
A. Pedialyte
B. Infalyte
C. Rehydralyte
D. Apple juice
Correct Answer: D
Expert Explanation: Clear liquids like apple juice, soda, and sports drinks are high
in sugar and low in electrolytes. The high osmolarity of these drinks can actually
worsen diarrhea via osmotic pull. Oral rehydration solutions (ORS) like Pedialyte
are specifically formulated with the correct balance of sodium and glucose.
Successful ORT helps prevent the need for more invasive intravenous therapy.
Parents should be educated that plain water alone does not replace lost electrolytes
effectively in a dehydrated child.
3. A 4-week-old infant is brought to the clinic for projectile vomiting after every
feeding. The nurse palpates an olive-shaped mass in the right upper quadrant. What is
the most likely diagnosis?
A. Intussusception
,B. Hirschsprung disease
C. Hypertrophic pyloric stenosis
D. Gastroesophageal reflux
Correct Answer: C
Expert Explanation: Hypertrophic pyloric stenosis is characterized by the
thickening of the pyloric sphincter, leading to gastric outlet obstruction. Projectile
vomiting usually begins between the second and fourth weeks of life. The hallmark
physical finding is a hard, olive-shaped mass in the epigastrium to the right of the
midline. This condition often results in metabolic alkalosis due to the loss of gastric
acid through vomiting. Surgical intervention via a pyloromyotomy is the definitive
treatment for this condition.
4. Which clinical manifestation should the nurse expect to find in a child diagnosed
with intussusception?
A. Currant jelly-like stools
B. Ribbon-like stools
C. Projectile vomiting
D. Steatorrhea
Correct Answer: A
, Expert Explanation: Intussusception occurs when one portion of the intestine
telescopes into another, causing obstruction and edema. The classic triad of
symptoms includes abdominal pain, a palpable sausage-shaped mass, and currant
jelly-like stools. These stools contain blood and mucus as a result of intestinal
ischemia and mucosal sloughing. Diagnosis is often confirmed and treated
simultaneously using an air or saline enema. The nurse must monitor for the
passage of normal brown stool, which indicates the intussusception has reduced.
5. A newborn has not passed meconium within the first 48 hours of life. The nurse
suspects Hirschsprung disease. Which pathophysiology underlies this condition?
A. Mechanical obstruction by a fecalith
B. Inflammation of the mucosal layer of the colon
C. Absence of ganglion cells in the distal colon
D. Hypersensitivity to gluten proteins
Correct Answer: C
Expert Explanation: Hirschsprung disease is a congenital anomaly resulting in
inadequate motility of part of the colon. It is caused by the absence of ganglion cells
in the submucosal and myenteric plexuses. This lack of innervation leads to a
functional obstruction and proximal dilation of the colon, known as megacolon.
Newborns typically present with failure to pass meconium and abdominal
