NR 328 Exam 3: Pediatric Nursing - Chamberlain
University Updated and Latest Questions and Correct
Answers with Rationale
1. A 6-week-old infant is brought to the clinic presenting with non-bilious projectile vomiting after feedings
and a palpable olive-shaped mass in the right upper quadrant. Which condition is the most likely diagnosis?
A. Intussusception
B. Gastroesophageal Reflux
C. Hirschsprung Disease
D. Hypertrophic Pyloric Stenosis
Correct Answer: D
Rationale: Hypertrophic pyloric stenosis involves the thickening of the pyloric sphincter, leading to a
gastric outlet obstruction. The most classic clinical indicators are projectile vomiting and the presence of
a firm, olive-shaped mass in the epigastrium. Patients are often hungry and irritable despite frequent
vomiting shortly after feedings. Preoperative care focuses on correcting fluid and electrolyte imbalances
caused by the persistent loss of gastric contents. Definitive treatment requires a pyloromyotomy to
surgically release the constricted muscle fibers.
2. A 4-year-old child with Type 1 Diabetes Mellitus presents to the emergency department with Kussmaul
respirations and a blood glucose level of 450 mg/dL. What is the priority nursing intervention?
A. Administer a bolus of 50% dextrose intravenously
B. Provide a subcutaneous injection of rapid-acting insulin
C. Initiate intravenous fluid resuscitation with normal saline
D. Administer oral glucose tablets immediately
,Correct Answer: C
Rationale: Diabetic Ketoacidosis (DKA) is a life-threatening emergency characterized by severe
dehydration and metabolic acidosis. The priority intervention is restoring circulatory volume through
intravenous fluid resuscitation using isotonic saline. Rapid rehydration helps lower blood glucose levels
and improves tissue perfusion before insulin therapy begins. Intravenous insulin is typically started after
fluid resuscitation is underway to slowly lower blood sugars. Nurses must monitor potassium levels
closely as insulin drives potassium back into the cells, potentially causing hypokalemia.
3. An infant with a myelomeningocele is awaiting surgical repair. Which nursing action is essential to
maintain the integrity of the sac?
A. Place the infant in a supine position with the head elevated
B. Apply a dry sterile dressing to the sac every 4 hours
C. Wrap the infant’s lower extremities tightly in a blanket
D. Keep the infant in a prone position with a sterile, moist, non-adherent dressing
Correct Answer: D
Rationale: Myelomeningocele is a type of neural tube defect where the spinal cord and meninges
protrude through the vertebrae. The nurse must place the infant in a prone position to prevent pressure
and trauma to the exposed sac. Keeping the sac moist with a sterile, non-adherent saline dressing
prevents drying and reduces the risk of infection. Frequent neurovascular assessments are required to
monitor for signs of increased intracranial pressure or lower extremity deficits. Careful handling is
necessary during all nursing procedures to avoid accidental rupture of the delicate sac membrane.
4. A 10-year-old child is being evaluated for a possible head injury after a fall. Which finding would be the
earliest sign of increased intracranial pressure (ICP)?
A. Bradycardia and widened pulse pressure
, B. Change in the child’s level of consciousness
C. Bilateral fixed and dilated pupils
D. Decerebrate posturing when stimulated
Correct Answer: B
Rationale: In older children, a change in the level of consciousness, such as irritability or confusion, is the
most sensitive and earliest indicator of rising ICP. As pressure increases, it affects the cerebral cortex,
leading to behavioral changes before physical symptoms appear. Cushing’s triad, which includes
bradycardia and hypertension, is considered a late sign of herniation. Pupils that are fixed and dilated or
abnormal posturing also represent advanced neurological deterioration. Nurses should use the Glasgow
Coma Scale to objectively track the child’s neurological status over time.
5. A 2-year-old is admitted with suspected Intussusception. Which clinical manifestation should the nurse
expect to find during the physical assessment?
A. Ribbon-like, foul-smelling stools
B. Painless rectal bleeding with bright red blood
C. Current jelly-like stools containing blood and mucus
D. Constant, dull abdominal pain in the lower left quadrant
Correct Answer: C
Rationale: Intussusception occurs when one segment of the bowel telescopes into another, causing
obstruction and ischemia. This process leads to the leakage of blood and mucus into the intestinal lumen,
creating characteristic ‘current jelly’ stools. The child typically experiences sudden, paroxysmal
abdominal pain that causes them to draw their knees to their chest. A sausage-shaped mass may also be
palpable in the right upper quadrant during the physical examination. While air or barium enemas are
University Updated and Latest Questions and Correct
Answers with Rationale
1. A 6-week-old infant is brought to the clinic presenting with non-bilious projectile vomiting after feedings
and a palpable olive-shaped mass in the right upper quadrant. Which condition is the most likely diagnosis?
A. Intussusception
B. Gastroesophageal Reflux
C. Hirschsprung Disease
D. Hypertrophic Pyloric Stenosis
Correct Answer: D
Rationale: Hypertrophic pyloric stenosis involves the thickening of the pyloric sphincter, leading to a
gastric outlet obstruction. The most classic clinical indicators are projectile vomiting and the presence of
a firm, olive-shaped mass in the epigastrium. Patients are often hungry and irritable despite frequent
vomiting shortly after feedings. Preoperative care focuses on correcting fluid and electrolyte imbalances
caused by the persistent loss of gastric contents. Definitive treatment requires a pyloromyotomy to
surgically release the constricted muscle fibers.
2. A 4-year-old child with Type 1 Diabetes Mellitus presents to the emergency department with Kussmaul
respirations and a blood glucose level of 450 mg/dL. What is the priority nursing intervention?
A. Administer a bolus of 50% dextrose intravenously
B. Provide a subcutaneous injection of rapid-acting insulin
C. Initiate intravenous fluid resuscitation with normal saline
D. Administer oral glucose tablets immediately
,Correct Answer: C
Rationale: Diabetic Ketoacidosis (DKA) is a life-threatening emergency characterized by severe
dehydration and metabolic acidosis. The priority intervention is restoring circulatory volume through
intravenous fluid resuscitation using isotonic saline. Rapid rehydration helps lower blood glucose levels
and improves tissue perfusion before insulin therapy begins. Intravenous insulin is typically started after
fluid resuscitation is underway to slowly lower blood sugars. Nurses must monitor potassium levels
closely as insulin drives potassium back into the cells, potentially causing hypokalemia.
3. An infant with a myelomeningocele is awaiting surgical repair. Which nursing action is essential to
maintain the integrity of the sac?
A. Place the infant in a supine position with the head elevated
B. Apply a dry sterile dressing to the sac every 4 hours
C. Wrap the infant’s lower extremities tightly in a blanket
D. Keep the infant in a prone position with a sterile, moist, non-adherent dressing
Correct Answer: D
Rationale: Myelomeningocele is a type of neural tube defect where the spinal cord and meninges
protrude through the vertebrae. The nurse must place the infant in a prone position to prevent pressure
and trauma to the exposed sac. Keeping the sac moist with a sterile, non-adherent saline dressing
prevents drying and reduces the risk of infection. Frequent neurovascular assessments are required to
monitor for signs of increased intracranial pressure or lower extremity deficits. Careful handling is
necessary during all nursing procedures to avoid accidental rupture of the delicate sac membrane.
4. A 10-year-old child is being evaluated for a possible head injury after a fall. Which finding would be the
earliest sign of increased intracranial pressure (ICP)?
A. Bradycardia and widened pulse pressure
, B. Change in the child’s level of consciousness
C. Bilateral fixed and dilated pupils
D. Decerebrate posturing when stimulated
Correct Answer: B
Rationale: In older children, a change in the level of consciousness, such as irritability or confusion, is the
most sensitive and earliest indicator of rising ICP. As pressure increases, it affects the cerebral cortex,
leading to behavioral changes before physical symptoms appear. Cushing’s triad, which includes
bradycardia and hypertension, is considered a late sign of herniation. Pupils that are fixed and dilated or
abnormal posturing also represent advanced neurological deterioration. Nurses should use the Glasgow
Coma Scale to objectively track the child’s neurological status over time.
5. A 2-year-old is admitted with suspected Intussusception. Which clinical manifestation should the nurse
expect to find during the physical assessment?
A. Ribbon-like, foul-smelling stools
B. Painless rectal bleeding with bright red blood
C. Current jelly-like stools containing blood and mucus
D. Constant, dull abdominal pain in the lower left quadrant
Correct Answer: C
Rationale: Intussusception occurs when one segment of the bowel telescopes into another, causing
obstruction and ischemia. This process leads to the leakage of blood and mucus into the intestinal lumen,
creating characteristic ‘current jelly’ stools. The child typically experiences sudden, paroxysmal
abdominal pain that causes them to draw their knees to their chest. A sausage-shaped mass may also be
palpable in the right upper quadrant during the physical examination. While air or barium enemas are
