PNR 204/PNR204 Exam 2 V2 | Pediatric
Nursing Q&A with Rationale | Fortis
College
1. A 4-year-old child is brought to the emergency department with a high fever, drooling, and
agitation. The nurse suspects epiglottitis. Which action is the highest priority?
A. Obtain a throat culture to identify the pathogen.
B. Place the child in a supine position for a physical exam.
C. Prepare for immediate airway management and keep the child calm.
D. Administer an oral antipyretic to reduce the fever.
Correct Answer: C
Expert Explanation: Epiglottitis is a medical emergency that can lead to rapid airway
obstruction. The nurse must avoid invasive procedures like throat cultures or using a
tongue blade, as these can trigger laryngospasm. Keeping the child in a position of comfort
and preparing for emergency intubation or tracheostomy is the priority intervention.
2. An infant with Congestive Heart Failure is prescribed Digoxin. The nurse notes the infant’s
apical heart rate is 88 beats per minute. What is the most appropriate nursing action?
A. Administer the dose and document the heart rate.
B. Administer half the dose and monitor for bradycardia.
C. Re-check the heart rate in 30 minutes before giving the medication.
,D. Withhold the dose and notify the healthcare provider.
Correct Answer: D
Expert Explanation: In infants, Digoxin should typically be withheld if the apical pulse is
less than 90 to 110 beats per minute. A heart rate of 88 is considered bradycardic for this
age group and may indicate Digoxin toxicity. The nurse must notify the provider to
determine if the medication should be held or adjusted.
3. A nurse is caring for a 6-week-old infant suspected of having pyloric stenosis. Which clinical
manifestation should the nurse expect to observe?
A. Currant jelly-like stools.
B. Bile-stained emesis after feedings.
C. Projectile vomiting followed by hunger.
D. Abdominal distention and ribbon-like stools.
Correct Answer: C
Expert Explanation: Hypertrophic pyloric stenosis is characterized by projectile, non-
bilious vomiting shortly after feeding. Because the obstruction is at the pylorus, the infant
remains hungry and often wants to feed again immediately after vomiting. An olive-shaped
mass may also be palpable in the right upper quadrant of the abdomen.
4. A toddler is hospitalized with a Vaso-occlusive Sickle Cell Crisis. What is the primary nursing
goal for this patient?
A. Providing adequate hydration and effective pain management.
, B. Administering oxygen via nasal cannula at 10 liters per minute.
C. Encouraging a low-protein diet to reduce metabolic waste.
D. Restricting fluids to prevent circulatory overload.
Correct Answer: A
Expert Explanation: During a vaso-occlusive crisis, sickled cells obstruct small blood
vessels, leading to severe ischemia and pain. Hydration is critical to decrease blood
viscosity and promote the flow of red blood cells. Pain management often requires
scheduled opioids to provide continuous relief from the intense cellular hypoxia.
5. A nurse is teaching parents about the care of a child with Celiac Disease. Which food item
should the nurse instruct the parents to avoid?
A. Wheat bread.
B. Fresh fruit.
C. Rice cakes.
D. Corn tortillas.
Correct Answer: A
Expert Explanation: Celiac disease is a permanent intolerance to gluten, which is found in
wheat, barley, rye, and oats. Ingesting gluten causes damage to the villi in the small
intestine, leading to malabsorption. Parents must be educated to strictly follow a gluten-
free diet to prevent long-term complications and nutritional deficiencies.
Nursing Q&A with Rationale | Fortis
College
1. A 4-year-old child is brought to the emergency department with a high fever, drooling, and
agitation. The nurse suspects epiglottitis. Which action is the highest priority?
A. Obtain a throat culture to identify the pathogen.
B. Place the child in a supine position for a physical exam.
C. Prepare for immediate airway management and keep the child calm.
D. Administer an oral antipyretic to reduce the fever.
Correct Answer: C
Expert Explanation: Epiglottitis is a medical emergency that can lead to rapid airway
obstruction. The nurse must avoid invasive procedures like throat cultures or using a
tongue blade, as these can trigger laryngospasm. Keeping the child in a position of comfort
and preparing for emergency intubation or tracheostomy is the priority intervention.
2. An infant with Congestive Heart Failure is prescribed Digoxin. The nurse notes the infant’s
apical heart rate is 88 beats per minute. What is the most appropriate nursing action?
A. Administer the dose and document the heart rate.
B. Administer half the dose and monitor for bradycardia.
C. Re-check the heart rate in 30 minutes before giving the medication.
,D. Withhold the dose and notify the healthcare provider.
Correct Answer: D
Expert Explanation: In infants, Digoxin should typically be withheld if the apical pulse is
less than 90 to 110 beats per minute. A heart rate of 88 is considered bradycardic for this
age group and may indicate Digoxin toxicity. The nurse must notify the provider to
determine if the medication should be held or adjusted.
3. A nurse is caring for a 6-week-old infant suspected of having pyloric stenosis. Which clinical
manifestation should the nurse expect to observe?
A. Currant jelly-like stools.
B. Bile-stained emesis after feedings.
C. Projectile vomiting followed by hunger.
D. Abdominal distention and ribbon-like stools.
Correct Answer: C
Expert Explanation: Hypertrophic pyloric stenosis is characterized by projectile, non-
bilious vomiting shortly after feeding. Because the obstruction is at the pylorus, the infant
remains hungry and often wants to feed again immediately after vomiting. An olive-shaped
mass may also be palpable in the right upper quadrant of the abdomen.
4. A toddler is hospitalized with a Vaso-occlusive Sickle Cell Crisis. What is the primary nursing
goal for this patient?
A. Providing adequate hydration and effective pain management.
, B. Administering oxygen via nasal cannula at 10 liters per minute.
C. Encouraging a low-protein diet to reduce metabolic waste.
D. Restricting fluids to prevent circulatory overload.
Correct Answer: A
Expert Explanation: During a vaso-occlusive crisis, sickled cells obstruct small blood
vessels, leading to severe ischemia and pain. Hydration is critical to decrease blood
viscosity and promote the flow of red blood cells. Pain management often requires
scheduled opioids to provide continuous relief from the intense cellular hypoxia.
5. A nurse is teaching parents about the care of a child with Celiac Disease. Which food item
should the nurse instruct the parents to avoid?
A. Wheat bread.
B. Fresh fruit.
C. Rice cakes.
D. Corn tortillas.
Correct Answer: A
Expert Explanation: Celiac disease is a permanent intolerance to gluten, which is found in
wheat, barley, rye, and oats. Ingesting gluten causes damage to the villi in the small
intestine, leading to malabsorption. Parents must be educated to strictly follow a gluten-
free diet to prevent long-term complications and nutritional deficiencies.
