G & D
The mother of a child 2 years 6 months has arranged a play date with the neighbor and her child 2 years 9 months. During the play date the two mothers should expect that the children will do which of the following?
A. Play with one another with little or no conflict
B. Share and trade their toys while playing
C. Play alongside one another but not actively with one another
D. Only play with one or two items, ignoring most of the other toys
Answer: C
C. Play alongside one another but not actively with one another
In which congenital heart defect would the nurse need to take upper and lower extremity blood pressures?
A. Coarctation of the Aorta (COA)
B. Tetralogy of Fallot (TOF)
C. Aortic stenosis (AS)
D. Transposition of the Great Vessels (Arteries)
Answer: A
A. Coarctation of the Aorta (COA)
Rationale: Coarctation of the Aorta (COA) is a narrowing of the aorta, typically just distal to the left subclavian artery.
Which parent statement indicates understanding of pancreatic enzyme therapy for cystic fibrosis?
A. “I will give enzymes at bedtime only.”
B. “I will give enzymes with every meal and snack.”
C. “Enzymes are only needed during illness.”
D. “I will crush enzymes and mix with hot food.”
Answer: B
B. “I will give enzymes with every meal and snack.”
Rationale: Enzymes must be given with all meals/snacks to promote digestion.
A 3-month-old infant presents with a history of vomiting after feeding. The plan for the infant is to rule out GERD. What information from the history would lead the nurse to believe that this infant may need further intervention?
A. Small "spits" after feedings
B. Sleeps through the night
C. Absence of nausea/vomiting
D. Poor weight gain
Answer: D
D. Poor weight gain
Rationale: Many infants have normal reflux because:
Lower esophageal sphincter is immature
They spend most of their time supine
They consume liquid diets
However, GERD becomes concerning when it affects growth and health.
Which lab finding is expected in acute glomerulonephritis?
A. Low BUN
B. Hematuria
C. Massive proteinuria
D. Hyperalbuminemia
Answer: B
B. Hematuria
Rationale: AGN → inflammation → blood in urine.
Which example demonstrates passive immunity?
A. Receiving DTaP vaccine
B. Developing antibodies after infection
C. Receiving maternal antibodies through placenta
D. Producing antibodies after varicella vaccine
Answer: C
C. Receiving maternal antibodies through placenta
Rationale:
Passive immunity occurs when a person receives preformed antibodies from another source rather than producing them through their own immune system.
The nurse is caring for a child admitted with congestive heart failure. Which of the following assessment findings would be expected?
A. Flattened neck veins
B. Bradypnea
C. Pulse deficit
D. Exercise intolerance
Answer: D
D. Exercise intolerance
Rationale: In pediatric congestive heart failure (CHF), the heart is unable to pump effectively to meet the body’s metabolic demands. As a result, tissues receive inadequate oxygen during activity.
A classic and early finding in children with CHF is:
Fatigue with feeding (infants)
Poor weight gain
Exercise intolerance (older children)
Tachycardia
Tachypnea
Diaphoresis with activity
A child 8 hours post-tonsillectomy is swallowing frequently and appears restless. What is the nurse’s priority action?
A. Offer red popsicles
B. Assess for bleeding
C. Administer ibuprofen
D. Encourage coughing
Answer: B
B. Assess for bleeding
Rationale: Frequent swallowing indicates bleeding.
The nurse in the nursery is caring for a 24-hour-old infant. The nurse suspects the infant of having pyloric stenosis. Which of the following manifestations would support this finding?
A. Steatorrhea
B. Currant jelly stools
C. Projectile vomiting
D. Melena
Answer: C
C. Projectile vomiting
Rationale: Steatorrhea, currant jelly stools and melena are not manifestations of pyloric stenosis.
An 8-month-old infant has been brought into an emergency department (ED) for acute diarrhea and decreased oral intake. Which assessment finding would an ED nurse anticipate?
A. Low hematocrit
B. Bulging anterior fontanel
C. Weight gain
D. Skin tenting
Answer: D
D. Skin tenting
Rationale: Poor skin turgor is a sign of dehydration.
A nurse is caring for a 4-month-old infant. Which nursing action best supports the infant’s developmental stage?
A. Encourage independent feeding
B. Respond consistently to crying
C. Allow the infant to choose toys
D. Encourage cooperative play
Answer: B
B. Respond consistently to crying
Rationale: Infants (0–1 year) are in Trust vs. Mistrust. Consistent caregiving builds trust and security.
The nurse is assessing a client diagnosed with ventricular septal defect (VSD), the nurse is aware that many infants with these conditions also receive a diagnosis of which of the following?
A. Trisomy 21
B. Turner syndrome
C. DiGeorge syndrome
D. Trisomy 18
Answer: A
A. Trisomy 21
Rationale: A ventricular septal defect (VSD) is one of the most common congenital heart defects and is frequently associated with Trisomy 21 (Down syndrome).
An adolescent with asthma suddenly has absent breath sounds, increasing respiratory rate, and appears anxious. What should the nurse do first?
A. Encourage coughing
B. Administer inhaled corticosteroid
C. Activate rapid response
D. Provide oral fluids
Answer: C
C. Activate rapid response
Rationale: A silent chest indicates severe obstruction and impending respiratory failure. This is an emergency.
A toddler presents with intermittent abdominal pain, drawing knees to chest, and currant jelly stools. What is the priority action?
A. Administer oral laxative
B. Prepare for air enema
C. Start high-fiber diet
D. Encourage ambulation
Answer: B
B. Prepare for air enema
Rationale: Air enema is diagnostic and therapeutic for intussusception.
Which statement by parents indicates correct understanding?
A. “We will punish accidents.”
B. “We will limit fluids all day.”
C. “We will encourage bathroom use before bed.”
D. “We will wake our child every hour.”
Answer: C
C. “We will encourage bathroom use before bed.”
Rationale: Supportive measures only — no punishment.
A nurse is speaking to parents about their toddler. The parents express concern that the child is becoming independent and that they prefer to perform activities for him. The most appropriate response for the nurse would be:
A. "Your child will develop shame"
B. "Your child will feel guilt"
C. "Your child will develop mistrust"
D. "Your child will feel inferior"
Answer: A
A. "Your child will develop shame"
Rationale: This question is based on Erikson’s Psychosocial Development Theory.
A toddler (1–3 years) is in the stage of: Autonomy vs. Shame and Doubt
During this stage, toddlers strive to:
Be independent
Do things “by myself”
Develop control over bodily functions and choices
The nurse is caring for a child diagnosed with a coarctation of the aorta who is scheduled for a surgical repair tomorrow morning. When the nurse auscultates the child's lungs sounds, the nurse notes diffuse crackles and rales throughout the lung fields. The nurse interprets this assessment as which of the following?
A. Systemic congestion
B. Foreign body aspiration
C. Pulmonary congestion
D. Pneumonia
Answer: C
C. Pulmonary congestion
Rationale:
Coarctation of the aorta causes increased afterload and left ventricular pressure. Over time, the left ventricle struggles to pump effectively against the narrowed aorta. When the left side of the heart begins to fail, blood backs up into the lungs.
Which is the earliest recognizable manifestation of cystic fibrosis?
A. Recurrent pneumonia
B. Steatorrhea
C. Meconium ileus
D. Clubbing
C. Meconium ileus
Rationale:
Meconium ileus is often the earliest clinical manifestation of cystic fibrosis and may present in the newborn period.
The nurse is preparing a teaching plan for the mother of a child who has been diagnosed with celiac disease. Choosing which lunch will be within the therapeutic management of a child with celiac disease?
A. Turkey salad, milk, and oatmeal cookies
B. Baked chicken, coleslaw, soda, and frozen fruit dessert
C. Turkey sandwich on rye bread, orange juice, and fresh fruit
D. Tuna salad sandwich on whole wheat bread, milk, and ice cream
Answer: B
B. Baked chicken, coleslaw, soda, and frozen fruit dessert
Rationale: Gluten free diet. No oatmeal, no rye, no wheat.
A child with recent strep throat presents with cola-colored urine and facial swelling. What is the priority assessment?
A. Blood pressure
B. Bowel sounds
C. Lung sounds
D. Pain level
Answer: A
A. Blood pressure
Rationale: AGN can cause hypertension → risk for encephalopathy and seizures.
The nurse is speaking to the parents of an adolescent client who report that their child is having difficulty finding their identity. The nurse responds that the failure of the adolescent to develop their identity would result in which of the following?
A. Shame
B. Role confusion
C. Guilt
D. Inferiority
Answer: B
B. Role confusion
Rationale: According to Erikson’s Psychosocial Development Theory, adolescence (approximately 12–18 years) corresponds to the stage of: Identity vs. Role Confusion
A nurse is caring for an infant who is newly diagnosed with tetralogy of Fallot. Which actions from the box below are appropriate for the nurse to perform during a hypercyanotic spell? Select all that apply.
A. Place the infant in a knee-chest position.
B. Use a calm, comforting approach.
C. Administer oxygen.
D. Administer morphine.
E. Hold the infant upright at a 45-degree angle
Answer: A, B, C, D.
A. Place the infant in a knee-chest position.
B. Use a calm, comforting approach.
C. Administer oxygen.
D. Administer morphine.
Rationale: Hold the infant upright at a 45-degree angle is incorrect. This position does NOT increase systemic vascular resistance and will not reduce right-to-left shunting. The correct position is knee-chest, not upright.
A 2-year-old presents with drooling, inspiratory stridor, tripod positioning, and sudden onset of high fever. What is the nurse’s priority action?
A. Obtain a throat culture
B. Place the child supine for assessment
C. Prepare for possible intubation
D. Administer a nebulized bronchodilator
Answer: C
C. Prepare for possible intubation
Rationale: Findings indicate acute epiglottitis. Airway obstruction is the priority. Do NOT visualize the throat.
An emergency department nurse is caring for a 7-month-old infant with acute abdominal pain when the nurse begins to suspect intussusception. Which assessment finding would most support this suspicion?
A. Ribbon-like stools
B. Red, currant jelly-like stools
C. Greasy, foul-smelling stools
D. Black, tarry stools
Answer: B
B. Red, currant jelly-like stools
Rationales: Ribbon-like stools, greasy, foul-smelling stools or black, tarry stools are not seen in intussusception.
Which symptom is most common in an infant with a urinary tract infection?
A. Burning with urination
B. Flank pain
C. Fever
D. Urinary frequency
Answer: C
C. Fever
Rationale: Infants often present with:
Fever
Irritability
Poor feeding
They do not verbalize dysuria.
Which pain assessment tool is most appropriate for a 2-year-old child?
A. Numeric rating scale
B. Visual analog scale
C. FLACC scale
D. FACES scale
Answer: C
C. FLACC scale
Rationale: FLACC (Face, Legs, Activity, Cry, Consolability) is used for infants and toddlers who cannot self-report pain.
To prevent infective endocarditis in the child with an artificial heart valve, the nurse teaches parents to:
A. Administer prophylactic antibiotics before dental work.
B. Immediately treat unexplained fevers with acetaminophen.
C. Avoid raw fruits and vegetables.
D. Avoid spending time with household pets.
Answer: A
A. Administer prophylactic antibiotics before dental work.
Answer Rationale: Dental procedures may allow organisms to enter the child’s bloodstream and grow on the artificial valve. This makes excellent oral hygiene also important. Unexplained fevers should be discussed with the child’s health care provider and not automatically treated at home. Raw fruits and vegetables and household pets are not a particular threat to this child.
The nurse is assigned four children in the emergency department. Which child should be seen first?
A. A 3-year-old with barking cough and low-grade fever
B. A 2-year-old with drooling, muffled voice, and tripod positioning
C. A 6-month-old with wheezing and rhinorrhea
D. A 4-year-old with sore throat and sandpaper rash
Answer: B
B. A 2-year-old with drooling, muffled voice, and tripod positioning
Rationale: Drooling + muffled voice + tripod positioning = epiglottitis → impending airway obstruction → airway first.
A 10-month-old with vomiting and diarrhea has dry mucous membranes, pulse slightly increased, sunken fontanelle, and decreased urine output. These findings indicate:
A. Mild dehydration
B. Moderate dehydration
C. Severe dehydration
D. Normal infant variation
Answer: B
B. Moderate dehydration
Rationale:
Moderate dehydration signs:
Dry mucosa
Sunken fontanelle
Decreased tears
Reduced urine output
Pulse slight increased
Severe: Parched mucous membranes, very increased pulse, hypotension.
An 8-year-old child is brought to the clinic for bedwetting. The parent reports the child had been dry at night for 2 years but recently began wetting the bed again. What is the nurse’s priority assessment?
A. Daily fluid intake
B. School performance and stressors
C. Caffeine intake
D. Family history of enuresis
Answer: B
B. School performance and stressors
Rationale: This is secondary enuresis (child was previously dry for ≥6 months).
Secondary enuresis is often associated with:
Emotional stress
School problems
Family changes (divorce, new sibling)
A & C → Important, but not the first concern.
D → More relevant in primary enuresis.
A school-age child becomes upset after receiving a poor grade and says, “I’m not good at anything.” This reflects difficulty in which developmental stage?
A. Identity vs. Role Confusion
B. Industry vs. Inferiority
C. Initiative vs. Guilt
D. Autonomy vs. Shame
Answer: B
B. Industry vs. Inferiority
Rationale: School-age children (6–12 years) are in Industry vs. Inferiority. Success builds confidence; repeated failure leads to inferiority.
A child with heart failure is receiving digoxin. Which finding requires immediate action?
A. Apical pulse 92 in a 4-year-old
B. Serum potassium 3.0 mEq/L
C. Mild nausea
D. Increased appetite
Answer: B
B. Serum potassium 3.0 mEq/L
Rationale: Digoxin toxicity risk increases with hypokalemia.
A 5-year-old with asthma is admitted. Which findings indicate impending respiratory failure? (Select all that apply.)
A. Wheezing
B. Silent chest
C. Increased respiratory rate
D. Sudden decrease in wheezing
E. Restlessness
Answers: B, C, D, E
B. Silent chest
C. Increased respiratory rate
D. Sudden decrease in wheezing
E. Restlessness
Rationale:
Silent chest = minimal air movement (very bad sign)
Sudden decrease in wheezing may mean airway is too constricted for airflow
Tachypnea + restlessness = hypoxia
Wheezing alone does not equal failure.
A newborn has abdominal distention and has not passed meconium within 48 hours. Which condition is suspected?
A. GERD
B. Pyloric stenosis
C. Hirschsprung disease
D. Intussusception
Answer: C
C. Hirschsprung disease
Rationale: Failure to pass meconium within 24–48 hours is a classic red flag for Hirschsprung disease.
A child diagnosed with acute glomerulonephritis develops a severe headache, vomiting, and blurred vision. What is the nurse’s priority action?
A. Administer antiemetic
B. Assess urine output
C. Check blood pressure
D. Encourage fluid intake
Answer: C
C. Check blood pressure
Rationale: AGN causes:
Fluid retention
Hypertension
Risk for hypertensive encephalopathy
Headache + vomiting + blurred vision = possible severe hypertension.
A 5-year-old child is hospitalized for appendicitis. The child tells the nurse, “I got sick because I was bad and didn’t listen to my mom.” This statement reflects which stage of Piaget’s cognitive development?
A. Sensorimotor
B. Preoperational
C. Concrete operational
D. Formal operational
Answer: B
B. Preoperational
Rationale:
A 5-year-old is in the Preoperational stage (ages 2–7 years).
Key characteristics of this stage include:
Magical thinking
Egocentrism
Believing illness is punishment
Limited understanding of cause and effect
Concrete, literal thinking
A nurse is assessing an infant diagnosed with patent ductus arteriosus (PDA). Which finding is most consistent with this condition?
A. Harsh systolic murmur
B. Continuous “machinery-like” murmur
C. Absent femoral pulses
D. Cyanosis with crying
Answer: B
B. Continuous “machinery-like” murmur
Rationale:
PDA is an acyanotic defect caused by failure of the ductus arteriosus to close after birth.
Classic findings include:
Continuous “machinery-like” murmur
Bounding pulses
Wide pulse pressure
Signs of heart failure in larger defects
A 4-month-old with RSV is admitted. Which nursing interventions are appropriate? (Select all that apply.)
A. Initiate contact precautions
B. Perform frequent nasal suctioning
C. Encourage large volume oral feedings
D. Continuous pulse oximetry
E. Administer prophylactic antibiotics
Answers: A, B, D
A. Initiate contact precautions
B. Perform frequent nasal suctioning D. Continuous pulse oximetry
Rationale: RSV management is supportive with suctioning, O₂ monitoring, and contact precautions. Antibiotics are not indicated for viral infections.
A newborn begins coughing, choking, and turning cyanotic during the first feeding. The nurse notices excessive drooling and frothy secretions. The nurse suspects esophageal atresia with tracheoesophageal fistula (EA/TEF). What is the priority nursing action?
A. Attempt to feed smaller amounts more frequently
B. Place the infant in a side-lying position and suction as needed
C. Insert an NG tube and begin gavage feedings
D. Lay the infant flat and administer oxygen
Answer: B
B. Place the infant in a side-lying position and suction as needed
Rationale: Side-lying positioning helps secretions drain and reduces aspiration risk.
Why the others are incorrect:
A. Feed smaller amounts
Feeding should be stopped immediately.
C. Insert NG tube and gavage feedings
In pure esophageal atresia, NG tube cannot pass into the stomach.
D. Lay infant flat
Flat positioning increases aspiration risk.
A 3-month-old infant is brought to the clinic with irritability and poor feeding. The infant’s temperature is 102.4°F (39.1°C). Urinalysis confirms a urinary tract infection. Which is the nurse’s priority concern?
A. Risk for dehydration
B. Risk for renal scarring
C. Risk for constipation
D. Risk for anemia
Answer: B
B. Risk for renal scarring
Rationale: In infants, UTIs can rapidly progress to pyelonephritis and cause permanent kidney damage.
A nurse is assessing a 6-month-old infant. Which findings are developmentally appropriate?
Select all that apply.
A. Rolls from back to stomach
B. Sits without support for long periods
C. Transfers objects hand to hand
D. Babbles
E. Pulls to stand
Answer: A, C, D
A. Rolls from back to stomach
C. Transfers objects hand to hand
D. Babbles
Rationale:
Rolling + transferring objects + babbling = appropriate
Sitting independently for long periods and pulling to stand occur later
The nurse working in the pediatric cardiac unit is reviewing the telemetry monitors for assigned clients. The nurse should initially plan to assess the client who is a:
A. 5-year-old child and is playing with other children in the playroom and has a pulse (P) of 110
B. 14-year-old adolescent and is resting in bed watching television and has a pulse (P) of 110
C. 2-year-old toddler and is sleeping and has a pulse (P) of 125
D. 3-month-old infant and has a fever and a pulse (P) of 148
Answer: B
B. 14-year-old adolescent and is resting in bed watching television and has a pulse (P) of 110
Rationale:
Normal Pediatric Heart Rates (approximate ranges):
Infant (0–12 months): 100–160 bpm
Toddler (1–3 years): 90–150 bpm
Preschooler (3–5 years): 80–140 bpm
School-age (6–12 years): 70–110 bpm
Adolescent (13–18 years): 60–100 bpm
A nurse is caring for an adolescent who is newly diagnosed with asthma. Which instructions from the box below should the nurse include in the discharge plan of care? Select all that apply:
A. Encourage the child to avoid triggers.
B. Encourage the child to use a peak expiratory flow meter.
C. Encourage the child to play sports that require short bursts of energy.
D. Encourage the child to keep an epinephrine auto-injector pen with them at all times.
E. Encourage the child to rinse their mouth after use of a metered-dose inhaler (MDI).
F. Encourage the child to use a long-term medication in an emergency
Answer: A, B, C & E
Rationale: Key Asthma Teaching Reminders:
Avoid triggers
Use peak flow meter
Carry rescue inhaler at all times
Rinse mouth after steroids
Use SABA for acute symptoms
Encourage appropriate exercise
A mother brings her 5-month-old infant to the clinic. The child has been vomiting since early morning and has had diarrhea since the day before. His temperature is 100.1 F, pulse 140, and respiratory rate 38. He has lost 6 oz since his well-child visit 4 days ago. He cries before passing a bowel movement, he will not breastfeed today. What is the priority nursing diagnosis?
A. Thermoregulation alteration
B. Fluid volume deficit related to excessive losses and inadequate intake
C. Abdominal pain related to diarrhea
D. Alteration in nutrition, less than body requirements, related to decreased oral intake
Answer: B
B. Fluid volume deficit related to excessive losses and inadequate intake
Rationale: In infants, dehydration develops rapidly because:
They have higher metabolic rates
They have higher total body water
They cannot communicate thirst
They rely entirely on caregivers for intake
Which parent statement indicates correct understanding of management for nocturnal enuresis?
A. “We will wake our child every 2 hours.”
B. “We will restrict all fluids after 2 PM.”
C. “We will use positive reinforcement for dry nights.”
D. “We will punish accidents so the child learns faster.”
Answer: C
C. “We will use positive reinforcement for dry nights.”
Rationale: Best practice management includes:
Positive reinforcement
Bedwetting alarms
Encourage voiding before bedtime
Avoid punishment
Punishment increases anxiety and worsens enuresis.
Which milestones are expected in a 12-month-old?
Select all that apply.
A. Pulls to stand
B. Says 1–3 words
C. Cruises along furniture
D. Builds a 4-block tower
E. Waves “bye-bye”
Answer: A, B, C, E
Rationale: Block tower building (4 blocks) is closer to 18–24 months.
A nurse is reviewing the echocardiogram report of a child diagnosed with Tetralogy of Fallot. Which of the following findings are components of this condition?
Select all that apply.
A. Ventricular septal defect
B. Pulmonary stenosis
C. Right ventricular hypertrophy
D. Overriding aorta
E. Atrial septal defect
Answer: A, B, C, D
Rationale: Tetralogy of Fallot has four classic structural abnormalities:
A. Ventricular septal defect
B. Pulmonary stenosis
C. Right ventricular hypertrophy
D. Overriding aorta
A nurse in the pediatric emergency department is assessing four children. Which child should the nurse assess first?
A. A 6-month-old with RSV who has RR 58, moderate subcostal retractions, and O₂ saturation 93% on room air
B. A 3-year-old with croup who has inspiratory stridor only when crying
C. A 5-year-old with asthma who has decreased wheezing compared to 1 hour ago, RR 34, and is now lethargic
D. A 2-year-old with suspected foreign body aspiration who is coughing forcefully and crying
Answer: C
C. A 5-year-old with asthma who has decreased wheezing compared to 1 hour ago, RR 34, and is now lethargic
Rationale: This is the most dangerous presentation.
This suggests:
Impending respiratory failure
“Silent chest” progression
Possible ventilatory collapse
This child needs immediate intervention.
Why the Others Are NOT First
A. RSV infant with RR 58, O₂ 93%
Tachypneic but oxygenation still acceptable
Moderate retractions expected in bronchiolitis
Not crashing
B. Croup with stridor only when crying
Stridor at rest would be severe
Stridor only when crying = mild/moderate
Not priority over impending failure
D. Foreign body aspiration, coughing forcefully
Crying + coughing = airway still open
DO NOT interfere
Partial obstruction = better than no air movement
A nurse is caring for four pediatric clients. Which child should the nurse assess first?
A. A 4-year-old with celiac disease who has abdominal bloating
B. A 2-year-old with intussusception who suddenly becomes lethargic
C. A 6-month-old with GERD who spits up small amounts
D. A 5-year-old with constipation who has not had a bowel movement in 3 days
Answer: B
B. A 2-year-old with intussusception who suddenly becomes lethargic
Rationale: This may indicate:
Bowel perforation
Shock
Severe obstruction
Sepsis
Lethargy in pediatrics is a major red flag.
Why not the others?
A. Bloating is expected in celiac.
C. Mild spit-up is common.
D. Constipation for 3 days is uncomfortable but not emergent.
Which assessment findings are expected in nephrotic syndrome? (Select all that apply.)
A. Periorbital edema
B. Massive proteinuria
C. Hypoalbuminemia
D. Hematuria
E. Hyperlipidemia
Answer: A, B, C, E
A. Periorbital edema
B. Massive proteinuria
C. Hypoalbuminemia
E. Hyperlipidemia
Rationale: Nephrotic syndrome =
Protein loss
Low albumin
Edema
High lipids
Hematuria is more common in glomerunephritis.