NUR 203/NUR203 Final Exam V2 |
Pediatric Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a 2-year-old child for developmental milestones. According to Erikson,
which psychosocial stage is the child expected to be in?
A. Trust vs. Mistrust
B. Industry vs. Inferiority
C. Initiative vs. Guilt
D. Autonomy vs. Shame and Doubt
Correct Answer: D
Expert Explanation: According to Erikson’s theory, toddlers aged 1 to 3 years are in the
Autonomy vs. Shame and Doubt stage. During this time, children focus on developing a
sense of personal control over physical skills and a sense of independence. Failure to
achieve this autonomy can lead to feelings of shame and doubt in their own abilities.
2. Which clinical manifestation should the nurse expect to observe in an infant with
suspected pyloric stenosis?
A. Projectile vomiting after feedings
B. Currant jelly-like stools
C. Steatorrhea and abdominal distention
,D. Bile-stained emesis
Correct Answer: A
Expert Explanation: Projectile vomiting is the classic sign of hypertrophic pyloric stenosis
due to the thickening of the pyloric sphincter preventing gastric emptying. This vomiting
typically occurs shortly after feeding and does not contain bile because the obstruction is
proximal to the bile duct. The infant may also present with an olive-shaped mass in the
epigastrium upon palpation.
3. A 4-year-old child is admitted with a diagnosis of Epiglottitis. Which nursing action is a
priority and must be avoided?
A. Providing humidified oxygen
B. Examining the throat with a tongue depressor
C. Inserting an intravenous line
D. Monitoring pulse oximetry
Correct Answer: B
Expert Explanation: In a child with suspected epiglottitis, examining the throat with a
tongue depressor is strictly contraindicated. This action can trigger a sudden
laryngospasm, leading to complete airway obstruction and respiratory arrest. The nurse
should keep the child calm and prepare for emergency intubation or tracheostomy if
necessary.
,4. A nurse is caring for an infant with Tetralogy of Fallot who suddenly becomes cyanotic and
dyspneic. What is the immediate priority action?
A. Administer 100% oxygen via mask
B. Call the healthcare provider
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 first intervention for a ‘tet spell’ or
hypercyanotic episode in an infant with Tetralogy of Fallot. This position increases
systemic vascular resistance, which decreases the right-to-left shunt and improves
pulmonary blood flow. Oxygen and medication administration follow once the child’s
position is stabilized to reduce cardiac demand.
5. A child with Cystic Fibrosis is prescribed pancreatic enzymes. When should the nurse
instruct the parents to administer this medication?
A. Once daily in the morning
B. Between meals to ensure absorption
C. With every meal and snack
D. Only when the child has fatty stools
Correct Answer: C
, Expert Explanation: Pancreatic enzymes must be taken with all meals and snacks to
facilitate the digestion and absorption of fats, proteins, and carbohydrates. Children with
Cystic Fibrosis lack these enzymes due to mucous plugging of the pancreatic ducts.
Effective enzyme replacement therapy is indicated by the reduction of steatorrhea and
improved weight gain.
6. When assessing a newborn for developmental dysplasia of the hip (DDH), which finding
should the nurse report?
A. Asymmetric thigh skin folds
B. Negative Ortolani maneuver
C. Symmetrical gluteal folds
D. Equal leg lengths
Correct Answer: A
Expert Explanation: Asymmetric thigh or gluteal skin folds are a classic sign of
developmental dysplasia of the hip in newborns. Other signs include a positive Ortolani or
Barlow maneuver and limited abduction of the hip on the affected side. Early detection is
critical to allow for successful treatment with devices like the Pavlik harness.
7. An adolescent is diagnosed with scoliosis and prescribed a Milwaukee brace. Which
statement by the patient indicates understanding of the teaching?
A. I will wear a thin t-shirt under the brace to protect my skin.
B. I only need to wear the brace while I am sleeping.
Pediatric Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a 2-year-old child for developmental milestones. According to Erikson,
which psychosocial stage is the child expected to be in?
A. Trust vs. Mistrust
B. Industry vs. Inferiority
C. Initiative vs. Guilt
D. Autonomy vs. Shame and Doubt
Correct Answer: D
Expert Explanation: According to Erikson’s theory, toddlers aged 1 to 3 years are in the
Autonomy vs. Shame and Doubt stage. During this time, children focus on developing a
sense of personal control over physical skills and a sense of independence. Failure to
achieve this autonomy can lead to feelings of shame and doubt in their own abilities.
2. Which clinical manifestation should the nurse expect to observe in an infant with
suspected pyloric stenosis?
A. Projectile vomiting after feedings
B. Currant jelly-like stools
C. Steatorrhea and abdominal distention
,D. Bile-stained emesis
Correct Answer: A
Expert Explanation: Projectile vomiting is the classic sign of hypertrophic pyloric stenosis
due to the thickening of the pyloric sphincter preventing gastric emptying. This vomiting
typically occurs shortly after feeding and does not contain bile because the obstruction is
proximal to the bile duct. The infant may also present with an olive-shaped mass in the
epigastrium upon palpation.
3. A 4-year-old child is admitted with a diagnosis of Epiglottitis. Which nursing action is a
priority and must be avoided?
A. Providing humidified oxygen
B. Examining the throat with a tongue depressor
C. Inserting an intravenous line
D. Monitoring pulse oximetry
Correct Answer: B
Expert Explanation: In a child with suspected epiglottitis, examining the throat with a
tongue depressor is strictly contraindicated. This action can trigger a sudden
laryngospasm, leading to complete airway obstruction and respiratory arrest. The nurse
should keep the child calm and prepare for emergency intubation or tracheostomy if
necessary.
,4. A nurse is caring for an infant with Tetralogy of Fallot who suddenly becomes cyanotic and
dyspneic. What is the immediate priority action?
A. Administer 100% oxygen via mask
B. Call the healthcare provider
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 first intervention for a ‘tet spell’ or
hypercyanotic episode in an infant with Tetralogy of Fallot. This position increases
systemic vascular resistance, which decreases the right-to-left shunt and improves
pulmonary blood flow. Oxygen and medication administration follow once the child’s
position is stabilized to reduce cardiac demand.
5. A child with Cystic Fibrosis is prescribed pancreatic enzymes. When should the nurse
instruct the parents to administer this medication?
A. Once daily in the morning
B. Between meals to ensure absorption
C. With every meal and snack
D. Only when the child has fatty stools
Correct Answer: C
, Expert Explanation: Pancreatic enzymes must be taken with all meals and snacks to
facilitate the digestion and absorption of fats, proteins, and carbohydrates. Children with
Cystic Fibrosis lack these enzymes due to mucous plugging of the pancreatic ducts.
Effective enzyme replacement therapy is indicated by the reduction of steatorrhea and
improved weight gain.
6. When assessing a newborn for developmental dysplasia of the hip (DDH), which finding
should the nurse report?
A. Asymmetric thigh skin folds
B. Negative Ortolani maneuver
C. Symmetrical gluteal folds
D. Equal leg lengths
Correct Answer: A
Expert Explanation: Asymmetric thigh or gluteal skin folds are a classic sign of
developmental dysplasia of the hip in newborns. Other signs include a positive Ortolani or
Barlow maneuver and limited abduction of the hip on the affected side. Early detection is
critical to allow for successful treatment with devices like the Pavlik harness.
7. An adolescent is diagnosed with scoliosis and prescribed a Milwaukee brace. Which
statement by the patient indicates understanding of the teaching?
A. I will wear a thin t-shirt under the brace to protect my skin.
B. I only need to wear the brace while I am sleeping.
