PNR 204/PNR204 Exam 3 V2 | Pediatric
Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing an infant who has tetralogy of Fallot. Which of the following clinical
manifestations should the nurse expect?
A. Decreased heart rate during feeding
B. High blood pressure in the upper extremities
C. Bounding peripheral pulses
D. Polycythemia and clubbing of the fingers
Correct Answer: D
Expert Explanation: Tetralogy of Fallot involves decreased pulmonary blood flow which
leads to chronic hypoxia. The body increases red blood cell production to compensate,
resulting in polycythemia. Clubbing occurs over time as a result of chronic tissue hypoxia
and is a hallmark sign in older infants and children.
2. A child with cystic fibrosis is prescribed pancrelipase. How should the nurse instruct the
parents to administer this medication?
A. Administer the medication 2 hours after every meal
B. Give the medication with every meal and snack
C. Mix the powder with hot oatmeal or formula
,D. Only administer the medication if the child has a bowel movement
Correct Answer: B
Expert Explanation: Pancreatic enzymes are necessary to aid in the digestion and
absorption of fats, proteins, and carbohydrates. These must be taken within 30 minutes of
eating any food containing these nutrients. Without these enzymes, the child will suffer
from malabsorption and steatorrhea.
3. Which of the following interventions is a priority for a child admitted with acute
epiglottitis?
A. Obtain a throat culture to identify the pathogen
B. Place the child in a supine position
C. Maintain a patent airway and avoid throat inspection
D. Start an IV line immediately for fluid resuscitation
Correct Answer: C
Expert Explanation: Epiglottitis is a medical emergency that can lead to sudden total
airway obstruction. The nurse must never use a tongue blade or swab the throat as this can
trigger a laryngospasm. Airway maintenance is the absolute priority until the child is
intubated or stable.
4. A nurse is caring for a child with sickle cell anemia who is experiencing a vaso-occlusive
crisis. What is the priority nursing action?
A. Administer oxygen at 2L/min via nasal cannula
, B. Encourage the child to increase physical activity
C. Initiate IV fluids and maintain hydration
D. Apply cold compresses to painful joints
Correct Answer: C
Expert Explanation: Hydration is the priority because it helps reduce the viscosity of the
blood and prevents further sickling. While pain management and oxygen are important,
fluids are essential to reverse the occlusion. The nurse should also monitor for signs of fluid
overload during rapid rehydration.
5. A 2-month-old infant is being evaluated for pyloric stenosis. Which finding should the
nurse expect?
A. Currant jelly-like stools
B. Steatorrhea and abdominal distention
C. Projectile vomiting after feedings
D. Visible peristalsis from right to left
Correct Answer: C
Expert Explanation: Hypertrophic pyloric stenosis causes an obstruction at the outlet of
the stomach, leading to forceful, non-bile stained projectile vomiting. This typically occurs
shortly after feeding and the infant usually remains hungry afterward. An olive-shaped
mass in the epigastrium is also a common physical finding.
Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing an infant who has tetralogy of Fallot. Which of the following clinical
manifestations should the nurse expect?
A. Decreased heart rate during feeding
B. High blood pressure in the upper extremities
C. Bounding peripheral pulses
D. Polycythemia and clubbing of the fingers
Correct Answer: D
Expert Explanation: Tetralogy of Fallot involves decreased pulmonary blood flow which
leads to chronic hypoxia. The body increases red blood cell production to compensate,
resulting in polycythemia. Clubbing occurs over time as a result of chronic tissue hypoxia
and is a hallmark sign in older infants and children.
2. A child with cystic fibrosis is prescribed pancrelipase. How should the nurse instruct the
parents to administer this medication?
A. Administer the medication 2 hours after every meal
B. Give the medication with every meal and snack
C. Mix the powder with hot oatmeal or formula
,D. Only administer the medication if the child has a bowel movement
Correct Answer: B
Expert Explanation: Pancreatic enzymes are necessary to aid in the digestion and
absorption of fats, proteins, and carbohydrates. These must be taken within 30 minutes of
eating any food containing these nutrients. Without these enzymes, the child will suffer
from malabsorption and steatorrhea.
3. Which of the following interventions is a priority for a child admitted with acute
epiglottitis?
A. Obtain a throat culture to identify the pathogen
B. Place the child in a supine position
C. Maintain a patent airway and avoid throat inspection
D. Start an IV line immediately for fluid resuscitation
Correct Answer: C
Expert Explanation: Epiglottitis is a medical emergency that can lead to sudden total
airway obstruction. The nurse must never use a tongue blade or swab the throat as this can
trigger a laryngospasm. Airway maintenance is the absolute priority until the child is
intubated or stable.
4. A nurse is caring for a child with sickle cell anemia who is experiencing a vaso-occlusive
crisis. What is the priority nursing action?
A. Administer oxygen at 2L/min via nasal cannula
, B. Encourage the child to increase physical activity
C. Initiate IV fluids and maintain hydration
D. Apply cold compresses to painful joints
Correct Answer: C
Expert Explanation: Hydration is the priority because it helps reduce the viscosity of the
blood and prevents further sickling. While pain management and oxygen are important,
fluids are essential to reverse the occlusion. The nurse should also monitor for signs of fluid
overload during rapid rehydration.
5. A 2-month-old infant is being evaluated for pyloric stenosis. Which finding should the
nurse expect?
A. Currant jelly-like stools
B. Steatorrhea and abdominal distention
C. Projectile vomiting after feedings
D. Visible peristalsis from right to left
Correct Answer: C
Expert Explanation: Hypertrophic pyloric stenosis causes an obstruction at the outlet of
the stomach, leading to forceful, non-bile stained projectile vomiting. This typically occurs
shortly after feeding and the infant usually remains hungry afterward. An olive-shaped
mass in the epigastrium is also a common physical finding.
