1.

A 4-year-old boy was taken by his mother to the clinic with complaints of heat that
had lasted for four days with one-time nosebleeds and did not want to eat. The results
of the assessment were found on the face appearing reddish, temperature 38 C,
respiratory frequency 30x / minute, pulse 98x / minute. What is the main and
appropriate problem of virginity in the case above?
a. Hypertermi
b. Activity intolerance
c. Risk of fluid deficit
d. Gas exchange damage
e. Nutritional risk is less than needed

2. A 5-month-old male baby is currently still breastfed. His weight is 7 kg and his height
is 65 cm. child growth is relatively normal. After drinking ASI, children often
experience spit (regurgitation), even though it has been belated. Which information is
the most appropriate for the case above?
a. Nutrition
b. Breastfeeding technique
c. Nutritional needs
d. Breast Care
e. Growing stimuli
3. An 8-month-old baby was delivered by her parents to the ER with complaints of
shortness of breath since yesterday. The results of the study obtained data on
breathing frequency of 60x / minute, there was nasal lobe breathing, pulling the chest
wall into and sounding stridor breath sounds. What is the right nursing plan in the
case above?
a. Collaboration of inhalation therapy
b. Give oxygen according to the program
c. Review and record TTV
d. Assess for signs of cyanosis
e. Set the semi-fowler position

4. A female baby aged 5 days, born spontaneously with BB 3kg and body length 55 cm
brought by her mother to a child polyclinic with complaints of baby's skin looking
yellow. Mother said ASI had not come out smoothly. The results of the assessment
were obtained by the data Beyi seemed lazy to breastfeed, and the results of blood
tests showed an indirect level of bilirubin 10 mg / dl. What actions are needed to
overcome the above problems?
a. The baby is fasted until the yellow is gone
b. Give enough drink according to your needs
c. Encourage drying the baby in the morning sun
d. Give a heating lamp to the baby bed
e. Perform breast care

5. A 6-year-old boy is hospitalized with complaints of nausea, vomiting accompanied by

heartburn, the mother says her child can only spend half the meal. The results of the
assessment were obtained and the breathing frequency was 20x / minute, pulse
 frequency 81x / minute temperature 38, 6 C, and there was hepatomegaly. Is the
nursing problem right in the case above?
a. Risk of lack of fluid volume
b. Nutrition is less than needed
c. Activity intolerance
d. Hypertermi
e. Pain

6. A 5-year-old girl was hospitalized with complaints of runny bowel movements,

abdominal pain and a weak child. The examination results obtained temperature data
of 37.5 C, pulse frequency 98x / minute, breathing frequency 30x / minute, vomiting
twice, sunken eyes, hyperactive bowel noise and decreased skin turgor. Laboratory
results obtained were 131 mmol / L sodium, 8.3 mmol / L potassium, chloride mmpl /
L. What is the most appropriate nursing plan in the case above?
a. Assess the level of pain scale
b. Give a warm compress
c. Assess the level of activity of children
d. Give fluids and electrolytes
e. Give nutrition a little but often

7. A 4 month old girl was hospitalized with complaints of phlegm cough. The results of
the study obtained data on pulse frequency 140x / minute, breathing frequency 30x /
minute, temperature 38.6 C, ronchi breath sounds, intercostal retraction, nasal lobe
breathing, and dry mucous membrane. Which is the main nursing problem in the case
above?
a. Nutritional changes are less than needed
b. The airway is not effective
c. Lack of fluid volume
d. The breathing pattern is not effective
e. Hypertermi

8. A girl of 2 years of age came to a children's clinic with her parents with complaints of
shortness of breath. Physical examination results obtained weezing, decreased
appetite, vomiting and fussing at night, TTV: RR: 38x / minute, S: 38 C, pulse 90x /
minute. What is the nursing problem in the case?
a. The breathing pattern is not effective
b. Sleep rest disorder
c. Gas exchange disruption
d. The airway is not effective
e. Changes in nutrition are less than the body's needs

9. A 2-year-old boy was taken by his mother to a child polyclinic with complaints of
liquid defecation with a frequency of 5x / day accompanied by vomiting, reduced
appetite and difficulty sleeping. The results of the study found a temperature of 38.7
C, slow back abdomen skin pinch, and dry lip mucosa. What is the main nursing
problem in the case?
 a. Fluid disorders
b. Nutritional disorders
c. Break disturbance
d. Discomfort
e. Risk of skin integrity disorders

10. A boy aged 3 years treated with a complaint of swelling in the face area ... Eyelid.
The doctor stated that the child had nephrotic syndrome. At the time of the study, the
nurse found the child's eyes closed due to edema of the eyelids and attached
eyebrows. What priority actions can be taken on the child?
a. Assess albumin levels in a child's blood
b. Apply eye ointment according to the program
c. Wipe your eyes with warm water
d. Give eye drops
e. Give lotion

11. A 5-year-old boy was hospitalized with a fever. The results of the study obtained data
that in addition to physical disorders, children also experience autism disorder which
is at risk for actions that endanger themselves and others. Is the intervention
appropriate for the above case?
a. Give handlers when he is hysterical
b. Use the right behavior modification technique
c. Use restrain so the patient doesn't go anywhere
d. Make contact as often as possible to avoid accidents
e. When a child behaves destructively, immediately secure him in the isolation room

12. A 1 week old baby boy was taken to the hospital with complaints of tightness and did
not want to mentee. The results of the study obtained data, respiratory frequency of
80x / minute, pulse frequency of 100x / minute, temperature of 36.5 C, BB 3200 g,
cyanotic infants with nasal lobe breathing and additional respiratory muscle use. What
is the nursing priority in the case above?
a. Nutritional disorders
b. Breath pattern disturbances
c. High risk of hypothermia
d. Gas exchange disruption
e. Disruption of oxygen transport

13. A 7-year-old boy came to the hospital with complaints of BAK difficulties by
standing up because his urine often touched his body. The results of the study
obtained data that the urethral meatus is located at the bottom of the shaft of the penis
and above the scrotal. What is the main nursing problem in the case above?
a. Discomfort
b. Personal hygiene disorders
c. Impaired skin integrity
 d. ADL disorder
e. High risk for body image

14. A 2-year-old girl was taken by her mother to the hospital with complaints of shortness
of breath accompanied by cough, runny nose and fever since 2 weeks ago. The results
of the study showed that the skin was pale, heart rate was 120x / minute, breathing
frequency was 32x / minute, temperature was 38.7 C. The breath sounds were
wheezing and intercostals and epigastric retractions, pulmonary percussion sounded
dullness, and less lung movement. What is the first nursing plan in the case above?
a. Liquid hydration
b. Chest physiotherapy
c. Postural drainage
d. Semi fowler position
e. Administration of binasal cannula therapy

15. A boy aged 2 years was brought by his parents to a health center with complaints of
liquid defecation with a frequency of 4 x / day since yesterday. The results of the
study obtained data: temperature 38.5 C, pulse frequency 148x / minute, breath
frequency 29x / minute, BP 80/60 mmHg, children's lips appear dry, sunken fontanel,
sunken eyes and skin turgor did not return in 3 seconds. Which major nursing
problems are based on the case above?
a. Lack of knowledge of parents
b. Less fluid volume
c. Fecal elimination disorders
d. Risk of parental anxiety
e. Hypertermi

16. A 10-year-old boy is brought by his parents to the hospital after fainting while playing
football. The results of the study showed that GCS 6 (E2M2V2), 36 C temperature,
pulse frequency 120x / minute, napass frequency 36x / minute, blood pressure 90/60
mmHg, stridor breath sounds, and a lot of saliva in the child's mouth. Which is the
first nursing action done?
a. Do suction
b. Give penkes
c. Assess vital signs
d. Give a semifowler position
e. Maintain the patency of the airway
4183/5000

17. An 8-year-old girl was hospitalized with a medical diagnosis of left heart failure.
When examined, nurses found data: temperature 37 C, pulse frequency 111x / minute,
breathing frequency 37x / minute, blood pressure 90/60 mmHg, ronchi, children
appear weak and complain of tightness. Furthermore, the nurse immediately arranges
the semi-fowler position on the child. Which evaluation criteria are appropriate for the
implementation of the above actions?
a. Shortness of complaint is reduced
b. Pulse rate decreases
c. Normal blood pressure
d. Child looks strong
e. Ronchi is reduced

18. A 2-year-old boy was taken by his mother to a child polyclinic with complaints of
liquid defecation with a frequency of 5 times a day with vomiting, reduced appetite
and difficulty sleeping. The results of the study showed that the temperature data was
38.7 C, the pinch of the stomach was very slow, and the lip mucosa was dry. What is
the main nursing problem in the case?
a. Fluid disorders
b. Nutritional disorders
c. Break disturbance
d. Discomfort
e. Impaired skin integrity

19. A 9-year-old male baby was admitted to the hospital. The results of the assessment
showed that the breathing frequency was 53x / minute, the pulse frequency was 92x /
minute, the temperature was 39C, and the chest wall and nasal lobe breathing were
seen. What are the main nursing actions in the case above?
a. Give oxygen 2 liters / minute
b. Do personal hygiene
c. Position the semi-fowler baby
d. Perform chest physiotherapy
e. Give inhalation therapy according to the program

20. A baby boy has just been born, then lenders are suctioned, after 1 minute assessment
is obtained of red body skin data blue extremity, heart rate 88 x / minute, weak crying,
exfoliation of flexion ties, poor muscle tone and effort weak breathing. How much is
the APGAR Score for the baby?
a. 4
b. 5
c. 6
d. 7
e. 8
21. A boy aged 2 years was brought by his parents to the emergency room with a lot of
diarrhea since 3 days ago, in a condition of dehydration with decreased consciousness.
The cause of the decline in An.C awareness is caused by:
a. Decreased awareness in the brain
b. Cardiovascular disorders
c. The mechanism of dieresis in kidney tissue damage
d. Hypoferpusion of cerebral tissue due to decreased vascular volume
e. The breathing pattern is not effective

22. A year-old boy was taken to the hospital with complaints of heat accompanied by
seizures 8 hours before being taken to the hospital. Seizures occur 1 time with a time
of ± 2 minutes, the client vomits and coughs with decreased consciousness. The
results of the study obtained data: temperature 38®C, leukocytes 14200 mm. What is
the main nursing problem in the case above?
a. Hypertermi
b. Risk of injury
c. Risk of fluid deficiency
d. The airway is not effective
e. Cerebral tissue perfusion disorders

23. M service nurse at the RSU orthopedic clinic, comes a mother with her 5-month-old
daughter Dina, and the results of the study found that there is an abnormality in the
child's foot D that is clubfoot according to an orthopedic doctor's diagnosis, D's feet
are hard and stiff, as a nurse we can communicate to doctors to do therapy for D.
Therapy children do we communicate to orthopedic doctors for early treatment in D
children?
a. Perform mild orthopedic bedag on the child's leg D
b. Perform a series of therapy casts for a period of 3 s.d 6 weeks
c. Advise the use of special shoes
d. Do not do any therapy because child D is still 5 months old
e. Break

24. A boy, aged 14, came to the hospital with a complaint of bleeding from his nose after
being hit by a basketball throw from his friend. Patients complain of dizziness and
pain in the nose with a subjective pain scale 4 (0-10). On examination found a
deformity in the nasal bone, there was bleeding, blood pressure 120/80 mmHg, pulse
frequency 86x / minute, breathing frequency 25x / minute, temperature 36 ° C. What
are the main nursing actions in these patients?
a. Give cold compresses
b. Advise to rest
c. Set the position of the semi-fowler patient
d. Giving fluids intravenously
e. Cover the nostrils with cotton

25. A 16-year-old boy with a medical diagnosis of perforated acute appendixitis. Post-
appendectomy cyto patients were treated in the pediatric ward. The results of the
examination of the bedrest patient, menakak changed position, the patient complained
of pain in the area of the postoperative wound such as stabbing. Blood pressure is
130/90 mmHg, temperature is 37.5 ° C, breathing is 30x / minute and pulse is 116x /
 minute. What is the main intervention that you will do for the case?
a. Do a warm compress
b. Observing vital signs
c. Teaching deep breathing relaxation techniques
d. Teaches postoperative mobilization exercises
e. Collaborate with antipyretic drugs

26. A 1 year old boy was treated in a public hospital complaining of vomiting 3 times, no
appetite, eating 3 spoons, BB before illness 8.5 kg, current BB 7 kg, ideal BB one
year old: 10 kg. HB laboratory results 10.3 gr / dl, Ht 39%, which is the most
appropriate intervention in the case above?
a. Give food in small portions but often
b. Give food warm
c. Weigh your weight every day
d. Give a child's favorite food
e. Consult with a nutritionist

27. A mother and her son went to Klinik Sehat Balita, on March 18, 2012 with the
intention of examining the growth of her son and at the same time wanting to consult.
The son was named Aldi who was born on April 17, 2010 with advanced pregnancy 2
weeks before the Estimated Birth Day (HPL), the test to be performed using the
Denver II instrument. From the above explanation before carrying out the test, the
nurse determines the age first. How old is Aldi when he comes to Klinik Sehat Balita?
a. 1 year 11 months 1 day
b. 1 year 10 months 17 days
c. 1 year 10 months 10 days
d. 1 year 10 months 3 days
e. 1 year 9 months 24 days

28. A baby born with a birth weight of 3.50 kg, born at term, good health at the First
Mother Maternity Clinic, with exclusive breastfeeding for 6 months and supported by
a good mother's nutritional intake, it can be expected to be a normal BB for a baby.
From the narrative above what is the normal BB baby at the age of 6 months, if you
use the BB formula according to Behrman?
a. 6 kg
b. 6.5 kg
c. 7 kg
d. 7.5 kg
e. 8 kg

29. A child aged 5 years comes to the Emergency Room of the General Hospital, has had
a fever for 6 days, coupled with complaints of extreme cold feeling weak pulse is not
palpable, vomiting mixed with blood like coffee, black defecation, bleeding from the
 nose and gums severe, bleeding spots accompanied by skin often vomiting with
diarrhea. From the narrative above the first action taken on child D is?
a. Advise mom to give her more drinking
b. Add as much liquid or ORS as possible
c. Prevent blood sugar levels from falling
d. Give the first dose of paracetamol
e. Immediately give intravenous fluids

30. A mother carries baby C age 12 days to the Regional General Hospital, with
complaints of difficulty in tasting, from the results of the study of the presence of
trismus in the mouth muscle, the presence of muscle spasms and spasms and stiff
neck, opistotonus, rigid and hardened abdominal wall, cyanosis, temperature 39 ° c.
from the above assessment is the first nursing diagnosis?
a. Disruption of body temperature imbalance
b. Disruption of nutritional needs
c. Lack of parental knowledge
d. Disorders of respiratory function
e. Risk of injury

31. A mother brought a 14-year-old F child with complaints of refusal to eat at Medika
Hospital, from the results of a study of low body temperature, bradycardia, decreased
blood pressure, cold intolerance, dry skin and brittle nails, and lanugo hair
appearance. From the above explanation, what happens to child F is?
a. Pika
b. Bulimia
c. Obesity
d. Malnutrition
e. Anorexia Nervosa

32. A mother brings a 5-year-old S child to a Regional General Hospital, with complaints
of lack of appetite, oucat and weakness. After the study was carried out by nurses, the
data obtained were muoloid muaka shape, pimples without nose, distance between the
eyes, wide forehead, pale conjunctiva, pale mouth and lips, Hb 6 gr%. From the above
narrative, is the intervention first done by a child S?
a. Avoid feeding containing ice
b. Give a high-calorie high-protein diet (TKTP)
c. Perform blood transfusions according to the protocol
d. Give food in small portions but often
e. Meet nutritional needs adequately

33. A child aged 7 years, was taken to the Regional General Hospital Emergency Unit
(UGD), with complaints of swelling throughout the body. From the results of the
study nurses found data BB before illness 22 kg, current BB 31 kg, edema, BAK,
shortness of breath with a frequency of 30x / minute, laboratory results found
proteinuria. From the above explanation, what is the top priority in the
implementation of nursing in the case of child D?
 a. Weigh weight
b. Lay down halfway down
c. Rest until edema is low
d. Give a high protein diet 2-3 grams / kg body weight / day
e. Give a cushion on both feet to the heel

34. A 12-year-old girl came to the RSU clinic clinic with her parents, complaining that
the heat had been 3 days, feeling weak, no appetite, from a physical examination
temperature of 38.5 ° C, there was a red papule and spread on the spread chest face,
shoulder and limbs, presence of vesicles and accompanied by itching. Is nursing
intervention to avoid scars that cannot be lost?
a. Damaged with 1% salinity
b. Collaboration in antipyretic administration
c. Tell the child not to scratch the vesicles
d. Encourage children to cut short their nails
e. Bath with a solution of kalikos permanganas (PK)

35. A 9-month-old baby G, brought by his parents to the regional hospital with
complaints about one week around the reddish genitals and buttocks. From the results
of interviews of nurses to mothers By G found data, the mother of the patient said this
one week By G using pampers and changing of the pampers every 8 hours sometimes
more, By G rarely cleaned the perineal and pantal areas every time changing pampers
only peeing. The first nursing implementation performed on the baby was?
a. Give cream or ointment and give for a while
b. Assess allergic factors for the use of disposable diapers (for example: pampers)
c. Avoid using pampers for too long and must be immediately anti-boiled every few
hours
d. Use cotton with warm water to clean the perineal area immediately after defecation
e. Use cotton with oil to clean the perineal area immediately after defecation

36. A newborn baby in the regional public hospital, in 24 hours found data did not come
out meconium, two days later flatulence, vomiting green. Then the nurse performs an
anal plug examination and results in air and meconium or spraying stools. Is nursing
implementation performed on baby H?
a. Prevent infection
b. Conduct biopsy checks
c. Collaborative colostomy surgery
d. Give parents an explanation about the disease
e. Sprinkle with warm physiological salt water every day

37. Treatment carried out on pediatric patients a 5-year-old man is hospitalized. At the
time of anamnesa, her mother said her child's body had been swollen since 4 months.
Physical examination revealed edema of the face, abdomen and lower extremities, and
blood pressure of 150/80 mmHg, pulse 87x / minute, respiration 28x / minute,
temperature 37.8 ° C. From the above explanation on the results of the examination
found the cause is?
 a. Excretion of water and sodium
b. Increased secretion of ADH and Aldosterone
c. Decreased colloid osmotic pressure
d. Increased permeability of the glomerular membrane
e. Hypoalbuminemia due to proteinuria

38. The maintenance of treatment carried out on a child aged 3 years, was carried out at
the puskesmas with a medical diagnosis of pharyngitis while from the anamnesa
results the mother said her child filed and coughed but was not accompanied by
shortness of breath. On physical examination, it was found that the respiratory
frequency was 33x / minute, pulse rate was 90x / minute, temperature was 36.5 ° C,
and it was planned to have chest fiseotherapy which was initiated from postural
drainage, claping and vibrating. The first time the nurse before doing drainage
treatment was?
a. Consult the lung
b. Determine client position
c. Drink warm water
d. Collaboration in expectorant medicine
e. Do percussion / klaping

39. An 8-month-old male nayi was brought by his mother to the Puskesmas to carry out
immunizations. The results obtained were 9 kg body weight, 36.8 ° C body
temperature, breathing 20x / minute, previously had Polio 2, BCG, and DPT I
immunization from the above cases what immunization should now be done?
a. BCG and Polio II
b. DPT II and Polio III
c. DPT II and Polio IV
d. Hepatitis and Polio III
e. DPT III and Polio IV
40. A boy aged 1 year, was brought by his parents to the health center because he
experienced an enlargement of his parents' head since the age of 2 months ago, then
the nurse conducted a physical examination, obtained results: head circumference 59
cm, body weight 7 kg, height 62 cm, sunset sign, rough motorized children cannot
walk, children often carried by their parents. From the results of the treatment above
what is the main problem in nursing?
a. Disruption of nutritional needs
b. Nutritional signals are less than needed
c. Disruption of growth and development
d. Risk of fluid and electrolyte disturbances
e. Ignorance in handling diseases

41. A child aged 2 years he was the first child and by his mother he was told to go to the
health center with complaints that he could not walk from the examination results
obtained weight 7 kg, height 65 cm, and the child could only crawl when examined by
the nurse. From the results of the child's examination, it has been delayed?
a. Behavioral disorders
 b. Social disorders
c. Gross motor disorder
d. Fine motor disorder
e. Speech disorder

42. A child aged 4 years came to the clinic with a breathing frequency of more than 30x /
minute, the rhythm was sometimes shallow and deep, the ronchi breath sound was
wet, the pharynx showed a thick secret. Is nursing diagnosis appropriate for the case
above?
a. The risk of tissue perfusion disorders is related to the expansion of outside
nutritional intake
b. The ineffectiveness of cleaning the airway is associated with a secret buildup in
the tracheobroncial
c. Gas exchange disorders are associated with increased pressure on the pulmonary
capillaries
d. The ineffectiveness of breathing patterns is associated with increased blood volume
in the lungs
e. Activity intolerance is related to an imbalance between oxygen supply and needs

43. A 10-year-old child experiences weight gain, edema, puffy face around the eyes when
morning is reduced during daytime, ascites, difficulty breathing, total swelling. Is the
nursing intervention appropriate for the case problem above?
a. Review the input relatively carefully
b. Manage fluid input carefully
c. Monitor intravenous infusion
d. Monitor vital signs
e. Give skin care

44. A 3-year-old child experienced recurrent seizure attacks, after a rectal temperature
examination the result was 39.5 ° C. Is the initial action of a child experiencing
recurrent seizures?
a. Gently give intravenous diazepam
b. Freeing the airway by tilting the head in a hypotensive position, loosening clothes
and sucking lenders
c. Immediately move the child to a safe place such as a floor that is soft but thin and
away from dangerous objects such as glasses, knives
d. Giving oxygen to help with adequate tissue perfusion
e. Providing ice compresses to help lower body temperature

45. A 10-year-old child, short of breath after exposure to an allergen material and staying
for a while. The respiration is 36x / minute, sometimes coughed, so it looks pale.
What should children avoid to reduce their tightness?
a. Bronchodilator inhalation therapy combination with mucolytic
b. Reducing children from excessive fatigue but not over protection
c. Keep your child from exposure to allergens such as dust, cold air
d. Giving oxygen according to advice
 e. Giving antibiotics to prevent secondary diseases

46. A baby girl aged 8 months was taken by her mother to go to a polyclonic child with
complaints since the last 2 weeks of the baby with a 4-5x / day CHAPTER with
output of undigested food. Mother works as a teacher, gives breast milk 1 x before
work and 3-4 times after work. Everyday, the baby is taken care of by her
grandmother by setting up a meal of milk 3x / day and squeezed orange juice 2x / day,
artificial milk 3x / day. What advice do you best give to the baby's mother?
a. Provision of milk porridge is stopped
b. Giving squeezed orange juice is stopped
c. Provision of artificial milk is stopped

e. Breastfeeding is stopped because it is not effective

47. A 4-year-old usa baby on her 5th May 2013 was taken by her mother to the health
service to get immunization, after seeing her KMS book obtained data on the baby's
immunization column and only got Neo Hb, Oral Polio I, and BCG. What
immunization will you give to the baby?
a. Test of BCG and Polio I
b. DPT I + HB I (Combo I) and Polio I
c. DPT I + HB I (Combo I) and Polio II
d. DPT II + HB II (Combo II) and Polio II
e. DPT III + HB III (Combo III) and Polio III48.

48. A 2.5-year-old girl is treated in the child's room with a complaint of demma. When
nurses conduct interviews with their mothers, the child continues to cry and disturb
his mother even though many times she tells the child to be quiet. Feeling disturbed,
my mother snaps and says "if you don't shut up, the nurse will inject you". At that
time the child immediately cried softly and hugged his mother's legs. How do nurses
deal with these communication problems?
a. Do not take action because at that time the child is silent
b. Tell the mother not to scare her child
c. Hugging the child and giving paper and rayon to draw
d. Tell the child that he does not inject because the child does not want to be silent
e. Give crayons and paper to children while he is interviewing his mother

49. A mother has a child aged 2.5 years and is currently pregnant with her second child.
Pregnancy is 8 months. The nurse will provide guidance for anticipation of the
mother. What can nurses tell the mother of the child?
a. Prepare for the submission process
b. Prepare the child to sleep separately with his mother
c. Include children in the baby care process
d. Reduces anxiety in children against stress
e. Prepare parents that their children will soon be given solid food
50. A 4-year-old boy has been treated in a child's room for 6 days because of a fever. At
present the condition of the child has begun to improve, but is still infused. Everyday
activities of children lie down and watch TV. What game can the nurse give to the
child?
a. Need a game tool
b. An active and energetic game
c. Requires friends to play
d. Can be combined with various ages
e. Games that do not conflict with therapy

51. A child aged 6 months delivered by his parents came to the ER with complaints of
diarrhea more than 7 times with liquid consistency. Data obtained from the
assessment of BB = 20 mg, while according to the family's explanation, weight was
two days ago 23 kg. Other data is found to be in good general condition, the large
fontanel is not sunken, when crying tears come out, the heart is warm and the child
still wants to drink. What actions will you do?
a. Assess the history of diarrhea
b. Advise immediate hospitalization
c. Provides isotonic fluid intravenously
d. Giving oral fluids to children whenever they want children by monitoring
e. Give oral fluids to 100-200 cc children every time they defecate

52. On July 5, 2013 a child came to his parents 'growth and development polyclinic. From
the assessment, the child was born on December 20, 2011. According to his mother,
her child was born at 33 weeks' gestation. What is the chronological age with the
correction of prematurity?
a. 1 year 3 months 22 days
b. 1 year 4 months 21 days
c. 1 year 4 months 24 days
d. 1 year 5 months 15 days
e. 1 year 6 months 15 days

53. A 10-year-old girl in her parents came to the growth and development clinic with
complaints that she had been alone for a week and did not want to play with her
friends. When asked by the child, they say they are embarrassed and are often
ridiculed by friends. Physical examination data includes BB = 40 kg, breast
enlargement, way to form the letter X. Does the nurse suggest proper advice to the
child's parents?
a. The child should be examined by the musculoskeletal system
b. The child should be examined further for nutrition
c. Parents should involve children in activities at home
d. Parents should consult with the psychiatry department for treatment
e. Children should be involved in social relations in the community with assistance
54. A 3-year-old boy has been treated in the child's room for 2 days with a fever. When
the nurse will do physical examination, the child cries and shouts and rejects the
presence of the nurse. What actions can the nurse do for the child?
a. Give children toys according to the child's wishes
b. Tells what is happening to the child at this time
c. Use a soft tone of voice and slow talk
d. Give children a chance to express their anxiety
e. Provide opportunities for children to touch the examination tool

55. A 16-year-old girl came to the health service polyclinic with her mother to ask for a
healthy letter of intent to continue school. When the nurse invited teenagers to go to
the examination center, her mother whispered to the nurse that she wanted to talk with
her in the eyes of the nurse. What response should the nurse give?
a. Ask the mother to say what she wants to convey in the presence of nurses and
teenagers
b. Tell the mother that the nurse can talk outside of working hours if she needs
c. Asking the teenager to take off her clothes to prepare for an examination while the
nurse takes her mother to another room
d. Told teenagers and their mothers that the nurse would talk to them both, starting
with talking to the next mother with the teenager
e. Told teenagers and their mothers that the nurse would talk with both of them,
beginning with talking to teenagers then with his mother.

56. An 8-year-old boy, Manojaya's address came with his mother to the child's polyclinic
with complaints of 3 days ago fever with reddish rashes on his ears, face and
extremities. Children also complain of coughing and swallowing. When the physical
examination was obtained a temperature of 39.2 ° C, pulse 116x / minute, respiration
28x / minute, the client's eyes appeared reddish, appetite was reduced and the spleen
complained of weakness. What are the main nursing problems that arise in the child?
a. Hypertermi
b. Activity intolerance
c. Damage to skin integrity
d. Ineffectiveness of the airway
e. Nutritional imbalance: less than need

57. A mother came with her baby to the Tunbuh Kembang polyclinic on the 10th of April
2013, the date of birth of the baby October 20, 2011. According to her mother's
information, now the child can brush his teeth with help, can pick up the doll, undress
and use a spoon. Based on the results of the nurses' assessment, the child has not been
able to compose a tattoo from 2 cubes, can doodle and take beads. Children can also
name 6 words, point 2 pictures, can walk up the stairs and kick the ball forward.
Based on the examination of 4 aspects of DDST, what interpretation can the nurse
give to the child?
 a. Delay
b. Normal
c. Suspect
d. No opportunity
e. Pass

58. A girl of 10 years old, entering the ED demographic complaint of shortness of breath
occurs almost every week. The assessment found that there was a parent's history of
having asthma, vital signs: respiration 36x / minute, TD 90 / 60x / minute,
consciousness compos mentis, could speak a few words, trheheosternal (+) retraction,
breathing assisted by respiratory muscles, pale extremity, AGD results obtained sat
O2 91%, PCO2 38. What nursing actions should be performed to resolve the main
problem in the child?
a. Give the child extra oxygen through a mask of 5 liters / minute
b. Adjust the sleeping position of the trendelenbrug child
c. Perform infusion as a fluid therapy
d. Support children with adequate rest and sleep
e. Encourage families to participate in care

59. A 7-year-old baby, brought by his mother to the ER, complained of a fussy baby and
had difficulty sucking. Previously my mother did not complain anything about her
baby, only 2 days ago the baby seemed to have difficulty sucking and often his back
was tense. Birth history, children are born at home by paraji because they did not have
time to be taken to the RSU due to a broken jetuban. What health education can
nurses give to the baby's mother?
a. Encourage mothers to keep breastfeeding their babies'
b. Advise mother to have her baby hospitalized
c. Give motivation to the mother so that her baby is immediately immunized
d. Encourage mothers not to carry too many babies
e. Encourage mothers to avoid excessive light while at home

60. A 15-year-old boy is known by his parents to be very backward, not fluent, and
difficult to be told to do something. From the results of the examination obtained IQ
data of children helped by paraji and experience asphyxia because of the absence of
cord infection, detection of growth and development is not carried out, but according
to his mother, the child is slow in fine motoric aspects and talk. Determine the mental
retention degree experienced by a child?
a. Borderline
b. Mild mental retention
c. Medium mental retention
d. Heavy mental retention