PNR 204/PNR204 Final Exam V1 | Pediatric
Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a 4-year-old child who has a high fever, is drooling, and is leaning
forward in a tripod position. Which action should the nurse take first?
A. Prepare for immediate airway management
B. Obtain a rectal temperature
C. Examine the child’s throat with a tongue depressor
D. Administer an oral antipyretic
Correct Answer: A
Expert Explanation: The child is exhibiting classic signs of epiglottitis, which is a medical
emergency due to the risk of complete airway obstruction. Attempting to visualize the
throat with a tongue depressor can trigger a laryngospasm and should never be done. The
nurse’s priority is to keep the child calm and prepare for emergency intubation or
tracheostomy.
2. When planning care for an 8-month-old infant, which developmental milestone should the
nurse expect to observe?
A. Walking without assistance
B. Saying three to five meaningful words
,C. Using a spoon to eat
D. Sitting steadily without support
Correct Answer: D
Expert Explanation: By 8 months of age, most infants can sit steadily without support and
may begin to pull themselves to a standing position. Walking and using a spoon are
typically milestones achieved closer to 12-15 months. Expressing several meaningful
words is also a milestone expected at approximately 1 year of age.
3. A nurse is caring for a child with Tetralogy of Fallot who suddenly becomes cyanotic and
dyspneic. Which position should the nurse place the child in?
A. Knee-chest
B. High-Fowler’s
C. Prone
D. Supine with legs elevated
Correct Answer: A
Expert Explanation: A ‘tet spell’ or hypercyanotic spell occurs due to a sudden decrease in
pulmonary blood flow. Placing the child in a knee-chest position increases systemic
vascular resistance, which helps force blood into the pulmonary artery. This intervention
improves oxygenation and is the priority action for a child experiencing an acute cyanotic
episode.
, 4. A 2-year-old child is admitted with a diagnosis of intussusception. Which clinical finding
should the nurse expect the parents to report?
A. Projectile vomiting
B. Currant jelly-like stools
C. Ribbon-like stools
D. Constant abdominal pain
Correct Answer: B
Expert Explanation: Intussusception is the telescoping of one portion of the intestine into
another, leading to obstruction and ischemia. The classic triad of symptoms includes
sudden onset of crampy abdominal pain, a palpable sausage-shaped mass, and stools mixed
with blood and mucus, often described as currant jelly. Ribbon-like stools are characteristic
of Hirschsprung disease, while projectile vomiting is seen in pyloric stenosis.
5. A nurse is teaching parents of a toddler about lead poisoning prevention. Which of the
following statements by a parent indicates a need for further teaching?
A. I will wet-mop the floors instead of vacuuming.
B. I will wash my child’s hands frequently, especially before eating.
C. I will use cold water from the tap for cooking.
D. I will ensure my child gets enough calcium and iron.
Correct Answer: A
Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a 4-year-old child who has a high fever, is drooling, and is leaning
forward in a tripod position. Which action should the nurse take first?
A. Prepare for immediate airway management
B. Obtain a rectal temperature
C. Examine the child’s throat with a tongue depressor
D. Administer an oral antipyretic
Correct Answer: A
Expert Explanation: The child is exhibiting classic signs of epiglottitis, which is a medical
emergency due to the risk of complete airway obstruction. Attempting to visualize the
throat with a tongue depressor can trigger a laryngospasm and should never be done. The
nurse’s priority is to keep the child calm and prepare for emergency intubation or
tracheostomy.
2. When planning care for an 8-month-old infant, which developmental milestone should the
nurse expect to observe?
A. Walking without assistance
B. Saying three to five meaningful words
,C. Using a spoon to eat
D. Sitting steadily without support
Correct Answer: D
Expert Explanation: By 8 months of age, most infants can sit steadily without support and
may begin to pull themselves to a standing position. Walking and using a spoon are
typically milestones achieved closer to 12-15 months. Expressing several meaningful
words is also a milestone expected at approximately 1 year of age.
3. A nurse is caring for a child with Tetralogy of Fallot who suddenly becomes cyanotic and
dyspneic. Which position should the nurse place the child in?
A. Knee-chest
B. High-Fowler’s
C. Prone
D. Supine with legs elevated
Correct Answer: A
Expert Explanation: A ‘tet spell’ or hypercyanotic spell occurs due to a sudden decrease in
pulmonary blood flow. Placing the child in a knee-chest position increases systemic
vascular resistance, which helps force blood into the pulmonary artery. This intervention
improves oxygenation and is the priority action for a child experiencing an acute cyanotic
episode.
, 4. A 2-year-old child is admitted with a diagnosis of intussusception. Which clinical finding
should the nurse expect the parents to report?
A. Projectile vomiting
B. Currant jelly-like stools
C. Ribbon-like stools
D. Constant abdominal pain
Correct Answer: B
Expert Explanation: Intussusception is the telescoping of one portion of the intestine into
another, leading to obstruction and ischemia. The classic triad of symptoms includes
sudden onset of crampy abdominal pain, a palpable sausage-shaped mass, and stools mixed
with blood and mucus, often described as currant jelly. Ribbon-like stools are characteristic
of Hirschsprung disease, while projectile vomiting is seen in pyloric stenosis.
5. A nurse is teaching parents of a toddler about lead poisoning prevention. Which of the
following statements by a parent indicates a need for further teaching?
A. I will wet-mop the floors instead of vacuuming.
B. I will wash my child’s hands frequently, especially before eating.
C. I will use cold water from the tap for cooking.
D. I will ensure my child gets enough calcium and iron.
Correct Answer: A
