PNR 204/PNR204 Exam 4 V2 | Pediatric
Nursing Q&A with Rationale | Fortis
College
1. A mother brings her 4-week-old infant to the clinic because the infant has been
experiencing forceful, non-bilious projectile vomiting after feedings. The nurse notes an olive-
shaped mass in the right upper quadrant. Which condition does the nurse suspect?
A. Intussusception
B. Hypertrophic Pyloric Stenosis
C. Gastroesophageal Reflux Disease
D. Hirschsprung Disease
Correct Answer: B
Expert Explanation: Hypertrophic pyloric stenosis is characterized by the thickening of
the pyloric sphincter, leading to obstruction. The classic clinical manifestations include
projectile vomiting and the presence of a palpable olive-shaped mass in the epigastrium.
Surgical intervention via pyloromyotomy is the standard treatment once electrolyte
imbalances are corrected.
2. When assessing a 2-year-old child with suspected Hirschsprung disease, which clinical
finding is most characteristic of this condition?
A. Currant jelly-like stools
,B. Ribbon-like, foul-smelling stools
C. Projectile vomiting
D. Severe perianal itching
Correct Answer: B
Expert Explanation: Hirschsprung disease, or congenital aganglionic megacolon, results
from the absence of ganglion cells in the distal colon. This lack of innervation leads to a lack
of peristalsis and subsequent functional obstruction. A hallmark sign in older infants and
children is the passage of ribbon-like, foul-smelling stools due to the narrowed segment of
the colon.
3. A nurse is caring for an infant who has just undergone a surgical repair for a cleft lip. Which
nursing intervention is a priority in the immediate postoperative period?
A. Use a Logan bow or similar device to protect the suture line.
B. Position the infant in a prone position to facilitate drainage.
C. Encourage the infant to use a pacifier to soothe crying.
D. Provide oral hygiene using a firm toothbrush.
Correct Answer: A
Expert Explanation: Postoperative care for cleft lip repair focuses on protecting the
surgical site from trauma. A Logan bow or butterfly adhesive is often used to reduce
, tension on the suture line. The infant should be placed in a supine or side-lying position,
and pacifiers are contraindicated to prevent suction-related damage.
4. The nurse is assessing a child with a diagnosis of Intussusception. Which finding should the
nurse report to the provider immediately as it may indicate a serious complication?
A. Passage of a normal brown stool.
B. A sausage-shaped mass in the right upper quadrant.
C. Bouts of colicky abdominal pain.
D. Crying with knees drawn up to the chest.
Correct Answer: A
Expert Explanation: The passage of a normal brown stool in a child with intussusception
may indicate that the bowel has spontaneously reduced itself. This change must be
reported immediately because it may alter the planned surgical or radiological
intervention. While the sausage-shaped mass and colicky pain are expected findings,
spontaneous reduction is a critical change in status.
5. Which dietary instruction is most appropriate for the parents of a child newly diagnosed
with Celiac Disease?
A. Eliminate all dairy products from the diet.
B. Provide a high-fiber diet including whole wheat bread.
C. Restrict fat intake to less than 20 percent of calories.
Nursing Q&A with Rationale | Fortis
College
1. A mother brings her 4-week-old infant to the clinic because the infant has been
experiencing forceful, non-bilious projectile vomiting after feedings. The nurse notes an olive-
shaped mass in the right upper quadrant. Which condition does the nurse suspect?
A. Intussusception
B. Hypertrophic Pyloric Stenosis
C. Gastroesophageal Reflux Disease
D. Hirschsprung Disease
Correct Answer: B
Expert Explanation: Hypertrophic pyloric stenosis is characterized by the thickening of
the pyloric sphincter, leading to obstruction. The classic clinical manifestations include
projectile vomiting and the presence of a palpable olive-shaped mass in the epigastrium.
Surgical intervention via pyloromyotomy is the standard treatment once electrolyte
imbalances are corrected.
2. When assessing a 2-year-old child with suspected Hirschsprung disease, which clinical
finding is most characteristic of this condition?
A. Currant jelly-like stools
,B. Ribbon-like, foul-smelling stools
C. Projectile vomiting
D. Severe perianal itching
Correct Answer: B
Expert Explanation: Hirschsprung disease, or congenital aganglionic megacolon, results
from the absence of ganglion cells in the distal colon. This lack of innervation leads to a lack
of peristalsis and subsequent functional obstruction. A hallmark sign in older infants and
children is the passage of ribbon-like, foul-smelling stools due to the narrowed segment of
the colon.
3. A nurse is caring for an infant who has just undergone a surgical repair for a cleft lip. Which
nursing intervention is a priority in the immediate postoperative period?
A. Use a Logan bow or similar device to protect the suture line.
B. Position the infant in a prone position to facilitate drainage.
C. Encourage the infant to use a pacifier to soothe crying.
D. Provide oral hygiene using a firm toothbrush.
Correct Answer: A
Expert Explanation: Postoperative care for cleft lip repair focuses on protecting the
surgical site from trauma. A Logan bow or butterfly adhesive is often used to reduce
, tension on the suture line. The infant should be placed in a supine or side-lying position,
and pacifiers are contraindicated to prevent suction-related damage.
4. The nurse is assessing a child with a diagnosis of Intussusception. Which finding should the
nurse report to the provider immediately as it may indicate a serious complication?
A. Passage of a normal brown stool.
B. A sausage-shaped mass in the right upper quadrant.
C. Bouts of colicky abdominal pain.
D. Crying with knees drawn up to the chest.
Correct Answer: A
Expert Explanation: The passage of a normal brown stool in a child with intussusception
may indicate that the bowel has spontaneously reduced itself. This change must be
reported immediately because it may alter the planned surgical or radiological
intervention. While the sausage-shaped mass and colicky pain are expected findings,
spontaneous reduction is a critical change in status.
5. Which dietary instruction is most appropriate for the parents of a child newly diagnosed
with Celiac Disease?
A. Eliminate all dairy products from the diet.
B. Provide a high-fiber diet including whole wheat bread.
C. Restrict fat intake to less than 20 percent of calories.
