Detailed Answer Key
Pediatric February
1. A nurse is collecting data from a 6-year-old child at a well-child visit. Which of the following statements by the child's
parent should the nurse report to the provider?
A. "The teacher says my child has to squint to see the board."
Rationale: Squinting is a manifestation of strabismus, which must be diagnosed early in order to prevent
vision loss.
B. "My child has recently lost both front top teeth."
Rationale: Children of this age begin to lose their deciduous teeth to accommodate the emergence of their
permanent teeth.
C. "My child often cheats when we play board games."
Rationale: Children of this age often cheat to win at games because they find it difficult to lose. This
behavior should disappear as the child matures.
D. "Sometimes my child has temper tantrums."
Rationale: Children of this age do have occasional temper tantrums. The nurse should provide the parent
with guidance on how to react to the tantrum and ensure the child is not causing self-harm.
2. A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the
following actions should the nurse take?
A. Perform a neurovascular check of the lower extremities.
Rationale: The client is at risk for compartment syndrome following the application of a cast because the
extremity can continue to swell inside the cast resulting in obstruction to circulation. Therefore,
the nurse should perform a neurovascular check following cast application to check circulation,
motion, and sensation of the lower extremities.
B. Keep the client's leg in a dependent position.
Rationale: The nurse should keep the client's leg elevated to promote venous return and minimize swelling.
C. Discourage the client from ambulating.
Rationale: After the cast dries, the nurse should assist the client to ambulate using crutches to promote
general circulation and prevent complications of immobility.
D. Use a hair dryer on a hot setting to dry the cast.
Rationale: The nurse should not expose the cast to heat, such as from a dryer or a fan, because heat
conduction can result in skin burns under the cast.
3. A nurse is caring for a 4-year-old child who refuses to take his medication because of the bad taste. Which of the
following strategies should the nurse use to elicit the child's cooperation?
Created on:02/16/2022 Page 1
, Detailed Answer Key
Pediatric February
A. Offer the child an ice pop prior to administering the medication.
Rationale: Giving the child an ice pop prior to administering the medication will help numb the tongue. This
technique also helps to alleviate the bad taste, making it easier for the child to take the
medication orally.
B. Tell the child the medicine tastes like candy.
Rationale: This is not an appropriate action for the nurse to take. Telling the child that medicine tastes like
candy can create the misconception that medicine is candy, which increases the risk of
accidental poisoning.
C. Hide the medication in apple slices.
Rationale: This is not an appropriate action for the nurse to take. The child will likely taste the hidden
medication and might not trust the nurse in the future. The experience could also cause the child
to refuse apples in the future, an essential food item.
D. Inform the child that if he does not take the medication he will need a shot.
Rationale: This is not an appropriate action for the nurse to take. Threatening a child with painful
medication alternatives decreases the trust the child has with the nurse.
4. A nurse is collecting data from an infant who has otitis media. The nurse should expect which of the following
findings?
A. Tugging on the affected ear lobe
Rationale: Otitis media is a middle ear infection that causes fever and pain and can be indicated by the
infant tugging at the affected ear.
B. Bluish-green discharge from the ear canal
Rationale: Drainage is not an expected finding of otitis media, unless the tympanic membrane ruptures. If
so, the drainage associated with otitis media is typically purulent. A bluish-green or gray
discharge occurs with otitis externa.
C. Increase in appetite
Rationale: An infant who has otitis media will have a loss of appetite due to pain that occurs in the ear from
moving the jaw.
D. Erythema and edema of the affected auricle
Rationale: Erythema and edema of the affected ear are associated with trauma to the external ear or otitis
externa.
5. A nurse is reinforcing teaching with a parent of a 1-month-old-infant who is to undergo the initial surgery to treat
Hirschsprung's disease. Which of the following statements should indicate to the nurse that the parent understands
the goal of the surgery?
Created on:02/16/2022 Page 2
, Detailed Answer Key
Pediatric February
A. "I'm glad that the ostomy is only temporary."
Rationale: A child who has Hirschsprung's disease is missing ganglion cells in a portion of the intestine.
The disease usually requires two surgical procedures. The first results in the creation of an
ostomy, which relieves the obstructed area and allows the bowel distal to the ostomy to rest.
B. "I'm glad my child will have normal bowel movements now."
Rationale: The child will usually have the second surgery at 12 to 18 months of age. The child will not have
normal bowel function until after the bowel repair that occurs during the second surgery.
C. "I want to learn how to use the feeding tube as soon as possible."
Rationale: A child who has Hirschsprung's disease does not typically require a feeding tube
postoperatively.
D. "The operation will straighten out the kink in the intestine."
Rationale: The surgery will remove the portion of the bowel that is not functioning correctly.
6. A nurse is reviewing the medical record of an adolescent and notes a calcium level of 11.4 mEq/L. Which of the
following findings should the nurse expect?
A. Diarrhea
Rationale: The nurse should expect a client who has an elevated calcium level to have constipation.
B. Muscle hypotonicity
Rationale: The nurse should expect a client who has an elevated calcium level to have muscle hypotonicity.
C. Tachycardia
Rationale: The nurse should expect a client who has an elevated calcium level to have bradycardia, which
can lead to cardiac arrest.
D. Positive Chvostek's sign
Rationale: The nurse should expect a client who has a decreased calcium level to have a positive Chvostek
sign and tetany.
7. A nurse is planning care for a 4-year-old child who has been admitted to the hospital. Which of the following toys
should the nurse plan to provide the child?
A. Modeling clay
Rationale: Preschool-age children enjoy molding clay with their fingers. This activity provides an
opportunity for creativity and entertainment, as well as a chance for fine motor development.
B. Brightly-colored mobile
Rationale:
Created on:02/16/2022 Page 3
, Detailed Answer Key
Pediatric February
A brightly-colored mobile is appropriate for a very young infant. It does not meet the activity
needs of a pre-school age child.
C. 100-piece jigsaw puzzle
Rationale: A 100-piece jigsaw puzzle is too difficult for a pre-school age child and will lead to frustration,
rather than providing entertainment for the child
D. Checkerboard and checkers
Rationale: A checkerboard and checkers are appropriate for a school-age child.
8. A nurse is caring for an infant who is 1 day postoperative following surgical repair of a cleft lip. Which of the
following actions should the nurse take?
A. Apply an antibiotic ointment to the suture site.
Rationale: The nurse should apply an antibiotic ointment to the suture site to help prevent a postoperative
infection.
B. Clear oral secretions using a bulb syringe.
Rationale: Suctioning in the infant's mouth can cause suture damage.
C. Feed the infant using a spoon.
Rationale: The nurse should feed the infant with a syringe or bottle or allow the infant to breastfeed. Placing
objects, such as a spoon, in the infant's mouth can cause suture damage.
D. Position the infant on her abdomen.
Rationale: Positioning the infant on her abdomen can cause suture damage.
9. A nurse is reinforcing discharge instructions with a parent of a child who has cystic fibrosis. Which of the following
statements by the parent indicates an understanding of the teaching?
A. "I will make sure my child washes her hands before eating."
Rationale: Clients who have cystic fibrosis are at high risk for infection and should use good hand washing
techniques before eating.
B. "I will restrict the amount of salt in my child's meals."
Rationale: Cystic fibrosis does not cause a child's sodium requirements to decrease. Adequate sodium
intake is required for electrolyte balance.
C. "I will put my child in daycare to ensure that she socializes with other children."
Rationale: Clients who have cystic fibrosis are at high risk for infection. The parent should avoid daycare
settings because of the high risks that the exposure to illnesses has.
Created on:02/16/2022 Page 4
Pediatric February
1. A nurse is collecting data from a 6-year-old child at a well-child visit. Which of the following statements by the child's
parent should the nurse report to the provider?
A. "The teacher says my child has to squint to see the board."
Rationale: Squinting is a manifestation of strabismus, which must be diagnosed early in order to prevent
vision loss.
B. "My child has recently lost both front top teeth."
Rationale: Children of this age begin to lose their deciduous teeth to accommodate the emergence of their
permanent teeth.
C. "My child often cheats when we play board games."
Rationale: Children of this age often cheat to win at games because they find it difficult to lose. This
behavior should disappear as the child matures.
D. "Sometimes my child has temper tantrums."
Rationale: Children of this age do have occasional temper tantrums. The nurse should provide the parent
with guidance on how to react to the tantrum and ensure the child is not causing self-harm.
2. A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the
following actions should the nurse take?
A. Perform a neurovascular check of the lower extremities.
Rationale: The client is at risk for compartment syndrome following the application of a cast because the
extremity can continue to swell inside the cast resulting in obstruction to circulation. Therefore,
the nurse should perform a neurovascular check following cast application to check circulation,
motion, and sensation of the lower extremities.
B. Keep the client's leg in a dependent position.
Rationale: The nurse should keep the client's leg elevated to promote venous return and minimize swelling.
C. Discourage the client from ambulating.
Rationale: After the cast dries, the nurse should assist the client to ambulate using crutches to promote
general circulation and prevent complications of immobility.
D. Use a hair dryer on a hot setting to dry the cast.
Rationale: The nurse should not expose the cast to heat, such as from a dryer or a fan, because heat
conduction can result in skin burns under the cast.
3. A nurse is caring for a 4-year-old child who refuses to take his medication because of the bad taste. Which of the
following strategies should the nurse use to elicit the child's cooperation?
Created on:02/16/2022 Page 1
, Detailed Answer Key
Pediatric February
A. Offer the child an ice pop prior to administering the medication.
Rationale: Giving the child an ice pop prior to administering the medication will help numb the tongue. This
technique also helps to alleviate the bad taste, making it easier for the child to take the
medication orally.
B. Tell the child the medicine tastes like candy.
Rationale: This is not an appropriate action for the nurse to take. Telling the child that medicine tastes like
candy can create the misconception that medicine is candy, which increases the risk of
accidental poisoning.
C. Hide the medication in apple slices.
Rationale: This is not an appropriate action for the nurse to take. The child will likely taste the hidden
medication and might not trust the nurse in the future. The experience could also cause the child
to refuse apples in the future, an essential food item.
D. Inform the child that if he does not take the medication he will need a shot.
Rationale: This is not an appropriate action for the nurse to take. Threatening a child with painful
medication alternatives decreases the trust the child has with the nurse.
4. A nurse is collecting data from an infant who has otitis media. The nurse should expect which of the following
findings?
A. Tugging on the affected ear lobe
Rationale: Otitis media is a middle ear infection that causes fever and pain and can be indicated by the
infant tugging at the affected ear.
B. Bluish-green discharge from the ear canal
Rationale: Drainage is not an expected finding of otitis media, unless the tympanic membrane ruptures. If
so, the drainage associated with otitis media is typically purulent. A bluish-green or gray
discharge occurs with otitis externa.
C. Increase in appetite
Rationale: An infant who has otitis media will have a loss of appetite due to pain that occurs in the ear from
moving the jaw.
D. Erythema and edema of the affected auricle
Rationale: Erythema and edema of the affected ear are associated with trauma to the external ear or otitis
externa.
5. A nurse is reinforcing teaching with a parent of a 1-month-old-infant who is to undergo the initial surgery to treat
Hirschsprung's disease. Which of the following statements should indicate to the nurse that the parent understands
the goal of the surgery?
Created on:02/16/2022 Page 2
, Detailed Answer Key
Pediatric February
A. "I'm glad that the ostomy is only temporary."
Rationale: A child who has Hirschsprung's disease is missing ganglion cells in a portion of the intestine.
The disease usually requires two surgical procedures. The first results in the creation of an
ostomy, which relieves the obstructed area and allows the bowel distal to the ostomy to rest.
B. "I'm glad my child will have normal bowel movements now."
Rationale: The child will usually have the second surgery at 12 to 18 months of age. The child will not have
normal bowel function until after the bowel repair that occurs during the second surgery.
C. "I want to learn how to use the feeding tube as soon as possible."
Rationale: A child who has Hirschsprung's disease does not typically require a feeding tube
postoperatively.
D. "The operation will straighten out the kink in the intestine."
Rationale: The surgery will remove the portion of the bowel that is not functioning correctly.
6. A nurse is reviewing the medical record of an adolescent and notes a calcium level of 11.4 mEq/L. Which of the
following findings should the nurse expect?
A. Diarrhea
Rationale: The nurse should expect a client who has an elevated calcium level to have constipation.
B. Muscle hypotonicity
Rationale: The nurse should expect a client who has an elevated calcium level to have muscle hypotonicity.
C. Tachycardia
Rationale: The nurse should expect a client who has an elevated calcium level to have bradycardia, which
can lead to cardiac arrest.
D. Positive Chvostek's sign
Rationale: The nurse should expect a client who has a decreased calcium level to have a positive Chvostek
sign and tetany.
7. A nurse is planning care for a 4-year-old child who has been admitted to the hospital. Which of the following toys
should the nurse plan to provide the child?
A. Modeling clay
Rationale: Preschool-age children enjoy molding clay with their fingers. This activity provides an
opportunity for creativity and entertainment, as well as a chance for fine motor development.
B. Brightly-colored mobile
Rationale:
Created on:02/16/2022 Page 3
, Detailed Answer Key
Pediatric February
A brightly-colored mobile is appropriate for a very young infant. It does not meet the activity
needs of a pre-school age child.
C. 100-piece jigsaw puzzle
Rationale: A 100-piece jigsaw puzzle is too difficult for a pre-school age child and will lead to frustration,
rather than providing entertainment for the child
D. Checkerboard and checkers
Rationale: A checkerboard and checkers are appropriate for a school-age child.
8. A nurse is caring for an infant who is 1 day postoperative following surgical repair of a cleft lip. Which of the
following actions should the nurse take?
A. Apply an antibiotic ointment to the suture site.
Rationale: The nurse should apply an antibiotic ointment to the suture site to help prevent a postoperative
infection.
B. Clear oral secretions using a bulb syringe.
Rationale: Suctioning in the infant's mouth can cause suture damage.
C. Feed the infant using a spoon.
Rationale: The nurse should feed the infant with a syringe or bottle or allow the infant to breastfeed. Placing
objects, such as a spoon, in the infant's mouth can cause suture damage.
D. Position the infant on her abdomen.
Rationale: Positioning the infant on her abdomen can cause suture damage.
9. A nurse is reinforcing discharge instructions with a parent of a child who has cystic fibrosis. Which of the following
statements by the parent indicates an understanding of the teaching?
A. "I will make sure my child washes her hands before eating."
Rationale: Clients who have cystic fibrosis are at high risk for infection and should use good hand washing
techniques before eating.
B. "I will restrict the amount of salt in my child's meals."
Rationale: Cystic fibrosis does not cause a child's sodium requirements to decrease. Adequate sodium
intake is required for electrolyte balance.
C. "I will put my child in daycare to ensure that she socializes with other children."
Rationale: Clients who have cystic fibrosis are at high risk for infection. The parent should avoid daycare
settings because of the high risks that the exposure to illnesses has.
Created on:02/16/2022 Page 4
