1.

What should the nurse do first when preparing to do a physical assessment on a

sleeping month
old baby?
a. Measure the occipital-frontal head circumference.
b. Auscultate the heart and lungs.
c. Check the eyes for the red reflex.
d. Wake the baby.
Answer: B.
Auscultation is always easiest in a sleeping or quite baby. Checking the eyes is
considered invasive and
should be saved in for the end of the examination. There is no need to awaken the
child because she or he will
begin to stir once the examination begins.
Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; p.29 & 54
2. A mother asks the pediatric nurse about what she should begin to feed her 6
month old infant. The
correct response is:
a. Egg whites are the least allergenic food to be introduced into the babys diet.
b. Rice cereal is the first solid introduced that is least allergenic of the cereals.
c. Formula is the only source of nutrition given for the first year.
d. Fruits and vegetables are good sources of iron.
Answer: B. Rice cereal is the first solid introduced that is least allergenic of the
cereals.
Introduction or solid foods is recommended at age 4 to 6 months, when the
gastrointestinal system has
matured sufficiently to handle complex nutrients. The suck reflex and tongue-thrust
reflex diminish at 4 months

of age. A Rice cereal is the first solid food because it is a rich source of iron and
rarely induce allergic
reactions. Fruits and vegetables, good source of vitamins and fiber, are introduced
after cereal, one at a time
to determine allergic reactions. Egg whites are highly allergenic.
Source: Prentice Hall Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; pages 22 & 25
3. Whenever the parents of a 10 month old leave their hospitalized child for short
periods, he begins
to cry and scream. The nurse explains that this behavior demonstrates that the
child:
a. Needs to remain with his parents at all times
b. Is experiencing separation anxiety
c. Is experiencing discomfort
d. Is extremely spoiled
Answer: B
Infants and toddlers between the ages of 6 months and 30 months experience
separation anxiety. There are
three stages of separation anxiety. The child who demonstrates crying and rejecting
anyone than the parent is
in protest, the first stage of separation anxiety. This behavior does not exhibiting
spoiling or any indication of
discomfort. The second stage is despair. The child expresses hopelessness, appears
quite and is withdrawn.
The third stage is detachment. The child becomes interested in the environment,
especially the caregivers. If
the parents return, the child ignores them.
Source: Prentice Hall Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; pages 23 & 25

4. Hospitalization of a child results in disturbance of the dynamic in family life. The

most appropriate
nursing diagnosis is:
a. Diversional activity deficit related to separations from siblings and peers
b. Sleep pattern disturbance related to unfamiliar surroundings
c. Altered family processes related to hospitalization
d. Ineffective individual coping related to procedures
Answer: C
Identification of nursing diagnosis that apply to the specific problems of the child
and family is an essential step
of the nursing process. Family-centered care addressed the needs of the family
members, including the childs
siblings. The primary goals are to maintain relationship with the child and siblings
during the period of
separation while hospitalized to avoid boredom and distress for the hospitalized
child.
Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; pages 23 & 26
5. When assessing the child who complains of abdominal pain, what is the most
appropriate nursing
action?
a. Palpate the most painful area first
b. Palpate for rebound tenderness
c. Avoid painful areas until the end of the assessment
d. Use deep palpation for abdominal tenderness
Answer: C
Save the painful area for last to avoid abdominal guarding and to gain the childs
trust. Always tell the child

before touching the tender area.

Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; pages 28 & 54
6. When preparing to examine a preschool child, the nurse should:
a. Give detailed explanations to alleviate the childs anxiety.
b. Give reassurance and feedback to the child during the examination.
c. Suggest that the child act like the big kids when he or she is examined.
d. Say that the shirt is only clothing that must be removed.
Answer: B
The preschooler may be somewhat anxious so the nurse should give feedback and
reassurance about what
will be done. Children do not need detailed explanations nor do they need to be told
to act older than they are.
Most children at this age are willing to remove clothing.
Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; pages 29 & 54
7. When using the otoscope to examine the ears of a 2 year old child, the nurse
should:
a. Pull the pinna up and back
b. Pull the pinna down and back
c. Hold the pinna gently but firmly in its normal positio
d. Hold the pinna against the skull
Answer: B
The ear canal in infant and young children is shorter, wider, and more horizontally
positioned than on older
children. To adequately examine the tympanic membrane in young children the
pinna must be pulled back and

down.
Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; pages 53-55
8. In infants, a positive Babinski reflex is:
a. An indication of a neurological problem
b. Dorsiflexion of the toes
c. Fanning of the toes
d. Withdrawing the foot from the stimulus
Answer: C
A positive Babinski in infants is fanning of the toes when a stimulus is applied to the
foot along the lateral edge
and cross the ball. The response disappears by about age 2.
Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; pages 53 & 55
9. The nurse would perform abdominal percussion to assess for:
a. Tenderness
b. Density of tissues and organs
c. Inflammation
d. Size and placement of liver
Answer: D
Percussion produces sound of varying loudness and pitch depending on the organs
and tissues density. The
nurse assesses the liver with palpation and percussion, but not for placement.
Inflammation is assessed with
inspection, and tenderness is assessed with palpation.
Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy

E. White; pages 53 & 55

10. When assessing a 4 year old child with a persistent cough, the nurse would
assess respirations
by observing which muscle group?
a. Thoracic
b. Accessory
c. Abdominal
d. Intercostal
Answer: C
Infants and young children use the diaphragm and abdominal muscles for
respiration, so the nurse would
watch the rise and fall of the abdomen to count respirations. Use of accessory or
intercostals muscles may be
observed in respiratory distress.
Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; pages 53 & 55
11. The physician orders amoxicillin (Amoxil) 500 mg IVPB q 8 hours for a pediatric
client with
tonsillitis. What is the appropriate nursing action?
a. Question the order because the route of administration is incorrect
b. Give the medication as ordered
c. Question the order because the dosage is too high
d. Question the order because the dosing frequency is incorrect
Answer: A. Question the order because the route of administration is incorrect.
Amoxicillin is given only by the oral route.
Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; pages 58 & 72

12. During 15 year-old Elizabeths previous physical, the nurse found that she was
significantly
underweight for her age. She was asked to keep a food diary so that her intake
could be assessed
more completely. In reviewing this diary, the nurse notices that a significant number
of Elizabeths
meals are eaten away from home and are made up of mostly fruits and vegetables.
Her overall diet is
low in calories and protein. Which of the following would be the nurses best
response to Elezabeths?
a. I am concerned about your nutritional status. Your body needs more calories and
protein than you
are getting in your diet. I think you will need some dietary supplements.
b. I am concerned about your nutritional status. You arent taking in adequate
calories. This could
affect your health and prevent you from growing.
c. I am Concerned about your nutritional status. Your body needs more calories and
protein
than you are getting. Lets discuss some ways that you could increase these aspect
of your
diet.
d. I am concerned of your nutritional status. I think you might have an eating
disorder called
anorexia.
Answer: C
Your body needs more calories and protein than you are getting. Lets discuss some
ways that you could
increase these aspect of your diet.
In this response, the nurse shares her/his concern in a non threatening manner and
includes the patient in
planning phase.

A- Although the nurse shares her/his concern in this response, it is premature to

suggest that a nutritional is
needed. This response might sound threatening to an adolescent.
B- Adolescent usually dont think in terms of future consequences of their actions,
This explanation would have
a little impact.
C- Not enough data are given to support the diagnosis of an eating disorder.
Source: Pediatric Nursing by: NSNAI page 19 & 20
13. The is observing Mrs. Wang with her child Kim. Kim is sitting on the floor without
support, playing
with toys, and transferring object from hand to hand. Mrs. Wang hides a toy under a
pillow, but Kim
does not look for it. The nurse estimate Kims age to be:
a. 4 months
b. 6 months
c. 8 months
d. 10 months
Answer: C
An 8-month-old child can sit securely without support and has ability to transfer
objects hand to hand. An
understanding of object permanence, however, does not develop until 9-10 months
of age.
a. and b. at 4 months and 6 months of age. Children cannot sit without support nor
do they transfer objects
from hand to hand.
d. A 10-month-old child understands object permanence and would look for placed
under a pillow.
Source Pediatric Nursing by: NSNAI page 30 & 31
14. Ms. Lee has been breastfeeding her infant for 4 months. She would like to stop
breastfeeding and

have her baby drink fro a bottle. The nurse should instruct Ms. Lee to start her baby
on:
a. Whole milk
b. Low-fat milk
c. Soy-based formula
d. Iron-supplemented formula
Answer: D
The American Academy of Pediatrics recommends breast milk or iron-fortified
formula during the first year life.
a. and b. Use of cows milk during the first year places the infant at risk for iron
deficiency anemia
c. Soy-based formula is for infants who have milk allergies.
Source Pediatric Nursing by NSNAI page 30 & 31
15. Two year old Bob weighs 27 lb and is 34 inches tall. At birth he weighed 7 lb 2
oz, nurse graphing
the childs growth interprets this as:
a. Failure to thrive
b. Below-normal growth
c. Normal growth.
d. above-normal growth.
Answer: C
A toddlers growth should be 4-6 lb per year. At this age, growth occurs in spurts; as
a result, the growth chart
will have a steplike appearance
a. This child is thriving
b. This childs weight is not bellow normal
d. This childs weight is not bellow normal growth pattern for toddler.
Source Pediatric Nursing by NSANI page 42 & 43

16. Mrs. Cryan is worried that her 2 year old daughter abby is not getting enough
to eat. She tells
the nurse, shes such a picky eater the first nursing action is to:
a. Encourage the mother to feed the child smaller and more frequent meals
b. Provide teaching pamphlets on nutritious snacks.
c. Review the basic food group requirements with the mother.
d. asses the daily eating pattern of the child.
Answer: D.
The first nursing action is to asses the childs daily intake and eating patterns. This
is data provides the
necessary information on which to base future nursing actions.
a,b and c . all appropriate nursing actions but only after the initial assessment is
completed.
Source Pediatric Nursing by: NSNAI page 42 & 43
17. Ms. N. tells you that she found her 5-year-old daughter and her male cousin of
the same age
inspecting each other private areas while getting ready for bed one night. What
interruption of this
behavior would you give to Ms. N?
a. The child should be punished so this behavior doesnt happen again.
b. your daughter may need counseling to understand this unusual and damaging
situation.
c. Sexual curiosity is quite normal during this stage of development.
d. Children are quite curious at this stage. You should give them lots of other
opportunities to explore
with each other.
Answer: C
Sexual curiosity is common during the preschool years. The nurse may suggest that
the curiosity may be

better deal with through discussion between parents and children rather than
through unsupervised sexual
games with other children.
a. The child should not punished for attempting to meet a normal need.
b. Inspecting each other probably was not damaging event to this child. She does
not need counseling at this
time.
d. Preschoolers are quite curious, and parents should provide guidance and conduct
honest should provide
guidance and conduct honest discussion rather than allow unsupervised sexual
activities.
Source Pediatric Nursing by: NSNA
18. Which of the following is correct about health protection and promotion during
the preschool
years?
a. Preschoolers are capable of thoroughly brushing their teeth without parental
supervision.
b. Daily naps are no longer necessary during the preschool years.
c. Preschool children will listen to parental warnings about potential dangers but still
require
close adult supervision during all activities.
d. Caloric and fluid requirements increase during the preschool
Answer: C
Preschoolers children will listen to parental warnings, but they still lack control to
direct their behavior
according to the warnings.
a. Preschoolers motor ability is not well develop enough to adequately clean all
surfaces of the teeth. Parents
still need to help preschool children brush.
b. Daily naps are necessary to ensure that the child obtains adequate rest daily.

d. Caloric and fluid requirements continue to decrease slightly during the preschool
years.
(Source Pediatric Nursing by NSNAI page 54 & 55)
19. Ms. Has a 12-year-old daughter has started puberty and her son has not. Which
of the following
will best explain this to Ms. P.?
a. This is abnormal development. Chronological age will usually determine the onset
puberty.
b. This is normal development. The onset of puberty is usually earlier in girls than in
boys.
c. This is normal development. The onset of puberty should be the same for siblings.
d. This is abnormal development. Her son should have a physical evaluation to
determine the cause
for his delayed sexual maturation.
Answer: B
The onset of puberty is typically at an earlier age for girls than boys.
a. Chronological age has little impact on the onset of puberty.
c. Genetics has little impact on the onset of puberty.
d. The absence of puberty at age 12 is not considered delayed or abnormal. The son
does not require physical
evaluation at this time.
(Source Pediatric Nursing by: NSNAI page 65 & 66 )
20. Which of the following is best describes parent-child relationship during
adolescence?
a. Major conflicts in the parent-child relationship occur over issue of independence
and
control.
b. Peer and family relationships are equally important during adolescence.
c. Parent-child relationships are generally most rewarding during this period.

d. During this period, girls and their parents have fewer conflicts than boys and their
parents.
Answer: A
Conflicts in the parent-child relationship occur during adolescence as the child
attempts to exert independence.
b. Peer relationship are more important during this time than are family
relationships.
c. Parent-child relationships are least rewarding during this period.
d. Differences in parent-child conflicts are not related to gender
(Source Pediatric Nursing by: NSNAI page 76 & 77)
21. The nurse is assessing a child with conjunctivitis (pink eye). Which of the
following would the
nurse most likely assess?
a. Serous drainage from the affected eye
b. Periorbital edema
c. Severe eye pain
d. Crusting of eyelids and eyelashes
Answer: D. Crusting of eyelids and eyelashes
Purulent exudate and crusting are characteristic of conjunctivitis. Conjunctivitis
associated with foreign body
can cause severe eye pain. The other option are incorrect.
Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; pages 59 & 73
22. The nurse teaches the family of a toddler with streptococcal pharyngitis the
importance of
finishing the full course of oral antibiotic therapy. The nurse explains that a potential
complication of
untreated streptococcal infection is.

a. Otitis media
b. Nephrotic syndrome
c. Diabetes insipidus
d. Acute rheumatic fever
Answer: D
Rheumatic fever can follow an infection of certain strains of group A beta hemolytic
streptococci. Other options
are incorrect.
Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; pages 72 & 74
23. A 4-year-old female child presents to the emergency department with a sore
throat, difficulty
swallowing and a suspected diagnosis of acute epiglottitis. Which of the following
should not be
included in her initial assessment?
a. Throat culture
b. Past medical history
c. Vital signs
d. Auscultation of chest
Answer: A
In epiglottitis, any manipulation of the throat can cause stimulation of the gag
reflex. The inflamed, edematous
epiglottis could then completely obstruct the airway. All other assessments should
be made.
Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; pages 76 & 99

24. A child with bacterial pneumonia is crying and says it hurts when he coughs.
The nurse would
teach the child to:
a. Hug his teddy bear when he coughs
b. Ask for pain medicine before he coughs
c. Take a sip of water before coughing
d. Try very hard not to cough
Answer: A. Hug his teddy bear when he coughs.
Splinting the affected side with a pillow or stuffed animal lessens the discomfort
experienced with bacterial
pneumonia.
Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; pages 77 & 100
25. A child with a respiratory infection is schedules to have a sweat rest. The mother
asks the
purpose of this diagnostic test. The nurses response would be based on the
knowledge that the test:
a. Determines if the child is dehydrated
b. Assesses if the sweat glands are functioning
c. Identifies the infectious organism
d. Establishes a diagnosis of cystic fibrosis
Answer: D. Establishes a diagnosis of cystic fibrosis
Children with cystic fibrosis have elevated chloride concentrations of sweat because
of the dysfunction of the
exocrine glands.
Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; pages 99 & 101

26. A child is admitted with a diagnosis of rule out rheumatic fever. Which
assessment finding
supports this diagnosis?
a. Elevated antistreptolysin-O (ASO)
b. Decreased hemoglobin
c. Elevated hematocrit
d. Decreased salicylate level
Answer: A
ASO titer indicates history of strptococcal infection, which is a precursor to
rheumatic fever. The other
symptoms are not related to this diagnosis.
Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; pages 104 & 122
27. A client with rheumatic fever is admitted to the nursing unit. The nurses most
important
intervention is to:
a. Prevent spread of rheumatic fever
b. Provide comfort from arthralgia
c. Evaluate for nervous system complications
d. Teach parents about cardiopulmonary resuscitation (CPR)
Answer: B
Among the symptoms of rheumatic fever is migratory polyarthritis. The child will
complain of aching joints. At
the time of diagnosis, the child is not infectious. CPR is not a priority at this time
because the child is
hospitalized.
Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy

E. White; pages 105 & 122

28. A pediatric client with a cyanotic heart defect experiences a cyanotic episode.
Symptoms
consistent with this cyanotic episode would include:
a. Skin is ruddy or mottled prior to cyanosis
b. Decreased heart rate
c. Decreased rate of respirations
d. Lethargy
Answer: A. Skin is ruddy or mottled prior to cyanosis
When pulmonary circulation is impaired, hemoglobin may not br reoxygenated
which leads to the cyanotic
appearance. The respirations and heart rate increase during acyanotic episode and
the child experiences
agitation or irritability.
Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; pages 105 & 122
29. A 2-year-old child is being discharged home and will have palliative surgery for
tetralogy of Fallot
at a later date. The mother wants to know about how much physical activity she can
allow the child.
The nurses best answer is:
a. Allow the child to regulate her activity.
b. Keep her on complete bed rest.
c. Limit her activities to a few hours.
d. Keep the child from crying.
Answer: A
Although a child requiring surgery for tetralogy of Fallot may have a need for
additional services, such as

supplemental oxygen at home, the child should be able to play and move about in
the environment to meet
both physiological and developmental needs.
Source: Prentice Hall, Review and Rationales Series for Nursing, Nursing and Child
Care by: Mary Ann Hogan and Judy
E. White; pages 121 & 123
30. Which of the following is the most common form of childhood cancer?
a. Lymphoma
b. Brain tumors
c. Leukemia
d. Osteosarcoma
Answer: C. Leukemia
Leukemia is the most common type of cancer in children, followed by brain tumors,
lymphoma, and kidney
tumors. Brain tumors are the second most common childhood cancer but they are
the most common form of
solid tumor cancer in childhood. Bone cancers account for 5% with osteosarcoma
being the most common
type.
Source: LRS: The ideal Study Aid Here's Why...Pediatric Nursing 3rd by Muscari p.
358
31. When assessing a child with a cleft palate, the nurse is aware that the child is at
risk for more
frequent episodes of otitis media due to which of the following?
a. Lowered resistance from malnutrition
b. Ineffective functioning of the eustachian tubes
c. Plugging of the Eustachian tubes with food particles
d. Associated congenital defects of the middle ear
Answer: B

Because of the structural defect, children with cleft palate may have ineffective
functioning of their Eustachian
tubes creating frequent bouts of otitis media. Most children with cleft palate remain
well-nourished and
maintain adequate nutrition through the use of proper feeding techniques. Food
particles do not pass through
the cleft palate and into the Eustachian tubes. There is no association between cleft
palate and congenital ear
deformities.
Source: LRS: The ideal Study Aid Here's Why...Pediatric Nursing 3rd by Muscari p.
361
32. Which of the following aspects of psychosocial development is necessary for the
nurse to keep in
mind when providing care for the preschool child?
a. The child can use complex reasoning to think out situations.
b. Fear of body mutilation is a common preschool fear.
c. The child engages in competitive types of play.
d. Immediate gratification is necessary to develop initiative.
Answer: B
During the preschool periods, the child has mastered a sense of autonomy and goes
on to master a sense of
initiative. During this periods, the child commonly experiences more fears than at
any other time. One common
fear is fear of body mutilation, especially associated with painful experiences. The
preschool child uses simple,
not complex reasoning, engages in associative, not competitive, play (interactive
and cooperative play with
sharing), and is able to tolerate longer periods of delayed fortification.
Source: LRS: The ideal Study Aid Here's why...Pediatric Nursing 3rd by Muscari p.
369

33. A 6-week-old infant is brought into the pediatricians office with a history of
frequent vomiting after
feedings and failure to gain weight. The diagnosis of gastroesophageal reflux is
made and discharge
instructions are begun. While planning discharge teaching on feeding techniques
with the parents, the
nurse should include instructions to:
a. Dilute the formula
b. Delay burping to prevent vomiting
c. Change from milk- based formula to soy-based formula
d. Position the infant at a 30- to 45-degree angle after feedings
Answer: D
Small, frequent feedings followed by placing the infant at a 30-to 45-degree angle
has been shown to be
beneficial in treating gastroesophageal reflux. Diluting the formula would not be
recommended because the
infant needs the calories from the full-strength formula. It may be recommended to
thicken the formula with rice
cereal. It is recommended to burp frequently; to delay burping would only increase
the occurrences of reflux.
Gastroesophageal reflux is not related to milk intolerance so changing the formula
would not help the child.
Source: Wongs Essential of Pediatric Nursing, Seventh Edition, by Marilyn J.
Hockenberry et. al, p. 856
34. The nurse is developing a teaching plan for the parents to an infant diagnosed
with hepatitis A.
Which of the following instructions would be included to reduce the risk for
transmission of this
disease?
a. Disinfect all clothing and eating utensils on a daily basis
b. Tell family members to wash their hands frequently

c. Spray the yard to eliminate infected insects

d. Vacuum the carpets and upholstery to rid the house of the infectious host
Answer: B
Hepatitis A is highly contagious and is transmitted primarily through the fecal Doral
route. The virus is
transmitted by direct person-to-person contact or through ingestion of
contaminated food or water. Especially
shellfish growing in contaminated water. The remaining answers are related to other
infectious diseases.
Source: Wongs Essential of Pediatric Nursing, Seventh Edition, by Marilyn J.
Hockenberry et. al p. 867
35. Which of the following signs would the nurse recognize as an indication of
moderate dehydration
in a preschooler?
a. Sunken fontanel
b. Diaphoresis
c. Dry mucous membranes
d. Decreased urine specific gravity
Your answer: C. Dry mucous membranes
Mucous membranes typically appear dry when moderate dehydration is observed.
Other typical findings
associated with moderate dehydration include restlessness with periods of
irritability (especially infants and
young children), rapid pulse, and poor skin turgor, delayed capillary refill, and
decreased urine output. Both
anterior and posterior fontanels are closed on a preschool-aged child. The skin is
usually dry with
decreased elasticity not diaphoretic. Urine specific gravity increases with decreased
urine output associated
with dehydration.

Source: Wongs Essential of Pediatric Nursing, Seventh Edition, by Marilyn J.

Hockenberry et. al, p. 842
36. A mother arrives at clinic with her 6-month-old child. Nurse is assessing the
child, the mother
points to the umbilicus and says: What are I going to do this? When he cries, it
looks like its going to
burst. The nurses best response would be:
a. Its best if you dont lat him cry. Just let him do what he wants.
b. It probably wont rupture unless he gets real mad. I wouldnt worry about him.
c. I know it looks scary, but it really wont burst,
d. Put a binder around it, and that will keep it from bursting when he gets mad.
Answer: C. I know it looks scary, but it really won't burst
It is a common finding that that when the infant with an umbilical hernia crys, it will
protrude. It is not going to
rupture. The family is instructed not to apply tape, straps, or coins to the umbilicus
to reduce the hernia
Source: Wongs Essential of Pediatric Nursing, Seventh Edition, by Marilyn J.
Hockenberry et. al, p. 163
37. The nurse is taking a nursing history from the mother of the child being
admitted with flare-up of
celiac disease. What piece of information would the nurse expect the mother to
report?
a. Steatorrhea
b. Unusually pleasant behavior
c. Increased appetite
d. Soft, formed stools
Answer: A. Steatorrhea
Acute episodes are characterized by bulky, frothy stools, anorexia, and irritability
Source: Wongs Essential of Pediatric nursing, Seventh Edition, by Marilyn J.
Hockenberry et. al, p. 885

38. The nurse is teaching the parents of a child with celiac disease about the dietary
restrictions. The
nurse would explain that the most appropriate diet for their child is:
a. Gluten-free
c. Fat-free
b. Salt-free
d. High-calorie, low fat
Answer: A
Most children who remain on a gluten-free diet remain healthy and free of
symptoms and complications
Source: Wongs Essential of Pediatric Nursing, Seventh Edition, by Marilyn J.
Hockenberry et. al, p. 886
39. Wu Chang is 3 years old and has chicken pox. His mother tells the nurse that
first noticed the
lesions on Monday. Which of the following children were mostly likely to have been
exposed to the
varicella virus during the period of communicability?
a. The day care friends he played with on the previous Thursday
b. The neighbors he played with on the previous Sunday
c. The cousin he visited 14 days ago.
d. The friends who stayed overnight 1 month ago.
Answer. B
The period of communicability for the varicella virus is from 1 day before the
eruption of lesions until all lesions
is crusted over.
a. His day care friend is not the most at risk because he played with them 4 days
prior to eruption of the first
lesions.

c. Wu was in the incubation period and not the communicable period when he
visited his cousins 14 days
previously.
d. The friends who stayed overnight 1 month ago were not a risk.
(Source Pediatric nursing by: NSNA1 page 42 & 43)
40. In assessing Amanda for cardiac anomaly which of the following sets of nursing
actions should
the nurse does first?
a. Weigh her, measure vital signs, and observe her during a feeding session.
b. Measure vital signs, auscultate heart sounds for a murmur, and obtain an
electrocardiogram.
c. Auscultate heart sounds for a murmur and obtain an echocardiogram
d. Obtain an electrocardiogram and prepare the patient for cardiac catheterization.
Answer: A
More information is needed about this infant. It is most appropriate to begin by
gathering noninvasive data first.
B, c, and d. These actions are needed also, but they are not the first ones to take
when gathering data about a
child suspected of having a congenital heart anomaly.
41. Gary, an 8-year-old boy with a history of sickle cell disease, is being admitted to
the medical unit I
a vaso-occlusive crisis. Which of the following nursing actions should the nurse
include when
developing a care plan for this child?
a. Evaluation of acid-base status and administration of sodium bicarbonate as
needed
b. Administration of a high concentration of oxygenation.
c. assessment of level of pain and administration of pain medications are needed
d. Replacement of factor VIII

Answer: C
Vaso-occlusive crises are painful experience.
a. Alterations in acid-base status do not generally occur during vaso-occlusive crisis.
b. Although oxygen may initially help Gary fell better, high concentrations are
generally not necessary.
d. This is not an independent nursing action?
(Source Pediatric Nursing by: NSNAI page 137 & 138)
42. Shantay, age 3 months, is admitted to the pediatric unit with a diagnosis of
Hirschsprungs
disease. In monitoring Shantays status, the most important nursing action is to:
a. weigh her daily.
b. Maintain accurate intake and output records.
c. measure her abdominal girth every 4 hours.
d. obtain serum sodium and potassium levels.
Answer: C
In Hirschsprungs disease, a lack of peristalsis in the lower colon causes
accumulation of intestinal contents,
distention of the bowel, and possible obstruction. The most important nursing action
is ongoing assessment of
abdominal girth.
a. daily weight is important to monitor nutritional status and hydration; however, it
is not the most important
nursing action.
b. Although maintaining an accurate intake and output record is an indicator of
bowel function and hydration
status, it is not the most important action
d. Laboratory values aid in assessing the status of the childs electrolytes; however,
this is not the most
important action.

(Source Pediatric Nursing by: NSNAI page 150 & 151)

43. Baby D has had frequent episodes of green mucus-containing stools. The
nursing assessment
reveals that baby D has dry mucous membranes, poor skin turgor, and an absence
of tearing. Based
on these data, the best nursing diagnosis is.
a. Impaired skin integrity related to irritation caused by frequent loose stools.
b. Fluid volume deficit related to excessive diarrhea.
c. High risk for fluid volume deficit related to diarrhea
d. Altered nutrition, less than body requirements, related to diarrhea.
Answer: B
Based on the data presented, Baby D has a fluid volume deficit related to her
frequent stools.
The data presented do not support a diagnosis of impaired skin integrity.
c. Baby D shows signs of an actual fluid volume deficit.
d. The data presented do not support a diagnosis of altered nutrition.
(Source Pediatric Nursing by NSNAI page 151 & 152)
44. Which of the following methods is the best way to assess fluid in a hospitalized
infant?
a. Make sure that intake and output are equal at the end of each 24-hour period.
b. weigh the infant each day at about the same time.
c. Measure abdominal girth at the same place on the abdomen each day
d. Record the infants blood pressure on a graph so that trends can be easily
identified.
Answer: B
Daily weighing yield the best information about overall fluid status in an infant
a. It is not always possible to accurately measure urine output in infants.
c. This measurement is usually unrelated to fluid status.

d. Blood pressure can be a reflection of fluid status, but it is generally among the
last signs to change in an
infant.
(Source Pediatric Nursing by: NSNAI page 198 & 199)
44. Rich is an 11-year-old boy with a history of hemophilia who comes to the school
nurse after falling
on his arm during recess. Which if the following actions should the nurse take first?
a. Wait until bleeding is localized and then apply warm, moist compresses to that
area.
b. Begin passive range of motion to keep the are mobile unless the pain is too
severe.
c. Immobilize his arm, and raise it above the level of his heart.
d. Administer factor VIII immediately.
Answer: C
Immobilization will prevent further tissue damage, and raising Richs arm above the
level of his heart will
decrease blood flow to the injured area.
Warm compresses increase vasodilatation and will increase any bleeding to the
area.
b. Passive range of motion will cause further tissue damage and may increase
bleeding.
d. This is not an independent nursing action.
(Source Pediatric Nursing by: NSNA page 225 & 228)
45. To prevent further increases in intracranial pressure in a child with elevated
intracranial pressure
that is comatose, the nurse should:
a. Elevate the head of the bed 15-30
b. Suction the airway every hour and as needed.
c. Reposition client from side to side every hour.

d. Maintain a dark room.

Answer: A
The head of the bed should be elevated 15-30 to facilitate venous drainage and
avoid jugular compression.
b. Suctioning is poorly tolerated in a client with increased intracranial pressure and
should not be done on a
regular basis.
c. A client who has increased intracranial pressure and should not be turned from
side to side because this
increases the risk of jugular compression and further rises in intracranial pressure.
d. There is no reason to maintain a dark room. The room should be quite and dim.
(Source Pediatric Nursing by: NSNAI page 225 & 229)
46. The nurse places the young child scheduled for a lumbar puncture in a side-lying
position with
head flexed and knees drawn up to the chest. The mother asks why the child has to
be positioned
this way. The nurse explains the rationale for the positioning is that:
a. Pain is decreased through this comfort measure
b. Injury to the spinal cord is prevented
c. Access to the spinal fluid is facilitated
d. Restraint is needed to prevent unnecessary movement
Answer: C
This position opens the intervertebral spaces and allows easier access to spinal
canal. The position does not
decrease pain or help to restrain the child. All lumbar puncture are done below L4
(the level of the spinal
nerves) so injury to the spinal cord is always avoided.
(Source: Prentice Hall, Reviews and Rationales Series for Nursing, Nursing and Child
Care; pages 153 &156)

47. The nurse is providing discharge instructions for a child who has suffered a head
injury within the
last four hours. The nurse will recognize the need for additional teaching when the
mother states:
a. I will call my doctor immediately if my child starts vomiting.
b. I wont give my child anything stronger than Tylenol for headache.
c. My child should sleep for at least 8 hours without arousing after we get home.
d. I recognize that continued amnesia about the injury is not uncommon.
Answer: C
Discharge instructions will include the necessity of waking the child to check for
neuro status throughout the
night. Vomiting could be a sign of increasing intracranial pressure and should be
reported. Narcotics are not
given after ahead injury. Amnesia for the events surrounding the injury may be
permanent. It is not a sign of
increasing intracranial pressure.
(Source: Prentice Hall, Reviews and Rationales Series for Nursing, Nursing and Child
Care; pages 154 &156)
48. The Glasgow Coma Scale is used to measure neurological functioning. Which of
the following
criteria would indicate the lowest level of functioning for an infant or young child?
a. Confused
b. Irritable, cries
c. Eyes open only to pain
d. No response to painful stimuli
Answer: D
No eye opening, no verbal response, and no motor response are the lowest criteria
on the scale. Confusion is
the criterion applicable only for the older child and adult but is comparable to
irritable and cries for the infant

(which is a 4 out of 5 on the verbal response subscale). Eyes open only to pain is
next to the lowest level on
the eye-opening category.
(Source: Prentice Hall, Reviews and Rationales Series for Nursing, Nursing and Child
Care; pages 154 &156)
49. The nurse is teaching the parents of preschooler information about urinary tract
infection and
means of reducing their recurrence. Which statement by the parents indicates the
need for additional
teaching?
a. I should try to get her to drink a lot of water and juices.
b. I will buy her underwear a little large.
c. Soaking in a bubble bath will reduce mental irritation.
d. If I notice her starting to wet the bed again, I need to have her checked for
another urinary tract
infection.
Answer: C
Bubble baths are irritating to the meatus and increase the incidence of urinary tract
infections.
(Source: Prentice Hall, Reviews and Rationales Series for Nursing, Nursing and Child
Care; pages 160 & 184)
50. When reviewing a urinalysis report of a client with acute glomerulonephritis, the
nurse would
expect to note:
a. Decreased creatinine clearance
b. Decreased specific gravity
c. Proteinuria
d. Decreased erythrocyte sedimentation rate ESR
Answer: C

Proteinuria (presence of protein in urine) is a prime manifestation of acute

glomerulonephritis. The other option
is inconsistent with this diagnosis.
(Source: Prentice Hall, Reviews and Rationales Series for Nursing, Nursing and Child
Care; pages 182 &184)