PEDIATRIC NURSING

Situation 1: Santino, a 3-year-old child is scheduled

for a tonsillectomy.
1. A nurse is reviewing the laboratory results of
Santino. The nurse determines that which of the 1. Answer: A (Saunders, 3rd Edition)
following laboratory values is most significant to
review?
a. Prothrombin time c. Blood urea nitrogen
b. Sedimentation rate d. Creatinine

2. On the day of surgery, Santino will most likely be

fearful of: 2. Answer: A
a. Intrusive procedure Rationale: One of the greatest fears of preschoolers is
b. Perceived abandonment fear of mutilation.
c. Premature death
d. Unfamiliar caregivers

3. A nurse panning care for Santino knows that which 3. Answer: B

of the following would present the highest risk of Rationale: In the preoperative period, the child should
aspiration during surgery? be observed for the presence of loose teeth to
a. Difficulty in swallowing decrease the risk of aspiration during surgery.
b. The presence of loose teeth A and D are indications for surgery.
c. Bleeding during surgery C. Bleeding during surgery will be controlled via
d. Exudate in the throat area packing and suction as needed. (Saunders, 3 rd Edition)

4. After a tonsillectomy, the nurse documents on the

plan of care to place Santino in which most 4. Answer: C
appropriate position? Rationale: The child should be placed in a prone or
a. Supine c. Side-lying side-lying position following tonsillectomy to facilitate
b. Trendelenburg's d. High Fowler's drainage. (Saunders, 3rd Edition)

5. After a tonsillectomy, the nurse suspects

hemorrhage postoperatively when the child:
a. Snores noisily c. Complains of thirst
b. Becomes pale d. Swallows frequently
Situation 2: A 3-year-old child with a family member
infected with tuberculosis is brought to the clinic for
confirmation of suspected tuberculosis.
6. A child exposed a family member with
tuberculosis but show no evidence of the disease:
a. Can be considered to be immune
b. Should be given anti-tubercular medications
c. Are usually given massive doses of penicillin
d. Are given x-ray examinations every 6 months
5. Answer: D
Rationale: The seeping of blood from the operative
site increases secretions, which the child adapts to by
swallowing frequently (Mosby’s, 18th Edition).
6. Answer: B
Rationale: Family members who have been exposed
are at high risk and should receive prophylactic
therapy (Mosby’s 18th Edition).

7. The Mantoux test of a 3-year-old-child indicates an

area of induration measuring 10 mm. The nurse 7. Answer: B (Saunders, 3rd Edition)
would interpret this results as:
a. Negative
b. Positive
c. Inconclusive
d. Definitive and requiring a repeat test

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8. A tentative diagnosis of tuberculosis is confirmed 8. Answer: B
by: Rationale: Direct Sputum Smear Microscopy is the
a. A chest radiograph confirmatory test for TB. The presence of AFB in the
b. AFB in a sputum smear sputum smear confirms.
c. A positive multiple-puncture skin test
d. Repeated Mantoux test that yields indurations
of 10 mm or greater

9. If a child has been exposed to tuberculosis but 9. Answer: C

shows no signs or symptoms except a positive Rationale: Tubercle bacilli multiply in caseous lesions,
tuberculin test, prophylactic drug therapy is which have poor vascular supply. These areas receive
usually continued after the last exposure for a lower levels of the drug, and as a result therapy must
period of: be prolonged at least 9 months (Mosby’s 18th Edition).
a. 3 weeks c. 9 months
b. 4 months d. 2 years

10. If the child has HIV, how long will the child take 10. Answer: D (Saunders, 3rd Edition)
the medication?
a. 4 months c. 9 months
b. 6 months d. 12 months

Situation 3: Janice, 4 years old, is admitted with 11. Answer: B

streptococcal pneumonia.
11. The priority nursing intervention for Janice should
be:
a. Administering an antiviral agent
b. Clustering care to conserve energy
c. Administering antitussive agents q4h
d. Encouraging oral fluids to prevent dehydration
Rationale: The infant will have decreased pulmonary
reserve, and the clustering of care is essential to
provide periods of rest (Mosby’s 18th Edition).
A. Antibiotics are used.
C. Used sparingly; it is desirable for the infant to cough
up some of the secretions.
D. IV fluids are given during the acute phase.

12. Selection of drugs of choice for the treatment of 12. Answer: C

bacterial pneumonia depends primarily on: Rationale: When an organism is sensitive to a
a. Tolerance of the client medication, the medication is capable of destroying
b. Selectivity of the organism the organism (Mosby’s 18th Edition).
c. Sensitivity of the organism
d. Preference of the physician

13. To alleviate the fretfulness of Janice, the most 13. Answer: A

effective nursing care would be: Rationale:
a. Reading a story to her B. Too complicated
b. Giving her a jigsaw puzzle C. Does not provide human contact
c. Letting her play with a doll D. Will increase child’s fretfulness (Mosby’s 18 th
d. Putting her in a room by herself Edition)

14. An immediate priority in Janice’s nursing care 14. Answer: A

would be: Rationale: Rest reduces the need for oxygen, and
a. Rest c. Nutrition minimizes metabolic needs (Mosby’s 18th Edition).
b. Exercise d. Elimination

15. Janice is expected to respond to antibiotic 15. Answer: B

therapy:
a. Within 6 hours
b. Between 1 and 2 days
c. By the fourth day
d. After 7 days

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Situation 4: A female toddler has had fever for
several days, and is vomiting. The toddler develops a
tonic-clonic seizure because of a high fever.
16. During the tonic-clonic stage of the seizure, the 16. Answer: B
nurse’s priority should be to: Rationale:
a. Turn her on her side A and D are done after the seizure.
b. Protect her from injury C. The nurse should not leave the child (Mosby’s 18 th
c. Call for additional help Edition).
d. Establish a patent airway

17. When explaining the occurrence of febrile seizures 17. Answer: A

to the toddler’s parents, the nurse should include
the fact that:
a. They may occur in minor illnesses
b. The cause is usually readily indentified
c. They usually occur after the first year of life
d. The frequency of occurrence is greater in
females than in males
Rationale: Febrile seizures are not associated with
major illness.
B. Cause is uncertain
C. Common among infants and toddlers
D. More common in males (Mosby’s 18th Edition)

18. While instituting measures to reduce the child’s 18. Answer: C

fever, the nurse recognizes that it is important to: Rationale: Shivering increase metabolic rate, and
a. Restrict oral fluids raises body temperature (Mosby’s 18th Edition).
b. Measure output every hour
c. Limit exposure to prevent shivering
d. Monitor vital signs every 10 minutes

19. In a plan of care, the nurse initiates seizure 19. Answer: A

precautions and documents that which items need Rationale: Because airway obstruction and increase
to be placed at the child’s bedside? oral secretions can occur during and after the seizure,
a. Suctioning equipment and an airway an airway and suctioning equipment are placed at the
b. Oxygen with a tracheotomy set bedside (Saunders, 3rd Edition).
c. Emergency cart
d. Airway and tracheotomy set

20. When assessing the child who is taking hydantoin 20. Answer: D
(Dilantin), the nurse would recognize which of the Rationale:
following as findings as side-effects? A. S/E of Phenobarbital (Luminal)
a. Drowsiness and irritability B. S/E of clonazepam (Klonopin)
b. Slurred speech and increased salivation C. S/E of Depakene
c. Hair loss and tremor (NSNA, 4th Edition)
d. Gum hyperplasia and nystagmus

Situation 5: A 1-month-old infant is seen in a clinic

and is diagnosed with unilateral hip dysplasia.
21. A nurse is assisting a physician during the
examination of an infant with hip dysplasia. The
physician performs an Ortolani maneuver. The
nurse is aware that this maneuver is performed to:
a. Push the unstable femoral head out of the
acetabulum
b. Reduce the dislocated femoral head back into
the acetabulum
c. Determine the extent of range of motion
d. Assess for asymmetry on the affected side
21. Answer: B
Rationale: In the Ortolani maneuver, the examiner
reduces the dislocated femoral head into the
acetabulum. A positive finding is a palpable click on
the entry or exit of the femoral head over the
acetabular ring.
A. This is Barlow maneuver (Saunders 3rd Edition).

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22. A nurse assesses the infant, knowing that which of
the following findings would be noted with this
condition?
a. An apparent lengthened femur in the affected
hip
b. Limited range of motion in the affected hip
c. Asymmetric adduction of the affected hip
while the infant is placed supine with the
knees and the hips flexed
d. Symmetry of the gluteal skinfolds when the
infant is placed prone and the legs are
extended against the examining table
22. Answer: B
Rationale: Assessment findings in an infant with hip
dysplasia include an apparent short femur on the
affected side; limited range of motion in the affected
extremity; asymmetric abduction of the affected hip
when the child is placed supine with the knees and
hips flexed; and asymmetry of gluteal folds. (Saunders
3rd Edition)

23. A clinic nurse provides instructions to the parents 23. Answer: C

of an infant with hip dysplasia regarding care of
the Pavlik harness. Which of the following does
the nurse include in the instructions?
a. The harness should be worn 12 hours a day
b. The harness needs to be removed for diaper
changes
c. The harness should be removed only to check
the skin and for bathing
d. The infant should not be moved when out of
the harness
Rationale: The harness should be removed only to
check the skin and for bathing.
A. The harness should be worn 16 to 23 hours a day.
B. The harness does not need to be removed for
diaper changes or feedings.
D. The infant can be moved when out of the harness,
but the hips and the buttocks should be supported
carefully. (Saunders 3rd Edition)

24. Which of the following will NOT be included in the
instructions for home care for the parents?
a. Turn her every three to four hours
b. Keep her off the affected side
c. Watch for signs of skin breakdown
d. Give her sponge baths, not tub baths
24. Answer: B
Rationale: The infant on a Pavlik harness can be
turned from back to abdomen but should not be
positioned on either side (NSNA NCLEX-RN Review, 4 th
Edition).

25. The infant’s mother asks if she can remove the
harness if it becomes soiled. The best response for
the nurse to make is:
a. No, the harness may not be removed
b. No, she will only be wearing it a few days
c. Yes, just long enough to clean the area
d. Yes, just overnight while she is sleeping
25. Answer: A
Rationale: The harness is not to be removed until the
hip is stable with 90 degrees of flexion and x-ray
confirmation. This usually occurs after about three
weeks in a Pavlik harness. (NSNA NCLEX-RN Review, 4th
Edition)

Situation 6: The Nurse bears accountability and

responsibility in the provision of nursing care. The
following questions will assess your knowledge on
how to handle children with conditions affecting
Fluids and Electrolytes.
26. The physician orders a tap-water enema for a 6- 26. Answer: B
month-old infant, The nurse should question the Rationale: Tap water enemas are hypotonic, and may
order because it could: cause increased absorption of fluid via the bowel
a. Result in a loss of necessary nutrients (Mosby’s 18th Edition).
b. Cause a fluid and electrolyte imbalance
c. Increase the infant’s fear of intrusive
procedures
d. Result in shock from a sudden drop in
temperature

27. The physician orders an isotonic enema for 2-year- 27. Answer: C (Mosby’s 18th Edition).
old child. The nurse is aware that the maximum
amount of fluid to be given to a small child
without a physician’s specific order is:
a. 100 to 150 mL c. 255 to 360 mL
b. 155 to 250 mL d. 365 to 500 Ml

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28. An infant receiving a parenteral therapy. The IV 28. Answer: D
orders are 400 mL of D5 0.45 NS to run in 8 hours. Rationale: 400 mL / 8 hours = 50 mL/hour
The nurse should maintain the hourly rate at:
a. 20 mL/hour c. 40 mL/hour
b. 30 mL/hour d. 50 mL/hour
29. Answer: B
29. An essential nursing action when caring for the Rationale: Weight is the best indicator of fluid
small child with severe diarrhea is to: loss/gain if measured each day at the same time, on
a. Maintain the IV the same scale, and with the same amount of clothing.
b. Take daily weights A. ORT is employed first; IV therapy is given only if
c. Replace lost calories there is severe dehydration or shock (Mosby’s 18th
d. Keep body temperature below 100oF Edition).

30. When vomiting is uncontrolled in an infant, the 30. Answer: C

nurse should observe for signs of: Rationale: excessive vomiting → loss of H+ ions →
a. Tetany c. Alkalosis metabolic alkalosis (Mosby’s 18th Edition)
b. Acidosis d. Hyperactivity

Situation 7: A mother arrives at an emergency room

with her 5-year-old child. The mother states that the
child was hit by a car while riding her bike. She
sustained a severe closed head injury. The nurse is
assessing the child continuously for signs of increased
intracranial pressure (ICP).
31. To identify possible increasing intracranial 31. Answer: B
pressure, the nurse should monitor the child for: Rationale: Because cranial sutures are closed by this
a. Restlessness, anorexia, rapid respirations age, increased pressure could cause headaches.
b. Vomiting, seizures, complaints of head pain Irritation of cerebral tissue would cause seizures, and
c. Anorexia, irritability, subnormal temperature pressure on vital centers would cause vomiting.
d. Bulging fontanels, decreased blood pressure,
elevated temperature

32. An ICP monitor is in place and reveals an ICP of 40 32. Answer: C

mmHg. In an effort to lower the ICP, the nurse Rationale: This facilitates venous return (NSNA, 4th
knows the best position for the child would be: Edition).
a. Supine with the heard turned to the right
b. Supine with the heard turned to the left
c. Supine with the heard midline
d. Side-lying on the right with the head turned to
the left

33. Mannitol is ordered. What is the rationale for 33. Answer: A (NSNA, 4th Edition)
administering mannitol?
a. It will produce a rise in the intravascular
osmolality, resulting in a shift of free water
from the interstitial and cellular spaces to the
intravascular space, thus decreasing the ICP
b. It will produce a decrease in the intravascular
osmolality, resulting in a shift of free water
form the interstitial and cellular spaces to the
intravascular space, thus decreasing the ICP
c. It will produce a rise in the intravascular
osmolality, resulting in a shift of free water
from the intravascular space to the cellular
space, thus decreasing the ICP
d. It will produce a decrease in the intravascular
osmolality, resulting in a shift of free water
from the intravascular space to the cellular
space, thus decreasing the ICP

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34. Which of the following would indicate a late sign 34. Answer: D
of increased ICP? Rationale: Late signs include decreased LOC, Cushing’s
a. Bulging fontanel triad (↑ systolic BP, widened pulse pressure;
b. Dilated scalp veins bradycardia; irregular respirations), fixed and dilated
c. Nausea pupils.
d. Widened pulse pressure A and B. Early sign; infants
e. C. Early sign (Saunders, 3rd Edition)

35. On assessment of the child, the nurse notes a 35. Answer: B

decerebrate posturing of the child. This position is Rationale:
described as: A describes decorticate position (Saunders, 3rd
a. Abnormal flexion of the upper extremities and Edition).
extension of lower extremities
b. Rigid extension and pronation of the arms and
legs
c. Rigid pronation of all extremities
d. Flaccid paralysis of all extremities

Situation 8: The nurse is taking care of a 6-month-old

infant of a woman who has HIV.
36. The newborn is tested for the presence of HIV
antibodies. An ELISA is performed, and the results
are positive. A nurse interprets these results as:
a. Positive for HIV
b. Indicating the presence of maternal infection
c. Indicating the absence of maternal infection
d. Negative for HIV
36. Answer: B
Rationale: A positive antibody test in a child younger
than 18 months indicates only that the mother is
infected because maternal IgG antibodies persist in
infants for 6 to 9 months (sometimes up to18 months).
ELISA does not indicate true infection (Saunders, 3 rd
Edition).

37. To determine the presence of HIV antigen, the 37. Answer: D

nurse anticipates that which laboratory study will Rationale: p24 antigen assay – confirmatory test for
be prescribed? HIV antigens (in infants)
a. Western blot c. CD4+ count A. Western blot – confirmatory test for HIV antibodies
b. Chest x-ray d. p24 antigen assay B. Chest x-ray – evaluates presence of pneumonia
C. CD4+ count – indicates how ell the immune system
is working (Saunders, 3rd Edition)

38. The most common opportunistic infection of 38. Answer: C

children infected with HIV is: Rationale: This is the most common; most frequent in
a. Gastroenteritis age 3 to 6 months.
b. Meningitis A and B. Not specific to HIV-infected child
c. Pneumocystis carinii pneumonia D. A form of chronic pneumonitis; characteristic of HIV
d. Lymphoid interstitial pneumonia infection but not the most common (Saunders, 3 rd
Edition)

39. The nurse instructs the mother of the child 39. Answer: B
regarding immunizations. The nurse tells the Rationale:
mother that: A. The varicella vaccine is avoided in the child who is
a. Household members need to avoid receiving infected with HIV.
the varicella vaccine C. Hepa B vaccine is administered.
b. Pneumococcal and influenza vaccines are D. Not necessary (Saunders, 3rd Edition)
recommended
c. The hepatitis B vaccine will not be given to the
child
d. A Western blot needs to be performed and
the results evaluated before immunizations

40. The child receives zidovudine (AZT, Retrovir). The 40. Answer: B
nurse monitors which laboratory study to Rationale: Zidovudine causes bone marrow
determine whether the child is experiencing an suppression; anemia occurs most commonly 4 to 6
adverse reaction from the medication? weeks of therapy (Saunders, 3rd Edition).
a. Sedimentation rate c. Calcium level
b. CBC d. Potassium level

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Situation 9: Accurate and immediate assessment of
what, when, and how much of the substance
swallowed is necessary in order to render the proper
remedy to poisoning.
41. The mother of a 3-year-old calls the clinic and 41. Answer: D
states that her child has just swallowed an Rationale: If child is conscious, 1st line of treatment is
unknown amount of baby aspirin. What is the best ipecac. If the child is unconscious, do not give ipecac
initial action for the nurse to take? (NSNA, 4th Edition).
a. Call the physician
b. Instruct the mother to bring the child to the
ER as soon as possible
c. Discuss with the mother observable changes
for which she should watch the child
d. Tell the mother to give ipecac to the child and
then come to the ER

42. A 7-year-old child has taken approximately 10 42. Answer: C

children’s aspirin. The physician places a Rationale: Charcoal is an adsorbent.
nasogastric tube in the child and administers A. Ipecac will induce vomiting (NSNA, 4th Edition).
activated charcoal. The mother asks the nurse
what the charcoal is for. The best response is that
it will:
a. Induce vomiting
b. Correct electrolyte imbalances
c. Absorb the aspirin in the stomach
d. Prevent bleeding tendencies

43. A child who swallowed several aspirin is admitted 43. Answer: B

to the ER. Aquamephyton is ordered. The nurse Rationale: Aspirin is an anticoagulant. Vitamin K
explains to the child’s mother that it is given to: (Aquamephyton) promotes clotting (NSNA, 4th Edition).
a. Promote metabolism of aspirin
b. Prevent bleeding
c. Decrease absorption of aspirin
d. Prevent hepatotoxicity
44. Answer: C (NSNA, 4th Edition)
44. What symptoms would be indicative of aspirin
toxicity?
a. Hypothermia
b. Hypoventilation
c. Decreased hearing acuity
d. Increased urinary output
45. Answer: C
45. A 16-year-old admits to her mother that she tried Rationale: This binds acetaminophen and helps
to commit suicide by swallowing bottle of Tylenol reduce levels.
(acetaminophen) 16 hours ago. Her mother brings A and C. Ingestion was too many hours ago for these
the girl to the ER. The nurse implements the to be effective (NSNA, 4th Edition)
treatment of choice, which is:
a. Ipecac syrup
b. Activated charcoal
c. Mucomyst
d. Milk and observation

Situation 10: Jasmine, an infant with Congestive

Heart Failure (CHF), is admitted to the hospital. 46. Answer: A (NSNA, 4th Edition)
46. When assessing the apical heart rate in infants and
toddlers, the point of maximal impulse is:
a. Between the 3rd and 4th left ICS
b. Between the 4th and 5th left ICS
c. 5th ICS midclavicular line
d. In the aortic area

47. Which one is the most common sign of heart

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 disease the nurse should assess?
a. Circumoral cyanosis
b. Hypertension
c. Diastolic murmur
d. Tachycardia

48. An infant’s blood pressure is reported to be very 48. Answer: C

high. What is the most appropriate nursing action Rationale: Cuff should be approximately 2/3 the
to take? length of the humerus (Davis, 2nd Edition).
a. Take it again in 20 minutes
b. Call the physician
c. Measure the cuff width to the infant’s arm
d. Prepare to give an antihypertensive
49. Answer: D
49. Among the last signs of heart failure in the infant Rationale: In heart failure, there is decrease in the
and child is: blood flow to the kidneys, causing sodium and water
a. Orthopnea c. Increased heart rate reabsorption resulting in peripheral edema. The
b. Tachypnea d. Peripheral edema peripheral edema indicates severe cardiac
decompensation.
A, B and C. These may be early attempts by the body
to compensate for decreased cardiac output.

50. Jasmine takes 1.25 oz of formula in 20 minutes. 50. Answer: D

The doctor ordered 2 oz of formula q3h. The best
action for the nurse to take at this time would be
to:
a. Ask the mother to feed the infant when she
arrives
b. Burp the infant and try to stimulate sucking
c. Continue feeding slowly, allowing as much
time as the infant needs to finish
d. Stop the feeding, and request an order for
gavage feedings PRN
Rationale: Infants with CHF should be given about 15-
20 minutes per feeding. If the infant is unable to finish
the feeding, or if the infant becomes cyanotic or
experiences respiratory distress during the feeding,
gavage feeding should be used to avoid exhausting the
infant and possibly precipitating an episode of apnea.
No attempts should be made to continue the feeding.
(Davis's NCLEX-RN Success, 2nd Edition)

Situation 11: A toddler is admitted with classic

hemophilia.
51. Assessment of the child’s health history includes: 51. Answer: D (Davis, 2nd Edition)
1. Hemarthrosis
2. Intracranial bleeding
3. Excessive hematoma formation
4. Prolonged bleeding from lacerations

a. 1 and 2 c. 1, 3 and 4
b. 3 and 4 d. All of the above

52. Which admission procedure would not be done 52. Answer: B

and probably be the most frightening for this Rationale: Toddlers fear intrusive procedures; imposes
child? risk for bleeding (Davis, 2ND Edition).
a. Blood pressure c. Urine specimen
b. Rectal temperature d. Weight

53. During the first night in the hospital, a child with
hemophilia suffers an episode of epistaxis. In
which position should the nurse place the child?
a. Prone, with heard turned to side
b. Semi-fowler’s with two pillows
c. Sitting up with head tilted backward
d. Sitting up and leaning forward slightly
53. Answer: D
Rationale: This allows blood to drain freely from the
nose and prevents aspiration.
A. Acceptable choice if the child is too weak to sit up
without assistance (Davis, 2nd Edition).

47. Answer: D (Davis, 2nd Edition) 54. Which of the following information regarding
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 hemophilia is true?
a. It is a Y-linked hereditary disorder
b. Males inherit hemophilia from their fathers
c. Females inherit hemophilia from their
mothers
d. Hemophilia A results from deficiency of factor
VIII
Rationale: Hemophilia A – Factor VIII deficiency;
Hemophilia B/Christmas disease – factor IX deficiency
A. X-linked genetic disorder
B. Males inherit hemophilia from their mothers
C. Females inherit carrier status from their fathers
(Saunders, 3rd Edition).

55. Which of the following would most likely be 55. Answer: D

abnormal in a child with hemophilia? Rationale: A, B and C are normal in hemophilia
a. Bleeding time (Saunders, 3rd Edition).
b. Platelet count
c. Prothrombin time
d. Partial thromboplastin time

Situation 12: Cesar, a 5-year-old child, is admitted for

repair of Tetralogy of Fallot (TOF).
56. The cardiac defects associated with TOF include: 56. Answer: C
a. Right ventricular hypertrophy, atrial and Rationale:
ventricular defects, and mitral valve stenosis B. Transposition of great vessels (Mosby’s, 18th Edition)
b. Origin of the aorta from the right ventricle and
of the pulmonary artery from the left ventricle
c. Right ventricular hypertrophy, ventricular
septal defect, pulmonic stenosis, and
overriding aorta
d. Abdominal connection between the
pulmonary artery and the aorta, right
ventricular hypertrophy, and atrial-septal
defects

57. Prior to surgery, Cesar is seen in squatting position 57. Answer: B

near his bed. The nurse should:
a. Administer oxygen
b. Take no action, but continue to observe
c. Pick him up, and place in Trendelenburg
position in bed
d. Have him stand up and walk around the room
Rationale: Squatting is a normal response to a
cyanotic heart defect. This will increase pulmonary
flow, thereby will increase oxygen level (NSNA. 4 th
Edition).

58. The laboratory results indicate a high RBC count. 58. Answer: D
The nurse recognizes that this polycythemia can Rationale: Decreased tissue oxygenation stimulates
best be understood as a compensatory erythropoiesis, resulting in excessive production of
mechanism for: RBC (Mosby’s, 18th Edition).
a. Low BP c. Low iron level
b. Cardiomegaly d. Tissue oxygen need

59. The nurse is aware that a common adaptation of 59. Answer: A

children with TOF is: Rationale: Hypoxia leads to poor peripheral
a. Clubbing of fingers circulation; clubbing occurs as result of tissue
b. Slow, irregular respirations hypertrophy.
c. Subcutaneous hemorrhages B. Respirations are generally rapid to compensate for
d. Decreased RBC count O2 deprivation.
D. Polycythemia occurs. (Mosby’s, 18th Edition)

60. Post repair of the defects associated with TOF, it is 60. Answer: C
essential that the nurse prevent: Rationale: Forceful evacuation increases intrathoracic
a. Crying pressure and puts excessive strain on the heart
b. Coughing sutures.
c. Hard stools A. Not a problem post-op
d. Unnecessary movement B. Coughing and deep breathing are essential post-op.
D. Activity is gradually increased post-op (Mosby’s, 18 th
Edition).

54. Answer: D Situation 13: RA 9262 is an act promulgated to

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protect the women and children against violence.
Nurses should know how to handle children
suspected of child abuse.
61. When interviewing a child suspected of being 61. Answer: D
sexually abused, the nurse should: Rationale: This ensures that the child understands
a. Ask leading questions what is being said.
b. Have the parents present B and C. No one except the nurse should be present
c. Have a security guard present during the interview, so the nurse will feel free to
d. Use the child’s words to describe body parts express her feelings (NSNA, 4th Edition).

62. When child abuse is suspected, the least 62. Answer: A

appropriate nursing action is to: Rationale: This is deleterious to the child; child’s safety
a. Take a wait-and-see position should be ensured (NSNA, 4th Edition).
b. Call a local social service agency for help
c. Prevent the child’s return to a dangerous
environment
d. Confront the parent with security present

63. Children are most frequently abused by a: 63. Answer: B

a. Ya-ya Rationale: In 90% of child physical abuse cases, the
b. Relative abuser is a relative whom the child trusts (NSNA, 4th
c. Teacher Edition).
d. Casual acquaintance

64. Which test is least likely to indicate that the child 64. Answer: A
has been sexually abused? Rationale: This detects changes in cells that may
a. Pap smear c. Throat culture indicate cancer and precancer changes (NSNA, 4 th
b. Urine culture d. Vaginal culture Edition).

65. Children who survive physical abuse are least 65. Answer: D (NSNA, 4th Edition)
likely to become:
a. Depressed c. Abusive parents
b. Drug abusers d. Academic achievers

Situation 14: A nurse working in the Gastro ward

encounters the following cases.
66. A nurse admits a child with pyloric stenosis. Which 66. Answer: D
of the following would the nurse expect to obtain Rationale: S/sx include projectile vomiting, irritability,
asking the mother about the child’s symptoms? hunger and crying, constipation and signs of
a. Vomiting large amounts of bile dehydration, including a decrease in urine output
b. Watery diarrhea (Saunders, 3rd Edition).
c. Increased urine output
d. Projectile vomiting

67. The surgeon orders a preoperative series of 67. Answer: B

cleansing enemas for an infant with Hirschsprung’s Rationale: Isotonic solution; will not alter fluid balance
disease. The nurse should expect the solution (Saunders, 3rd Edition).
ordered for these enemas to be:
a. Soapsuds enema c. Pediatric fleets
b. Normal saline d. Tap water

68. A nurse is preparing to care for a child with a 68. Answer: A

diagnosis of intussusception. The nurse reviews Rationale: Classic manifestation is currant-jelly stool
the child’s record and expects to note which B. Pyloric stenosis
symptom of this disorder? D. Hirschsprung’s disease (Saunders, 3rd Edition)
a. Bright red blood and mucus in the stool
b. Profuse projectile vomiting
c. Watery diarrhea
d. Ribbon-like stools

69. A nurse provides instructions to a mother of an

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 infant diagnoses with gastroesophageal reflux. To
assist in reducing the episodes of emesis. The
nurse tells the mother to:
a. Thin the feedings by adding water to the
formula
b. Thicken the feedings by adding rice cereal to
the formula
c. Provide less frequent, larger feedings
d. Burp the infant less frequently during the
feeding
70. A clinic nurse reviews the record of an infant seen
in the clinic. The nurse notes that a diagnosis of
esophageal atresia with tracheoesophageal fistula
suspected. The nurse expects to note which most
likely sign of this condition documented in the
record?
a. Severe projectile vomiting
b. Coughing at nighttime
c. Choking with feedings
d. Incessant crying
Situation 15: The following questions apply to Agua, an
infant born with a unilateral cleft lip.
71. A cleft lip predisposes an infant to infections
primarily because of:
a. Poor nutrition from disturbed feedling
b. Poor circulation to the defective area
c. Waste products that accumulate along the
defect
d. Mouth breathing, which dries the oropharyngeal
mucous membranes
72. Feeding for Agua will probably be:
a. Limited to IV fluids
b. With a cross-cut nipple
c. Too difficult because of breathing problems
d. With a rubber-tipped syringe or medicine
dropper
73. Agua has just returned to the nursing unit following a
surgical repair of a cleft lip located on the right side
of the lip. The nurse places the infant in which most
appropriate position?
a. On the right side c. Prone
b. On the left side d. Supine
74. The most critical factor in the immediate care of an
infant after repair of cleft lip would be the:
a. Prevention of vomiting
b. Maintenance of a patent airway
c. Administration if parenteral fluids
d. Administration of drugs to reduce oral secretions
75. Nursing care for Agua after the surgical repair of a
cleft lip should include:
a. Keeping the baby NPO
b. Keeping the infant from crying
c. Placing the infant in a semi-sitting position
d. Spoon-feeding for the first 2 days after surgery
69. Answer: B
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Rationale:
C and D. Small frequent feedings with frequent
burpings are prescribed (Saunders, 3rd Edition).
70. Answer: C
Rationale: 3C’s – coughing, choking with feedings and
unexplained cyanosis (Saunders, 3rd Edition)
71. Answer: D
Rationale: Infants with a cleft lip breathe through their
mouth, bypassing the natural humidification provided by
the nose. As a result, the mucous membranes become
dry and cracked and are easily infected.
A. Feeding can be adequate with special equipment and
a slow approach.
B. Circulation to the area is unimpaired.
D. The area may be kept clean by washing with water
after feeding. (Mosby’s, 18th Edition)
72. Answer: D
Rationale: Because an infant with a cleft lip and palate is
unable to form the vacuum needed for sucking, a rubber-
tipped syringe or dropper is used.
A. IV fluids do not supply ample calories.
B. A soft cross-cut nipple maybe used with some infants,
but rapid flow can cause aspiration.
C. Feeding can be accomplished with a child in an upright
position to facilitate swallowing and prevent choking.
(Mosby’s, 18th Edition)
73. Answer: B
Rationale: Post cleft lip repair, the infant should be
positioned supine or on the side lateral to the repair to
prevent the contact of the suture lines with the bed
linens. Placing the infant on the left side rather than
supine immediately after surgery is best to prevent the
risk of aspiration of the infant vomits. (Saunders, 3rd
Edition)
74. Answer: B
Rationale: These children frequently have difficulty
swallowing secretions as well as difficulty breathing after
surgery. (Mosby’s, 18th Edition)
75. Answer: B
Rationale: Crying should be prevented because it places
tension on the suture line.
A. This is not necessary.
C. Infant may be positioned on the side or supine.
D. The feeding method of choice is by rubber-tipped
syringe/dropper. (Mosby’s, 18th Edition)
Situation 16: James, 5 years old, is admitted with the
11
diagnosis of Acute Glomerulonephritis (AGN).
76. When performing a physical assessment, the nurse 76. Answer: D
should expect to find: Rationale: The glomerular filtration rate is reduced,
a. Anorexia, hematuria, proteinuria 1+, and resulting in sodium retention, protein loss, and fluid
decreased blood pressure accumulation producing these signs.
b. Normal blood pressure, anorexia, proteinuria A, B and C. Not all of these support the diagnosis of
1+, and glycosuria 3+ glomerulonephritis.
c. Lowered blood pressure, periorbital edema,
proteinuria 1+, and decreased specific gravity
1.001
d. Moderately elevated blood pressure,
periorbital edema, proteinuria 4+, and
increased specific gravity 1.030

77. When planning nursing care for James, the nurse
realizes that he needs help in understanding the
necessary restrictions. One of which is:
a. Daily doses of IM penicillin
b. A bland diet high in protein
c. Bed rest for at least 4 weeks
d. Isolation from other children with infections
77. Answer: D
Rationale: During the acute stage, anorexia and loss of
protein lower the child's resistance to infection.
A. Antibiotics are not necessary for all children with
AGN, only those with persistent streptococcal
infections.
B. A bland diet is not necessary, but high-protein and
high-sodium foods should be avoided.
C. Bed rest is necessary only during the acute stage.

78. The mother of James asks why the child is being 78. Answer: A
weighed every morning. The nurse's best response Rationale: Daily changes in weight are indicators of
would be: fluid changes.
a. “It is the best way to measure your child's fluid
balance.”
b. “When weight loss stops it indicates the
disease process is over.”
c. “It gives the doctors a good idea of how much
protein is being lost.”
d. “The dietitian plans the daily caloric intake
according to the daily weight change.”

79. James' mother asks why his eyes are so puffy. The
nurse responds:
a. “This is a common finding due to circulatory
congestion in the kidneys.”
b. “Children cry a lot with glomerulonephritis
and the puffiness should subside when he
feels better.”
c. “Has he been rubbing his eyes excessively?”
d. “Periorbital edema is associated with
hypertension.”
79. Answer: A
Rationale: Periorbital edema is often associated with
circulatory congestion in the kidneys.
B. Edema associated with crying clears 30 minutes
after the child stops crying. Periorbital edema does
not.
C. Excessive eye rubbing is not consistent with
prolonged periorbital edema.
D. Hypertension is a sign of glomerulonephritis, but
not a cause of periorbital edema.

80. James' parents are very concerned about the 80. Answer: D
activity restrictions after discharge. The nurse Rationale: When urinary findings are normal, such as
bases the answer to them on the fact that after no evidence of hematuria or proteinuria, the child may
the urinary findings are nearly normal: resume pre-illness activities.
a. Activity must be limited for 1 month
b. The child must not play active games
c. The child must remain in bed for 2 weeks
d. Activity does not affect the course of the
disease

Situation 17: Nurses should consider the

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developmental stage of the child in rendering nursing
care.
81. A hospitalized 4-year-old calls out repeatedly for
the mother who is unable to visit the child after
work. The nurse’s best response would be:
a. “Stop crying and I’ll take you to the playroom.” 81. Answer: C
b. “Mommy will come back later.” Rationale: This gives specific information when to
c. “Mommy will come back after dinner.” expect to see the mother.
d. “Mommy is at work right now.”

82. The most appropriate person to administer a

preoperative series of cleansing enemas to a 9-
month-old with Hirschsprung’s disease would be
the: 82. Answer: B
a. Primary nurse c. Nursing student Rationale: Fear of strangers peaks at 8 to 9 months
b. Mother d. Nursing aide (Davis, 2nd Edition).

83. Which behavior should the nurse expect a 5-

month-old with CHF to be capable of
demonstrating?
a. Rolling over from stomach to back
b. Sitting with support
c. Pincer grasp
d. Bearing weight on legs
84. A mother of a 4-year-old expresses concern
because her hospitalized child has begun thumb
sucking. The mother states that this behavior
began 2 days after hospital admission. The most
appropriate nursing response is which of the
following?
a. “A 4-year-old is too old for this type of
behavior.”
b. “Your child is acting like baby.”
c. “The doctor will need to be notified”
d. “It is best to ignore this behavior.”
83. Answer: A
Rationale: This can be achieved normally by 3 months
of age, but due to child’s condition, developmental
delays are anticipated. An infant with CHF can do this
by 5 months of age.
B. Achieved normally by 6 months
C. Achieved normally by 9 to 12 months
D. Achieved normally by 4 to 6 months (Davis, 2nd
Edition)
84. Answer: D
Rationale: Regression may occur due to stress of
hospitalization. It is best to ignore (Saunders, 3 rd
Edition).

85. A 3-month-old is NPO for surgery. The nurse

attempts to comfort him by:
a. Administering acetaminophen
b. Encouraging parents to leave the child so the 85. Answer: C
child can rest Rationale: This helps console and pacify the infant.
c. Offering pacifier B. Family should stay (Saunders, 3rd Edition).
d. Giving 10 cc Pedialyte

Situation 18: Nurses play an essential role in

counseling parents regarding the handling their
toddlers.
86. The best advice the nurse can give to parents to
handle a toddler’s temper tantrums would be to:
a. Allow the toddler to make own choices
b. Ignore this behavior
c. Change the setting in which they occur
d. Give in to the toddler’s demand to nurture
autonomy
87. The most important factor in the process of toilet
training is the:
a. Child’s desire to be dry
b. Ability of the child to sit still
c. Parent’s willingness to work at it
d. Approach and attitude of the parent
86. Answer: B
Rationale:
A. If a parent allows child to make choices and does
not follow through with this choice either because of
personal preference, or because the choice is unsafe,
tantrums will increase.
C. This is often a catalyst for tantrums as the child is
moved from one area to another.
D. Unrealistic (Davis, 2nd Edition)
87. Answer: D (Mosby’s, 18th Edition)

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 the infant’s current condition?
a. Physiological jaundice
b. Liver failure
c. Neonatal sepsis
d. Blood incompatibility
88. A mother verbalizes that she has a difficulty 88. Answer: A
getting the child to go to bed at night. Which of Rationale: Establishing a routine before-bedtime
the following is most appropriate for the nurse to routine and enforcing consistent limits on the child’s
suggest to the mother? bedtime behavior reduce bedtime protests (Saunders,
a. Inform the child of bedtime a few minutes 3rd Edition).
before it is time for bed
b. Allow the child to have temper tantrums
c. Allow the child to set the bedtime limits
d. Avoid a nap during the day

89. The parents of a 2-year-old child arrive at a 89. Answer: D

hospital to visit their child. When the parents Rationale: This is normal. When young children are
enter the room child does not readily approach separated from their parents, they progress through
the parents. The nurse interprets this behavior as phases namely protest, despair and denial (Saunders,
indicating that: 3rd Edition).
a. The child is withdrawn
b. The child is self-centered
c. The child has adjusted to the hospital setting
d. This is a normal pattern

90. The mother of a 3-year-old is concerned because 90. Answer: D

her child still is insisting on a bottle at nap time Rationale: A toddler should never be allowed to fall
and at bedtime. Which of the following is the most asleep with a bottle containing milk, juice, soda, or
appropriate suggestion to the mother? sweetened water because of the risk of nursing caries
a. Do not allow the child to have the bottle (Saunders, 3rd Edition).
b. Allow the bottle during naps but not at
bedtime
c. Allow the bottle if it contains juice
d. Allow the bottle if it contains water

Situation 19: Keen assessment is necessary in order to

deliver proper nursing care, especially to infants.
Infancy
91. After circumcision of a 6-month-old infant, the 91. Answer: B
most essential nursing action during the initial Rationale: This is an extremely vascular area (Mosby’s
post-operative period is to assess the infant for: 18th Edition).
a. Infection
b. Hemorrhage
c. Shrill, piercing cry 92. Answer: B
d. Decreased urinary output Rationale: An immunosuppressed child maybe
overwhelmed the live viruses.
92. The presence of what condition would necessitate A. MMR vaccine contains eggs, but a child allergic to
a change in the standard immunization schedule eggs would still receive the vaccine on schedule in very
for a child? small doses at 20-minute intervals with adrenalin
a. Allergy to eggs c. Congenial defects available should anaphylaxis occur.
b. Immunosuppression d. Mental retardation C and D would not interfere with immunization
schedule (NSNA, 4th Edition)

93. What important observation would the nurse look 93. Answer: B
for in a newborn 24-48 hours after birth? Rationale: Passage of meconium ensures a patent
a. Decrease in size of caput succedaneum anus, and a functional GI tract (Davis, 2 nd Edition).
b. Passage of meconium stool
c. Presence of milia
d. Decrease in vernix

94. A 3-day-old infant has been exclusively breastfed 94. Answer: A

since birth. The infant has now developed lethargy Rationale: This normally appears on the 2 nd to 4th day
and appears icteric. What is the probable cause of in normal full-term infants.
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B. S/sx of liver failure will occur before 3 days.
C. S/sx of neonatal sepsis would include lethargy and
poor feeding.
D. Jaundice caused by blood incompatibility appears
before 24 hours of age (Davis, 2nd Edition)
95. While performing a neurodevelopmental 95. Answer: D
assessment on a 3-month-old infant, which of the Rationale: A 3-month-old infant should be able to lift
following characteristics would be expected? the head and chest when prone.
a. A strong Moro reflex A. The Moro reflex typically diminishes or subsides by
b. A strong parachute reflex 3 months.
c. Rolling from front to back B. The parachute reflex appears at 9 months.
d. Lifting of head and chest when prone C. Rolling from front to back usually is accomplished at
about 5 months.
Situation 20: Knowledge of the Growth and
Developmental milestones of children allows the
parents and health care providers to identify delays
in the growth and development of the child.
96. Which of the following is the highest level of 96. Answer: B
developmental achievement of a 4-month-old Rationale:
infant? A. Occurs by 9 months
a. Uses simple words such as ”ma-ma” C. Occurs between 6 and 9 months
b. Uses monosyllabic babbling D. Occurs by 2 months (Saunders, 3rd Edition)
c. Links syllables together
d. Coos when comforted

97. A nurse is evaluating the developmental level of a 97. Answer: B

2-year-old. Which of the following does the nurse Rationale: Can use a cup and spoon correctly with
expect to observe in this child? some spilling
a. Uses a fork to eat A. Achieved by age 3 and 4
b. Uses a cup to drink C and D. Achieved by the end of preschool period
c. Uses a knife for cutting food (Saunders, 3rd Edition).
d. Pours own milk into a cup

98. In which circumstance would a nurse be 98. Answer: A

concerned about language development of a 3- Rationale: A 3-year-old child should have conversation
year-old child? that is 75% intelligible. 50% intelligible is typical of a 2-
a. Conversation with the child is 50% intelligible year-old.
b. The child uses pronouns and prepositions
when talking
c. The child has a vocabulary of about 900 words
d. The child is inquisitive and asks “why”
majority of the time

99. At what age should an infant begin to locate an 99. Answer: C

object hidden under a blanket? Rationale: Object permanence begins by 10 months of
a. 6 months c. 10 months age (Pillitteri, 5th Edition).
b. 8 months d. 12 months

100. The average 5-year-old is incapable of: 100. Answer: B

a. Tying shoelaces Rationale: Piaget stresses that age 7 is the turning
b. Abstract thought point in mental development. New forms of
c. Making decisions organization appear at this age that mark the
d. Hand-eye coordination beginning of logic, symbolism, and abstract thought.
A. A 5-year-old is capable of tying laces.
C. A toddler is capable of making simple decisions.
D. An infant is capable of hand-eye coordination.

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