NUR 254 Exam 3: Pediatrics - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A 6-week-old infant is brought to the clinic with reports of projectile, non-bilious vomiting after every
feeding. Which physical assessment finding should the nurse expect to identify?
A. A sausage-shaped mass in the upper right quadrant.
B. A palpable olive-shaped mass in the epigastrium.
C. Hyperactive bowel sounds in all four quadrants.
D. Severe abdominal distention and ribbon-like stools.
Correct Answer: B
Rationale: Hypertrophic pyloric stenosis is characterized by the narrowing of the pyloric sphincter,
leading to projectile vomiting. A classic assessment finding is a palpable olive-shaped mass in the right
upper quadrant of the abdomen. The nurse should also assess for signs of dehydration and metabolic
alkalosis due to frequent vomiting. Treatment usually involves a surgical pyloromyotomy to relieve the
obstruction. Postoperative care includes a gradual return to feeding while monitoring for vomiting or
infection.
2. A school-age child with Type 1 Diabetes Mellitus presents with Kussmaul respirations, dehydration, and a
fruity breath odor. What is the nurse’s priority intervention?
A. Administer subcutaneous rapid-acting insulin immediately.
B. Provide a high-protein snack to stabilize blood glucose.
C. Encourage the child to drink orange juice with sugar.
D. Initiate intravenous access and begin fluid resuscitation.
,Correct Answer: D
Rationale: The child is showing classic signs of Diabetic Ketoacidosis (DKA), which is a medical
emergency. The priority in managing DKA is the restoration of fluid volume to treat dehydration and
improve perfusion. Once fluids are initiated, an intravenous insulin infusion is typically started to correct
hyperglycemia and acidosis. Monitoring potassium levels is critical as insulin therapy can cause a rapid
shift of potassium into cells. The nurse must also monitor neurological status to detect early signs of
cerebral edema.
3. The nurse is assessing a child suspected of having bacterial meningitis. Which maneuver should the nurse
perform to check for Kernig’s sign?
A. Flex the leg at the hip and knee, then attempt to extend the knee.
B. Tapping the facial nerve to check for muscular contraction.
C. Flex the child’s head toward the chest and observe for hip flexion.
D. Apply pressure to the nail bed and observe for a withdrawal reflex.
Correct Answer: A
Rationale: Kernig’s sign is a clinical indicator of meningeal irritation commonly seen in meningitis. To
perform this, the nurse flexes the child’s leg at the hip and knee and then tries to straighten the leg.
Resistance or pain during knee extension constitutes a positive Kernig’s sign. This occurs because the
maneuver stretches the inflamed meninges surrounding the spinal cord. In contrast, Brudzinski’s sign
involves involuntary hip flexion when the neck is flexed.
4. An infant is admitted with suspected intussusception. Which stool characteristic is most indicative of this
condition?
A. Stools that are thin and ribbon-like.
, B. Loose, foul-smelling stools containing fat.
C. Stools mixed with blood and mucus, appearing like currant jelly.
D. Hard, marble-like stools with streaks of blood.
Correct Answer: C
Rationale: Intussusception occurs when one segment of the bowel telescopes into another, causing
obstruction and ischemia. This process leads to the leaking of blood and mucus into the intestinal lumen,
creating currant jelly stools. The condition often causes sudden, episodic abdominal pain where the
infant pulls their knees to their chest. A barium or air enema is frequently used for both diagnosis and
non-surgical reduction of the intussusception. If non-surgical methods fail, the infant may require
immediate surgical intervention to prevent bowel necrosis.
5. A child is diagnosed with Congenital Hypothyroidism. Which instruction is most important for the nurse
to provide the parents regarding medication administration?
A. The medication should be stopped once the child’s energy levels improve.
B. Administer the medication with a high-calcium soy formula.
C. Only give the medication if the child appears lethargic or cold.
D. Crush the tablet and mix it with a small amount of water or formula.
Correct Answer: D
Rationale: Levothyroxine is the standard treatment for congenital hypothyroidism and must be taken
daily for life. Parents should be taught to crush the tablet and mix it with a small amount of liquid to
ensure the infant swallows the full dose. It is crucial to avoid mixing the medication with soy-based
formulas or iron, as these can interfere with absorption. Routine blood tests are necessary to monitor
Updated and Latest Questions and Correct Answers with
Rationale
1. A 6-week-old infant is brought to the clinic with reports of projectile, non-bilious vomiting after every
feeding. Which physical assessment finding should the nurse expect to identify?
A. A sausage-shaped mass in the upper right quadrant.
B. A palpable olive-shaped mass in the epigastrium.
C. Hyperactive bowel sounds in all four quadrants.
D. Severe abdominal distention and ribbon-like stools.
Correct Answer: B
Rationale: Hypertrophic pyloric stenosis is characterized by the narrowing of the pyloric sphincter,
leading to projectile vomiting. A classic assessment finding is a palpable olive-shaped mass in the right
upper quadrant of the abdomen. The nurse should also assess for signs of dehydration and metabolic
alkalosis due to frequent vomiting. Treatment usually involves a surgical pyloromyotomy to relieve the
obstruction. Postoperative care includes a gradual return to feeding while monitoring for vomiting or
infection.
2. A school-age child with Type 1 Diabetes Mellitus presents with Kussmaul respirations, dehydration, and a
fruity breath odor. What is the nurse’s priority intervention?
A. Administer subcutaneous rapid-acting insulin immediately.
B. Provide a high-protein snack to stabilize blood glucose.
C. Encourage the child to drink orange juice with sugar.
D. Initiate intravenous access and begin fluid resuscitation.
,Correct Answer: D
Rationale: The child is showing classic signs of Diabetic Ketoacidosis (DKA), which is a medical
emergency. The priority in managing DKA is the restoration of fluid volume to treat dehydration and
improve perfusion. Once fluids are initiated, an intravenous insulin infusion is typically started to correct
hyperglycemia and acidosis. Monitoring potassium levels is critical as insulin therapy can cause a rapid
shift of potassium into cells. The nurse must also monitor neurological status to detect early signs of
cerebral edema.
3. The nurse is assessing a child suspected of having bacterial meningitis. Which maneuver should the nurse
perform to check for Kernig’s sign?
A. Flex the leg at the hip and knee, then attempt to extend the knee.
B. Tapping the facial nerve to check for muscular contraction.
C. Flex the child’s head toward the chest and observe for hip flexion.
D. Apply pressure to the nail bed and observe for a withdrawal reflex.
Correct Answer: A
Rationale: Kernig’s sign is a clinical indicator of meningeal irritation commonly seen in meningitis. To
perform this, the nurse flexes the child’s leg at the hip and knee and then tries to straighten the leg.
Resistance or pain during knee extension constitutes a positive Kernig’s sign. This occurs because the
maneuver stretches the inflamed meninges surrounding the spinal cord. In contrast, Brudzinski’s sign
involves involuntary hip flexion when the neck is flexed.
4. An infant is admitted with suspected intussusception. Which stool characteristic is most indicative of this
condition?
A. Stools that are thin and ribbon-like.
, B. Loose, foul-smelling stools containing fat.
C. Stools mixed with blood and mucus, appearing like currant jelly.
D. Hard, marble-like stools with streaks of blood.
Correct Answer: C
Rationale: Intussusception occurs when one segment of the bowel telescopes into another, causing
obstruction and ischemia. This process leads to the leaking of blood and mucus into the intestinal lumen,
creating currant jelly stools. The condition often causes sudden, episodic abdominal pain where the
infant pulls their knees to their chest. A barium or air enema is frequently used for both diagnosis and
non-surgical reduction of the intussusception. If non-surgical methods fail, the infant may require
immediate surgical intervention to prevent bowel necrosis.
5. A child is diagnosed with Congenital Hypothyroidism. Which instruction is most important for the nurse
to provide the parents regarding medication administration?
A. The medication should be stopped once the child’s energy levels improve.
B. Administer the medication with a high-calcium soy formula.
C. Only give the medication if the child appears lethargic or cold.
D. Crush the tablet and mix it with a small amount of water or formula.
Correct Answer: D
Rationale: Levothyroxine is the standard treatment for congenital hypothyroidism and must be taken
daily for life. Parents should be taught to crush the tablet and mix it with a small amount of liquid to
ensure the infant swallows the full dose. It is crucial to avoid mixing the medication with soy-based
formulas or iron, as these can interfere with absorption. Routine blood tests are necessary to monitor
