NUR2513/NUR 2513 Exam 3 V1 | Maternal
Child Nursing Q&A with Rationale |
Rasmussen University
1. A 2-year-old child is brought to the emergency department with a barking cough and
stridor. The nurse suspects laryngotracheobronchitis (Croup). Which intervention should the
nurse prioritize?
A. Administer oral antibiotics as ordered
B. Place the child in a supine position for easier breathing
C. Perform a throat culture to identify the pathogen
D. Maintain a calm environment and provide humidified oxygen
Correct Answer: D
Rationale: Croup is primarily a viral condition, so antibiotics are not the initial priority
treatment. Maintaining a calm environment helps prevent the child from becoming
agitated, which can worsen airway obstruction and stridor. Humidified air or oxygen helps
soothe the inflamed airway and improve gas exchange in the pediatric patient.
2. A nurse is caring for a child with suspected epiglottitis. Which action by the nurse is
contraindicated?
A. Setting up for emergency intubation
B. Monitoring oxygen saturation continuously
,C. Encouraging the child to sit in a tripod position
D. Visualizing the throat with a tongue blade
Correct Answer: D
Rationale: Visualizing the throat with a tongue blade or performing a throat culture can
trigger a sudden laryngospasm in a child with epiglottitis. This can lead to complete airway
obstruction, which is a life-threatening emergency. The nurse must avoid any invasive
airway assessment until emergency equipment and personnel are ready for intubation.
3. 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. With every meal and snack
C. Only when the child has a bowel movement
D. Two hours after eating
Correct Answer: B
Rationale: Pancreatic enzymes are essential for children with cystic fibrosis to digest fats,
proteins, and carbohydrates due to pancreatic insufficiency. These enzymes must be taken
within 30 minutes of eating to ensure they mix with food in the digestive tract. Failure to
take them with every meal and snack results in malabsorption and steatorrhea.
, 4. Which clinical manifestation is a hallmark sign of Tetralogy of Fallot in an infant?
A. Bounding peripheral pulses
B. Machine-like murmur heard at the left sternal border
C. High blood pressure in the upper extremities
D. Cyanosis during crying or feeding
Correct Answer: D
Rationale: Tetralogy of Fallot involves four heart defects that result in poorly oxygenated
blood pumping to the body. Infants often experience ‘Tet spells,’ characterized by acute
cyanosis during times of exertion such as crying or feeding. This occurs because the right-
to-left shunt increases under stress, decreasing pulmonary blood flow.
5. The nurse is assessing a child with a Ventricular Septal Defect (VSD). Which heart sound is
most characteristic of this condition?
A. A loud, harsh holosystolic murmur
B. A soft diastolic murmur
C. A click sound during mid-systole
D. An absent second heart sound
Correct Answer: A
Rationale: A Ventricular Septal Defect allows blood to flow from the high-pressure left
ventricle to the low-pressure right ventricle. This abnormal flow creates a characteristic
Child Nursing Q&A with Rationale |
Rasmussen University
1. A 2-year-old child is brought to the emergency department with a barking cough and
stridor. The nurse suspects laryngotracheobronchitis (Croup). Which intervention should the
nurse prioritize?
A. Administer oral antibiotics as ordered
B. Place the child in a supine position for easier breathing
C. Perform a throat culture to identify the pathogen
D. Maintain a calm environment and provide humidified oxygen
Correct Answer: D
Rationale: Croup is primarily a viral condition, so antibiotics are not the initial priority
treatment. Maintaining a calm environment helps prevent the child from becoming
agitated, which can worsen airway obstruction and stridor. Humidified air or oxygen helps
soothe the inflamed airway and improve gas exchange in the pediatric patient.
2. A nurse is caring for a child with suspected epiglottitis. Which action by the nurse is
contraindicated?
A. Setting up for emergency intubation
B. Monitoring oxygen saturation continuously
,C. Encouraging the child to sit in a tripod position
D. Visualizing the throat with a tongue blade
Correct Answer: D
Rationale: Visualizing the throat with a tongue blade or performing a throat culture can
trigger a sudden laryngospasm in a child with epiglottitis. This can lead to complete airway
obstruction, which is a life-threatening emergency. The nurse must avoid any invasive
airway assessment until emergency equipment and personnel are ready for intubation.
3. 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. With every meal and snack
C. Only when the child has a bowel movement
D. Two hours after eating
Correct Answer: B
Rationale: Pancreatic enzymes are essential for children with cystic fibrosis to digest fats,
proteins, and carbohydrates due to pancreatic insufficiency. These enzymes must be taken
within 30 minutes of eating to ensure they mix with food in the digestive tract. Failure to
take them with every meal and snack results in malabsorption and steatorrhea.
, 4. Which clinical manifestation is a hallmark sign of Tetralogy of Fallot in an infant?
A. Bounding peripheral pulses
B. Machine-like murmur heard at the left sternal border
C. High blood pressure in the upper extremities
D. Cyanosis during crying or feeding
Correct Answer: D
Rationale: Tetralogy of Fallot involves four heart defects that result in poorly oxygenated
blood pumping to the body. Infants often experience ‘Tet spells,’ characterized by acute
cyanosis during times of exertion such as crying or feeding. This occurs because the right-
to-left shunt increases under stress, decreasing pulmonary blood flow.
5. The nurse is assessing a child with a Ventricular Septal Defect (VSD). Which heart sound is
most characteristic of this condition?
A. A loud, harsh holosystolic murmur
B. A soft diastolic murmur
C. A click sound during mid-systole
D. An absent second heart sound
Correct Answer: A
Rationale: A Ventricular Septal Defect allows blood to flow from the high-pressure left
ventricle to the low-pressure right ventricle. This abnormal flow creates a characteristic
