NUR 203/NUR203 Exam 2 V1 | Pediatric
Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a 4-year-old child diagnosed with epiglottitis. Which of the following
nursing actions is the highest priority?
A. Obtain a throat culture to identify the causative organism.
B. Keep emergency intubation equipment at the bedside.
C. Place the child in a supine position to facilitate breathing.
D. Encourage the child to drink plenty of cold fluids.
Correct Answer: B
Expert Explanation: Epiglottitis is a life-threatening medical emergency that can lead to
sudden airway obstruction. The nurse must have emergency airway equipment, such as an
intubation tray or tracheostomy kit, immediately available at the bedside. Avoiding
invasive procedures like throat cultures is essential to prevent laryngospasm.
2. An infant with pyloric stenosis is admitted to the pediatric unit. What clinical manifestation
should the nurse expect to observe?
A. Projectile vomiting of non-bilious emesis after feedings.
B. Currant jelly-like stools containing blood and mucus.
C. Steatorrhea and foul-smelling, fatty stools.
,D. Abdominal distention and ribbon-like stools.
Correct Answer: A
Expert Explanation: The hallmark sign of hypertrophic pyloric stenosis is forceful,
projectile vomiting that occurs shortly after feeding. This occurs because the thickened
pyloric muscle prevents gastric contents from entering the duodenum. An olive-shaped
mass may also be palpable in the epigastrium just to the right of the umbilicus.
3. A child is hospitalized with Kawasaki disease. Which medication should the nurse
anticipate administering to prevent coronary artery complications?
A. Low-dose heparin and acyclovir.
B. Oral corticosteroids and broad-spectrum antibiotics.
C. High-dose aspirin and intravenous immunoglobulin (IVIG).
D. Acetaminophen and diphenhydramine.
Correct Answer: C
Expert Explanation: Kawasaki disease requires treatment with IVIG to reduce the
incidence of coronary artery aneurysms. High-dose aspirin is used initially for its anti-
inflammatory effects and then continued at low doses for its antiplatelet properties.
Monitoring for cardiac involvement and signs of heart failure is a critical nursing
responsibility during the acute phase.
,4. A nurse is providing discharge teaching to the parents of a child with Cystic Fibrosis. Which
instruction regarding pancreatic enzymes is correct?
A. Give the enzymes once daily every morning.
B. Omit the enzymes if the child is having a loose stool.
C. Mix the enzymes into hot oatmeal for better absorption.
D. Administer enzymes with every meal and snack.
Correct Answer: D
Expert Explanation: Pancreatic enzymes must be taken with every meal and snack to
facilitate the digestion and absorption of fats, proteins, and carbohydrates. In cystic
fibrosis, the pancreatic ducts are blocked by thick mucus, preventing natural enzymes from
reaching the duodenum. For infants, the capsules can be opened and the beads sprinkled
on a small amount of acidic food like applesauce.
5. A 2-year-old child is diagnosed with Laryngotracheobronchitis (Croup). Which sound would
the nurse most likely hear upon auscultation?
A. Expiratory wheezing and prolonged expiration.
B. Inspiratory stridor and a barking cough.
C. Crackles in the lower lung bases.
D. Diminished breath sounds throughout the right lung.
Correct Answer: B
, Expert Explanation: Croup is characterized by edema of the larynx, trachea, and bronchi,
which results in a characteristic brassy, barking cough. Inspiratory stridor occurs as air is
forced through the narrowed subglottic area. Management often includes cool mist therapy
or nebulized epinephrine to reduce airway swelling.
6. The nurse is assessing a child with Tetralogy of Fallot who suddenly becomes cyanotic and
tachypneic. Which action should the nurse take first?
A. Administer 100% oxygen via a non-rebreather mask.
B. Place the child in the knee-chest position.
C. Prepare for immediate administration of morphine sulfate.
D. Call a Code Blue and begin chest compressions.
Correct Answer: B
Expert Explanation: The knee-chest position is the priority intervention for a ‘tet spell’ or
hypercyanotic episode. This maneuver increases systemic vascular resistance, which helps
shunt blood from the right ventricle into the pulmonary artery instead of the aorta. Once
the child is positioned, oxygen and morphine may be administered as ordered to further
stabilize the patient.
7. A child with Nephrotic Syndrome is receiving care. Which of the following findings is most
consistent with this diagnosis?
A. Increased urine output and weight loss.
B. Gross hematuria and hypertension.
Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a 4-year-old child diagnosed with epiglottitis. Which of the following
nursing actions is the highest priority?
A. Obtain a throat culture to identify the causative organism.
B. Keep emergency intubation equipment at the bedside.
C. Place the child in a supine position to facilitate breathing.
D. Encourage the child to drink plenty of cold fluids.
Correct Answer: B
Expert Explanation: Epiglottitis is a life-threatening medical emergency that can lead to
sudden airway obstruction. The nurse must have emergency airway equipment, such as an
intubation tray or tracheostomy kit, immediately available at the bedside. Avoiding
invasive procedures like throat cultures is essential to prevent laryngospasm.
2. An infant with pyloric stenosis is admitted to the pediatric unit. What clinical manifestation
should the nurse expect to observe?
A. Projectile vomiting of non-bilious emesis after feedings.
B. Currant jelly-like stools containing blood and mucus.
C. Steatorrhea and foul-smelling, fatty stools.
,D. Abdominal distention and ribbon-like stools.
Correct Answer: A
Expert Explanation: The hallmark sign of hypertrophic pyloric stenosis is forceful,
projectile vomiting that occurs shortly after feeding. This occurs because the thickened
pyloric muscle prevents gastric contents from entering the duodenum. An olive-shaped
mass may also be palpable in the epigastrium just to the right of the umbilicus.
3. A child is hospitalized with Kawasaki disease. Which medication should the nurse
anticipate administering to prevent coronary artery complications?
A. Low-dose heparin and acyclovir.
B. Oral corticosteroids and broad-spectrum antibiotics.
C. High-dose aspirin and intravenous immunoglobulin (IVIG).
D. Acetaminophen and diphenhydramine.
Correct Answer: C
Expert Explanation: Kawasaki disease requires treatment with IVIG to reduce the
incidence of coronary artery aneurysms. High-dose aspirin is used initially for its anti-
inflammatory effects and then continued at low doses for its antiplatelet properties.
Monitoring for cardiac involvement and signs of heart failure is a critical nursing
responsibility during the acute phase.
,4. A nurse is providing discharge teaching to the parents of a child with Cystic Fibrosis. Which
instruction regarding pancreatic enzymes is correct?
A. Give the enzymes once daily every morning.
B. Omit the enzymes if the child is having a loose stool.
C. Mix the enzymes into hot oatmeal for better absorption.
D. Administer enzymes with every meal and snack.
Correct Answer: D
Expert Explanation: Pancreatic enzymes must be taken with every meal and snack to
facilitate the digestion and absorption of fats, proteins, and carbohydrates. In cystic
fibrosis, the pancreatic ducts are blocked by thick mucus, preventing natural enzymes from
reaching the duodenum. For infants, the capsules can be opened and the beads sprinkled
on a small amount of acidic food like applesauce.
5. A 2-year-old child is diagnosed with Laryngotracheobronchitis (Croup). Which sound would
the nurse most likely hear upon auscultation?
A. Expiratory wheezing and prolonged expiration.
B. Inspiratory stridor and a barking cough.
C. Crackles in the lower lung bases.
D. Diminished breath sounds throughout the right lung.
Correct Answer: B
, Expert Explanation: Croup is characterized by edema of the larynx, trachea, and bronchi,
which results in a characteristic brassy, barking cough. Inspiratory stridor occurs as air is
forced through the narrowed subglottic area. Management often includes cool mist therapy
or nebulized epinephrine to reduce airway swelling.
6. The nurse is assessing a child with Tetralogy of Fallot who suddenly becomes cyanotic and
tachypneic. Which action should the nurse take first?
A. Administer 100% oxygen via a non-rebreather mask.
B. Place the child in the knee-chest position.
C. Prepare for immediate administration of morphine sulfate.
D. Call a Code Blue and begin chest compressions.
Correct Answer: B
Expert Explanation: The knee-chest position is the priority intervention for a ‘tet spell’ or
hypercyanotic episode. This maneuver increases systemic vascular resistance, which helps
shunt blood from the right ventricle into the pulmonary artery instead of the aorta. Once
the child is positioned, oxygen and morphine may be administered as ordered to further
stabilize the patient.
7. A child with Nephrotic Syndrome is receiving care. Which of the following findings is most
consistent with this diagnosis?
A. Increased urine output and weight loss.
B. Gross hematuria and hypertension.
