NUR 203/NUR203 Final Exam V3 |
Pediatric Nursing Q&A with Rationale |
Fortis College
1. A 4-year-old child is admitted with a diagnosis of Wilms tumor. What is the most important
nursing intervention during the pre-operative physical assessment?
A. Auscultating bowel sounds every 4 hours
B. Measuring head circumference daily
C. Checking blood pressure in all four extremities
D. Avoiding abdominal palpation
Correct Answer: D
Expert Explanation: Wilms tumor, or nephroblastoma, is an encapsulated abdominal
tumor common in children. Palpation of the abdomen is strictly contraindicated because it
can cause the tumor to rupture and spill malignant cells into the peritoneal cavity. A sign
should be placed above the child’s bed to alert all healthcare members to avoid abdominal
palpation.
2. A nurse is caring for a toddler who is in the ‘autonomy versus shame and doubt’ stage of
development. Which behavior should the nurse expect?
A. Asking ‘why’ questions repeatedly
B. Establishing a sense of trust with the primary caregiver
,C. Showing pride in new accomplishments and wanting to do things alone
D. Following rules strictly to avoid punishment
Correct Answer: C
Expert Explanation: According to Erikson, the toddler years are focused on developing
independence and self-control. Children in this stage often use the word ‘no’ and insist on
doing tasks by themselves even if they struggle. Supporting this need for independence
while maintaining safety is a key nursing goal for this age group.
3. An infant with Tetralogy of Fallot begins to cry and becomes cyanotic and tachypneic.
Which action should the nurse take first?
A. Administer 100% oxygen via face mask
B. Call for the emergency response team
C. Administer a dose of morphine sulfate IV
D. Place the infant in the knee-chest position
Correct Answer: D
Expert Explanation: The knee-chest position is the immediate priority for a ‘tet spell’ or
hypercyanotic episode. This maneuver increases systemic vascular resistance, which
reduces the right-to-left shunting of blood through the ventricular septal defect and
improves pulmonary blood flow. Oxygen and morphine may follow, but the physical
positioning provides the fastest physiological correction.
, 4. A nurse is educating the parents of a child with Celiac disease. Which food choice indicates
the parents understand the dietary restrictions?
A. Whole wheat crackers
B. Oatmeal cookies
C. Corn tortillas with grilled chicken
D. Barley soup with vegetables
Correct Answer: C
Expert Explanation: Celiac disease is an immune reaction to eating gluten, which is a
protein found in wheat, barley, and rye. Corn, rice, and soy are safe gluten-free alternatives
for these patients. Patients must strictly avoid wheat-based products to prevent intestinal
damage and malabsorption symptoms.
5. A child is admitted with suspected acute epiglottitis. Which of the following is a
contraindicated nursing action?
A. Allowing the child to sit in a tripod position
B. Using a tongue blade to visualize the throat
C. Providing humidified oxygen via blow-by
D. Keeping the child as calm as possible
Correct Answer: B
Pediatric Nursing Q&A with Rationale |
Fortis College
1. A 4-year-old child is admitted with a diagnosis of Wilms tumor. What is the most important
nursing intervention during the pre-operative physical assessment?
A. Auscultating bowel sounds every 4 hours
B. Measuring head circumference daily
C. Checking blood pressure in all four extremities
D. Avoiding abdominal palpation
Correct Answer: D
Expert Explanation: Wilms tumor, or nephroblastoma, is an encapsulated abdominal
tumor common in children. Palpation of the abdomen is strictly contraindicated because it
can cause the tumor to rupture and spill malignant cells into the peritoneal cavity. A sign
should be placed above the child’s bed to alert all healthcare members to avoid abdominal
palpation.
2. A nurse is caring for a toddler who is in the ‘autonomy versus shame and doubt’ stage of
development. Which behavior should the nurse expect?
A. Asking ‘why’ questions repeatedly
B. Establishing a sense of trust with the primary caregiver
,C. Showing pride in new accomplishments and wanting to do things alone
D. Following rules strictly to avoid punishment
Correct Answer: C
Expert Explanation: According to Erikson, the toddler years are focused on developing
independence and self-control. Children in this stage often use the word ‘no’ and insist on
doing tasks by themselves even if they struggle. Supporting this need for independence
while maintaining safety is a key nursing goal for this age group.
3. An infant with Tetralogy of Fallot begins to cry and becomes cyanotic and tachypneic.
Which action should the nurse take first?
A. Administer 100% oxygen via face mask
B. Call for the emergency response team
C. Administer a dose of morphine sulfate IV
D. Place the infant in the knee-chest position
Correct Answer: D
Expert Explanation: The knee-chest position is the immediate priority for a ‘tet spell’ or
hypercyanotic episode. This maneuver increases systemic vascular resistance, which
reduces the right-to-left shunting of blood through the ventricular septal defect and
improves pulmonary blood flow. Oxygen and morphine may follow, but the physical
positioning provides the fastest physiological correction.
, 4. A nurse is educating the parents of a child with Celiac disease. Which food choice indicates
the parents understand the dietary restrictions?
A. Whole wheat crackers
B. Oatmeal cookies
C. Corn tortillas with grilled chicken
D. Barley soup with vegetables
Correct Answer: C
Expert Explanation: Celiac disease is an immune reaction to eating gluten, which is a
protein found in wheat, barley, and rye. Corn, rice, and soy are safe gluten-free alternatives
for these patients. Patients must strictly avoid wheat-based products to prevent intestinal
damage and malabsorption symptoms.
5. A child is admitted with suspected acute epiglottitis. Which of the following is a
contraindicated nursing action?
A. Allowing the child to sit in a tripod position
B. Using a tongue blade to visualize the throat
C. Providing humidified oxygen via blow-by
D. Keeping the child as calm as possible
Correct Answer: B
