PNR 204/PNR204 Final Exam V2 | Pediatric
Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a 6-month-old infant. According to Erikson’s stages of psychosocial
development, which task should the nurse expect the infant to be working on?
A. Autonomy vs. Shame and Doubt
B. Initiative vs. Guilt
C. Trust vs. Mistrust
D. Industry vs. Inferiority
Correct Answer: C
Expert Explanation: The Trust vs. Mistrust stage occurs from birth to approximately 18
months of age. During this period, infants learn to rely on their caregivers for basic needs
such as food and affection. A failure to provide consistent care can lead to a lasting sense of
insecurity and suspicion.
2. A child is admitted with a suspected diagnosis of Tetralogy of Fallot. Which clinical
manifestation is most characteristic of this condition?
A. Hypercyanotic ‘Tet’ spells
B. Machine-like murmur
C. Bounding peripheral pulses
,D. High blood pressure in the arms
Correct Answer: A
Expert Explanation: Tetralogy of Fallot is a congenital heart defect that includes
pulmonary stenosis and right ventricular hypertrophy. Hypercyanotic spells, often called
‘Tet’ spells, occur when oxygen levels drop suddenly during crying or feeding. This
condition requires immediate nursing intervention such as placing the infant in a knee-
chest position.
3. A nurse is providing discharge instructions to the parents of a child newly diagnosed with
Celiac disease. Which food should the nurse instruct the parents to avoid?
A. Wheat crackers
B. Corn bread
C. Rice cereals
D. Fresh potatoes
Correct Answer: A
Expert Explanation: Celiac disease is a malabsorption syndrome characterized by an
intolerance to gluten. Gluten is found in wheat, barley, rye, and oats, which can damage the
small intestine lining. Therefore, wheat crackers must be eliminated from the diet to
prevent gastrointestinal symptoms and promote healing.
, 4. A 4-week-old infant is brought to the clinic with reports of projectile vomiting after
feedings. The nurse notes a palpable olive-shaped mass in the epigastrium. Which condition
is most likely?
A. Intussusception
B. Pyloric Stenosis
C. Hirschsprung Disease
D. Gastroesophageal Reflux
Correct Answer: B
Expert Explanation: Hypertrophic pyloric stenosis causes an obstruction of the pyloric
sphincter, leading to forceful, non-bile stained vomiting. The palpable olive-shaped mass is
a classic diagnostic sign of this condition in infants. Surgical intervention, known as a
pyloromyotomy, is typically required to correct the narrowing.
5. A nurse is assessing a toddler for possible intussusception. Which type of stool is the nurse
most likely to document?
A. Ribbon-like, foul-smelling stools
B. Hard, marble-like stools
C. Steatorrhea or fatty stools
D. Currant jelly-like stools
Correct Answer: D
Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a 6-month-old infant. According to Erikson’s stages of psychosocial
development, which task should the nurse expect the infant to be working on?
A. Autonomy vs. Shame and Doubt
B. Initiative vs. Guilt
C. Trust vs. Mistrust
D. Industry vs. Inferiority
Correct Answer: C
Expert Explanation: The Trust vs. Mistrust stage occurs from birth to approximately 18
months of age. During this period, infants learn to rely on their caregivers for basic needs
such as food and affection. A failure to provide consistent care can lead to a lasting sense of
insecurity and suspicion.
2. A child is admitted with a suspected diagnosis of Tetralogy of Fallot. Which clinical
manifestation is most characteristic of this condition?
A. Hypercyanotic ‘Tet’ spells
B. Machine-like murmur
C. Bounding peripheral pulses
,D. High blood pressure in the arms
Correct Answer: A
Expert Explanation: Tetralogy of Fallot is a congenital heart defect that includes
pulmonary stenosis and right ventricular hypertrophy. Hypercyanotic spells, often called
‘Tet’ spells, occur when oxygen levels drop suddenly during crying or feeding. This
condition requires immediate nursing intervention such as placing the infant in a knee-
chest position.
3. A nurse is providing discharge instructions to the parents of a child newly diagnosed with
Celiac disease. Which food should the nurse instruct the parents to avoid?
A. Wheat crackers
B. Corn bread
C. Rice cereals
D. Fresh potatoes
Correct Answer: A
Expert Explanation: Celiac disease is a malabsorption syndrome characterized by an
intolerance to gluten. Gluten is found in wheat, barley, rye, and oats, which can damage the
small intestine lining. Therefore, wheat crackers must be eliminated from the diet to
prevent gastrointestinal symptoms and promote healing.
, 4. A 4-week-old infant is brought to the clinic with reports of projectile vomiting after
feedings. The nurse notes a palpable olive-shaped mass in the epigastrium. Which condition
is most likely?
A. Intussusception
B. Pyloric Stenosis
C. Hirschsprung Disease
D. Gastroesophageal Reflux
Correct Answer: B
Expert Explanation: Hypertrophic pyloric stenosis causes an obstruction of the pyloric
sphincter, leading to forceful, non-bile stained vomiting. The palpable olive-shaped mass is
a classic diagnostic sign of this condition in infants. Surgical intervention, known as a
pyloromyotomy, is typically required to correct the narrowing.
5. A nurse is assessing a toddler for possible intussusception. Which type of stool is the nurse
most likely to document?
A. Ribbon-like, foul-smelling stools
B. Hard, marble-like stools
C. Steatorrhea or fatty stools
D. Currant jelly-like stools
Correct Answer: D
