PNR 204/PNR204 Exam 4 V3 | Pediatric
Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for an infant with Tetralogy of Fallot who begins to cry and becomes
cyanotic. Which of the following actions should the nurse take first?
A. Administer 100% oxygen via a face mask.
B. Prepare for the administration of morphine sulfate.
C. Place the infant in a knee-chest position.
D. Assess the infant’s heart rate and rhythm.
Correct Answer: C
Expert Explanation: Placing the infant in a knee-chest position increases systemic
vascular resistance, which helps to decrease the right-to-left shunt. This action forces more
blood into the pulmonary artery to improve oxygenation during a hypercyanotic spell. It is
the immediate nursing priority before secondary interventions like oxygen or medication.
2. A nurse is providing discharge teaching to the parents of a child with Digoxin (Lanoxin)
therapy. Which instruction is most critical for the nurse to include?
A. Mix the medication with the child’s favorite juice to improve taste.
B. Hold the dose and notify the provider if the infant’s heart rate is below 90 beats per
minute.
,C. If the child vomits after a dose, repeat the dose immediately.
D. Store the medication in a clear bottle on the kitchen counter.
Correct Answer: B
Expert Explanation: Digoxin toxicity is a serious concern in pediatric patients, often
manifesting as bradycardia or vomiting. The nurse must teach parents to check the apical
pulse and hold the dose if the rate falls below specific parameters, typically 90-110 in
infants and 70 in older children. Reporting these findings to the healthcare provider
ensures safety and prevents further cardiac depression.
3. A 4-week-old infant is admitted with suspected hypertrophic pyloric stenosis. Which
clinical finding does the nurse expect to observe?
A. Currant jelly-like stools containing blood and mucus.
B. Bile-stained emesis occurring shortly after feeding.
C. Projectile vomiting followed by immediate hunger.
D. Abdominal distention and ribbon-like stools.
Correct Answer: C
Expert Explanation: Pyloric stenosis is characterized by non-bilious, projectile vomiting
due to the mechanical obstruction of the pyloric sphincter. Affected infants are typically
‘hungry vomiters’ who wish to be fed again immediately after an episode. An olive-shaped
mass may also be palpable in the epigastrium to the right of the midline.
, 4. A toddler is diagnosed with intussusception. Which of the following is the hallmark clinical
manifestation of this condition?
A. Hard, pebble-like stools and chronic constipation.
B. Pain that radiates to the right lower quadrant.
C. Stools that resemble red currant jelly.
D. Painless rectal bleeding and abdominal mass.
Correct Answer: C
Expert Explanation: Intussusception occurs when one segment of the bowel telescopes
into another, leading to lymphatic and venous obstruction. This obstruction causes edema
and the leaking of blood and mucus into the intestinal lumen, resulting in the classic
‘currant jelly’ stool. It is often accompanied by sudden, severe abdominal pain that causes
the child to scream and draw their knees to the chest.
5. A nurse is caring for a child with Nephrotic Syndrome. Which of the following laboratory
findings should the nurse expect?
A. Decreased serum cholesterol levels.
B. Increased serum albumin levels.
C. Massive proteinuria and hypoalbuminemia.
D. Elevated red blood cells in the urine (hematuria).
Correct Answer: C
Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for an infant with Tetralogy of Fallot who begins to cry and becomes
cyanotic. Which of the following actions should the nurse take first?
A. Administer 100% oxygen via a face mask.
B. Prepare for the administration of morphine sulfate.
C. Place the infant in a knee-chest position.
D. Assess the infant’s heart rate and rhythm.
Correct Answer: C
Expert Explanation: Placing the infant in a knee-chest position increases systemic
vascular resistance, which helps to decrease the right-to-left shunt. This action forces more
blood into the pulmonary artery to improve oxygenation during a hypercyanotic spell. It is
the immediate nursing priority before secondary interventions like oxygen or medication.
2. A nurse is providing discharge teaching to the parents of a child with Digoxin (Lanoxin)
therapy. Which instruction is most critical for the nurse to include?
A. Mix the medication with the child’s favorite juice to improve taste.
B. Hold the dose and notify the provider if the infant’s heart rate is below 90 beats per
minute.
,C. If the child vomits after a dose, repeat the dose immediately.
D. Store the medication in a clear bottle on the kitchen counter.
Correct Answer: B
Expert Explanation: Digoxin toxicity is a serious concern in pediatric patients, often
manifesting as bradycardia or vomiting. The nurse must teach parents to check the apical
pulse and hold the dose if the rate falls below specific parameters, typically 90-110 in
infants and 70 in older children. Reporting these findings to the healthcare provider
ensures safety and prevents further cardiac depression.
3. A 4-week-old infant is admitted with suspected hypertrophic pyloric stenosis. Which
clinical finding does the nurse expect to observe?
A. Currant jelly-like stools containing blood and mucus.
B. Bile-stained emesis occurring shortly after feeding.
C. Projectile vomiting followed by immediate hunger.
D. Abdominal distention and ribbon-like stools.
Correct Answer: C
Expert Explanation: Pyloric stenosis is characterized by non-bilious, projectile vomiting
due to the mechanical obstruction of the pyloric sphincter. Affected infants are typically
‘hungry vomiters’ who wish to be fed again immediately after an episode. An olive-shaped
mass may also be palpable in the epigastrium to the right of the midline.
, 4. A toddler is diagnosed with intussusception. Which of the following is the hallmark clinical
manifestation of this condition?
A. Hard, pebble-like stools and chronic constipation.
B. Pain that radiates to the right lower quadrant.
C. Stools that resemble red currant jelly.
D. Painless rectal bleeding and abdominal mass.
Correct Answer: C
Expert Explanation: Intussusception occurs when one segment of the bowel telescopes
into another, leading to lymphatic and venous obstruction. This obstruction causes edema
and the leaking of blood and mucus into the intestinal lumen, resulting in the classic
‘currant jelly’ stool. It is often accompanied by sudden, severe abdominal pain that causes
the child to scream and draw their knees to the chest.
5. A nurse is caring for a child with Nephrotic Syndrome. Which of the following laboratory
findings should the nurse expect?
A. Decreased serum cholesterol levels.
B. Increased serum albumin levels.
C. Massive proteinuria and hypoalbuminemia.
D. Elevated red blood cells in the urine (hematuria).
Correct Answer: C
