NUR 203/NUR203 Exam 3 V3 | Pediatric
Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing an infant with suspected Tetralogy of Fallot. The infant suddenly
becomes cyanotic and dyspneic. Which action should the nurse take first?
A. Administer 100% oxygen via face mask
B. Notify the healthcare provider immediately
C. Prepare for immediate administration of morphine
D. Place the infant in a knee-chest position
Correct Answer: D
Expert Explanation: The knee-chest position is the priority intervention for a ‘tet spell’ or
hypercyanotic episode. This position increases systemic vascular resistance, which helps
reduce the right-to-left shunt and improves pulmonary blood flow. After positioning the
infant, the nurse can then proceed with oxygen administration and notify the provider.
2. A school-age child is diagnosed with Acute Post-Streptococcal Glomerulonephritis (APSGN).
Which assessment finding is most characteristic of this condition?
A. Profuse watery diarrhea
B. Generalized hypotension
C. Periorbital edema and tea-colored urine
,D. Increased urinary output
Correct Answer: C
Expert Explanation: APSGN typically manifests with hematuria, which gives the urine a
smoky or tea-colored appearance. Periorbital edema is common in the morning due to fluid
retention and decreased glomerular filtration. This condition often follows a group A beta-
hemolytic streptococcal infection of the throat or skin.
3. A 4-year-old child is hospitalized with Kawasaki disease. Which medication should the
nurse expect to be included in the acute phase of treatment?
A. Antibiotics and corticosteroids
B. Intravenous Immunoglobulin (IVIG) and high-dose Aspirin
C. Warfarin and Heparin
D. Albuterol and Prednisone
Correct Answer: B
Expert Explanation: IVIG and high-dose aspirin are the standard treatments during the
acute phase of Kawasaki disease to prevent coronary artery aneurysms. IVIG helps reduce
the inflammatory response and fever associated with the vasculitis. Aspirin is used for its
anti-inflammatory and antiplatelet effects despite the general risk of Reye syndrome in
children.
, 4. The nurse is providing discharge instructions to the parents of a child with Celiac disease.
Which food choice indicates the parents understand the dietary restrictions?
A. Wheat crackers with cheese
B. Oatmeal cookies
C. Rice cakes with peanut butter
D. Rye bread sandwiches
Correct Answer: C
Expert Explanation: Celiac disease requires a strict gluten-free diet, which excludes
wheat, rye, barley, and sometimes oats. Rice and corn are safe alternatives for children with
this malabsorption syndrome. Peanut butter provides a good source of protein and fats that
are generally well-tolerated if there are no allergies.
5. An infant is admitted with projectile vomiting and a palpable olive-shaped mass in the right
upper quadrant. Which condition should the nurse suspect?
A. Intussusception
B. Hypertrophic pyloric stenosis
C. Gastroesophageal reflux
D. Hirschsprung disease
Correct Answer: B
Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing an infant with suspected Tetralogy of Fallot. The infant suddenly
becomes cyanotic and dyspneic. Which action should the nurse take first?
A. Administer 100% oxygen via face mask
B. Notify the healthcare provider immediately
C. Prepare for immediate administration of morphine
D. Place the infant in a knee-chest position
Correct Answer: D
Expert Explanation: The knee-chest position is the priority intervention for a ‘tet spell’ or
hypercyanotic episode. This position increases systemic vascular resistance, which helps
reduce the right-to-left shunt and improves pulmonary blood flow. After positioning the
infant, the nurse can then proceed with oxygen administration and notify the provider.
2. A school-age child is diagnosed with Acute Post-Streptococcal Glomerulonephritis (APSGN).
Which assessment finding is most characteristic of this condition?
A. Profuse watery diarrhea
B. Generalized hypotension
C. Periorbital edema and tea-colored urine
,D. Increased urinary output
Correct Answer: C
Expert Explanation: APSGN typically manifests with hematuria, which gives the urine a
smoky or tea-colored appearance. Periorbital edema is common in the morning due to fluid
retention and decreased glomerular filtration. This condition often follows a group A beta-
hemolytic streptococcal infection of the throat or skin.
3. A 4-year-old child is hospitalized with Kawasaki disease. Which medication should the
nurse expect to be included in the acute phase of treatment?
A. Antibiotics and corticosteroids
B. Intravenous Immunoglobulin (IVIG) and high-dose Aspirin
C. Warfarin and Heparin
D. Albuterol and Prednisone
Correct Answer: B
Expert Explanation: IVIG and high-dose aspirin are the standard treatments during the
acute phase of Kawasaki disease to prevent coronary artery aneurysms. IVIG helps reduce
the inflammatory response and fever associated with the vasculitis. Aspirin is used for its
anti-inflammatory and antiplatelet effects despite the general risk of Reye syndrome in
children.
, 4. The nurse is providing discharge instructions to the parents of a child with Celiac disease.
Which food choice indicates the parents understand the dietary restrictions?
A. Wheat crackers with cheese
B. Oatmeal cookies
C. Rice cakes with peanut butter
D. Rye bread sandwiches
Correct Answer: C
Expert Explanation: Celiac disease requires a strict gluten-free diet, which excludes
wheat, rye, barley, and sometimes oats. Rice and corn are safe alternatives for children with
this malabsorption syndrome. Peanut butter provides a good source of protein and fats that
are generally well-tolerated if there are no allergies.
5. An infant is admitted with projectile vomiting and a palpable olive-shaped mass in the right
upper quadrant. Which condition should the nurse suspect?
A. Intussusception
B. Hypertrophic pyloric stenosis
C. Gastroesophageal reflux
D. Hirschsprung disease
Correct Answer: B
