PNR 204/PNR204 Exam 4 V1 | Pediatric
Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a 4-year-old child suspected of having epiglottitis. Which of the
following actions should the nurse avoid performing?
A. Allowing the child to remain in a tripod position
B. Administering humidified oxygen via a blow-by method
C. Preparing the child for a lateral neck x-ray
D. Attempting to visualize the throat with a tongue depressor
Correct Answer: D
Expert Explanation: In cases of suspected epiglottitis, visualizing the throat with a tongue
blade is strictly contraindicated because it can cause a laryngospasm and immediate
airway obstruction. The primary goal is to maintain a patent airway and keep the child as
calm as possible to prevent further respiratory distress. Medical personnel should be
prepared for emergency intubation or tracheostomy if the airway closes completely.
2. A mother brings her 3-week-old infant to the clinic reporting projectile vomiting after every
feeding. Upon palpation, the nurse notes an olive-shaped mass in the right upper quadrant.
Which condition does the nurse suspect?
A. Intussusception
,B. Gastroesophageal reflux
C. Hirschsprung’s disease
D. Hypertrophic pyloric stenosis
Correct Answer: D
Expert Explanation: Hypertrophic pyloric stenosis is characterized by the thickening of
the pyloric sphincter, which obstructs the stomach outlet. The classic symptoms include
non-bilious projectile vomiting and a palpable olive-shaped mass in the epigastrium.
Surgical intervention, known as a pyloromyotomy, is the definitive treatment to allow for
normal gastric emptying.
3. The nurse is caring for a child with cystic fibrosis. Which nutritional intervention is essential
to include in the plan of care?
A. Limiting sodium intake to prevent fluid retention
B. Administering pancreatic enzymes with all meals and snacks
C. Providing a low-calorie, low-fat diet to prevent obesity
D. Restricting fluid intake to decrease thick mucus secretions
Correct Answer: B
Expert Explanation: Children with cystic fibrosis suffer from pancreatic insufficiency,
which prevents the proper digestion of fats and proteins. Pancreatic enzyme replacement
therapy must be given with every meal and snack to facilitate nutrient absorption and
,prevent steatorrhea. Additionally, these children require a high-calorie, high-protein diet to
meet their increased metabolic demands.
4. A school-age child is diagnosed with Acute Post-Streptococcal Glomerulonephritis (APSGN).
Which clinical manifestation should the nurse expect to observe?
A. Hypotension and tachycardia
B. High-volume, dilute, straw-colored urine
C. Grossly bloody or tea-colored urine
D. Profuse watery diarrhea and weight loss
Correct Answer: C
Expert Explanation: APSGN is an immune-complex disease that occurs following a
streptococcal infection, leading to inflammation of the glomeruli. The hallmark signs
include tea-colored or smoky-colored urine due to hematuria, along with periorbital edema
and hypertension. Management focuses on blood pressure control and monitoring fluid
balance to prevent complications like heart failure.
5. A nurse is providing discharge teaching to the parents of a child with a new diagnosis of
asthma. What is the primary purpose of using a peak flow meter?
A. To deliver a metered dose of bronchodilator medication
B. To measure the concentration of oxygen in the blood
C. To prevent the occurrence of exercise-induced bronchospasm
, D. To monitor the child’s daily respiratory status and lung function
Correct Answer: D
Expert Explanation: A peak flow meter measures the maximum speed of expiration,
providing an objective assessment of the child’s airway obstruction levels. By tracking daily
readings, parents can identify early signs of an asthma flare-up before symptoms become
severe. This tool is a critical component of the asthma action plan for managing chronic
respiratory health.
6. A 2-year-old child is admitted with a diagnosis of intussusception. Which stool
characteristic is most associated with this condition?
A. Steatorrhea that is foul-smelling and greasy
B. Ribbon-like, foul-smelling stools
C. Red currant jelly-like stools containing blood and mucus
D. Hard, marble-like stools with streaks of bright red blood
Correct Answer: C
Expert Explanation: Intussusception occurs when one portion of the intestine telescopes
into another, leading to inflammation and ischemia. The classic ‘currant jelly’ stool is
caused by the sloughing of the intestinal mucosa mixed with blood and mucus. This
condition is a surgical emergency but can often be reduced using an air or barium enema
under fluoroscopy.
Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a 4-year-old child suspected of having epiglottitis. Which of the
following actions should the nurse avoid performing?
A. Allowing the child to remain in a tripod position
B. Administering humidified oxygen via a blow-by method
C. Preparing the child for a lateral neck x-ray
D. Attempting to visualize the throat with a tongue depressor
Correct Answer: D
Expert Explanation: In cases of suspected epiglottitis, visualizing the throat with a tongue
blade is strictly contraindicated because it can cause a laryngospasm and immediate
airway obstruction. The primary goal is to maintain a patent airway and keep the child as
calm as possible to prevent further respiratory distress. Medical personnel should be
prepared for emergency intubation or tracheostomy if the airway closes completely.
2. A mother brings her 3-week-old infant to the clinic reporting projectile vomiting after every
feeding. Upon palpation, the nurse notes an olive-shaped mass in the right upper quadrant.
Which condition does the nurse suspect?
A. Intussusception
,B. Gastroesophageal reflux
C. Hirschsprung’s disease
D. Hypertrophic pyloric stenosis
Correct Answer: D
Expert Explanation: Hypertrophic pyloric stenosis is characterized by the thickening of
the pyloric sphincter, which obstructs the stomach outlet. The classic symptoms include
non-bilious projectile vomiting and a palpable olive-shaped mass in the epigastrium.
Surgical intervention, known as a pyloromyotomy, is the definitive treatment to allow for
normal gastric emptying.
3. The nurse is caring for a child with cystic fibrosis. Which nutritional intervention is essential
to include in the plan of care?
A. Limiting sodium intake to prevent fluid retention
B. Administering pancreatic enzymes with all meals and snacks
C. Providing a low-calorie, low-fat diet to prevent obesity
D. Restricting fluid intake to decrease thick mucus secretions
Correct Answer: B
Expert Explanation: Children with cystic fibrosis suffer from pancreatic insufficiency,
which prevents the proper digestion of fats and proteins. Pancreatic enzyme replacement
therapy must be given with every meal and snack to facilitate nutrient absorption and
,prevent steatorrhea. Additionally, these children require a high-calorie, high-protein diet to
meet their increased metabolic demands.
4. A school-age child is diagnosed with Acute Post-Streptococcal Glomerulonephritis (APSGN).
Which clinical manifestation should the nurse expect to observe?
A. Hypotension and tachycardia
B. High-volume, dilute, straw-colored urine
C. Grossly bloody or tea-colored urine
D. Profuse watery diarrhea and weight loss
Correct Answer: C
Expert Explanation: APSGN is an immune-complex disease that occurs following a
streptococcal infection, leading to inflammation of the glomeruli. The hallmark signs
include tea-colored or smoky-colored urine due to hematuria, along with periorbital edema
and hypertension. Management focuses on blood pressure control and monitoring fluid
balance to prevent complications like heart failure.
5. A nurse is providing discharge teaching to the parents of a child with a new diagnosis of
asthma. What is the primary purpose of using a peak flow meter?
A. To deliver a metered dose of bronchodilator medication
B. To measure the concentration of oxygen in the blood
C. To prevent the occurrence of exercise-induced bronchospasm
, D. To monitor the child’s daily respiratory status and lung function
Correct Answer: D
Expert Explanation: A peak flow meter measures the maximum speed of expiration,
providing an objective assessment of the child’s airway obstruction levels. By tracking daily
readings, parents can identify early signs of an asthma flare-up before symptoms become
severe. This tool is a critical component of the asthma action plan for managing chronic
respiratory health.
6. A 2-year-old child is admitted with a diagnosis of intussusception. Which stool
characteristic is most associated with this condition?
A. Steatorrhea that is foul-smelling and greasy
B. Ribbon-like, foul-smelling stools
C. Red currant jelly-like stools containing blood and mucus
D. Hard, marble-like stools with streaks of bright red blood
Correct Answer: C
Expert Explanation: Intussusception occurs when one portion of the intestine telescopes
into another, leading to inflammation and ischemia. The classic ‘currant jelly’ stool is
caused by the sloughing of the intestinal mucosa mixed with blood and mucus. This
condition is a surgical emergency but can often be reduced using an air or barium enema
under fluoroscopy.
