NUR 254 Exams 4 | Galen College |
Complete Maternal & Pediatric
Nursing Exam
Questions and Ansẉers with
rationales
2026\2027 update
151. A nurse is caring for an infant who just returned from surgical
repair of a cleft lip. Which nursing intervention is the priority in the
immediate postoperative period?
A) Feeding the infant with a spoon
B) Placing the infant in a prone position
C) Using elbow restraints to prevent the infant from touching the
suture line
D) Cleaning the suture line with hydrogen peroxide
AnswerC
Rationale: The priority is to prevent the infant from rubbing or
pulling at the suture line, which could cause dehiscence. Elbow
restraints are used (not wrist restraints, to prevent circulation
issues). The infant should be placed on their back or side, never
prone.
152. A nurse is caring for a child with a ventriculoperitoneal (VP)
shunt. The parents ask what complication is most common. The
nurse should respond:
,A) Hydrocephalus recurrence due to shunt obstruction
B) Infection of the shunt
C) Over-drainage of CSF
D) Seizures
AnswerB
Rationale: Shunt infections are the most common and severe
complication of VP shunts, occurring most often within the first few
months after placement. Obstruction is also common, but infection
is the primary life-threatening complication parents must monitor
for (fever, lethargy, irritability).
153. Which of the following children is at the highest risk for
developing bronchiolitis?
A) A 3-year-old child with asthma
B) A 6-month-old infant born prematurely
C) A 10-year-old child with cystic fibrosis
D) A 5-year-old child with a heart murmur
AnswerB
Rationale: Bronchiolitis, primarily caused by RSV, most commonly
affects infants under 2 years old, with the peak severity in infants
aged 2 to 6 months. Premature infants and those with congenital
heart or lung disease are at the highest risk for severe disease.
154. A nurse is assessing a child with suspected Wilms tumor
(nephroblastoma). What is the priority nursing instruction to the
parents upon admission?
A) "Do not allow your child to eat solid foods."
B) "Do not palpate your child's abdomen."
, C) "Keep your child on strict bed rest."
D) "Monitor your child's urine for protein."
AnswerB
Rationale: Wilms tumor is a highly vascular kidney tumor. Palpating
the abdomen can cause the tumor capsule to rupture, seeding
cancer cells into the abdomen. A sign is often placed on the bed
warning against abdominal palpation.
155. A 2-year-old child is diagnosed with tetralogy of Fallot. The
nurse understands that this condition consists of four defects.
Which of the following is NOT one of the four defects?
A) Ventricular septal defect (VSD)
B) Pulmonary stenosis
C) Right ventricular hypertrophy
D) Patent ductus arteriosus (PDA)
AnswerD
Rationale: Tetralogy of Fallot includes four defects: 1) VSD, 2)
Pulmonary stenosis, 3) Overriding aorta, and 4) Right ventricular
hypertrophy. PDA is a separate congenital heart defect, not part of
Tetralogy of Fallot.
156. A nurse is teaching a parent about caring for a child with
conjunctivitis. Which statement by the parent indicates a need for
further teaching?
A) "I will wash my hands frequently."
B) "I will use separate towels for my child."
C) "I will clean the crusted discharge with a warm, damp cloth."
Complete Maternal & Pediatric
Nursing Exam
Questions and Ansẉers with
rationales
2026\2027 update
151. A nurse is caring for an infant who just returned from surgical
repair of a cleft lip. Which nursing intervention is the priority in the
immediate postoperative period?
A) Feeding the infant with a spoon
B) Placing the infant in a prone position
C) Using elbow restraints to prevent the infant from touching the
suture line
D) Cleaning the suture line with hydrogen peroxide
AnswerC
Rationale: The priority is to prevent the infant from rubbing or
pulling at the suture line, which could cause dehiscence. Elbow
restraints are used (not wrist restraints, to prevent circulation
issues). The infant should be placed on their back or side, never
prone.
152. A nurse is caring for a child with a ventriculoperitoneal (VP)
shunt. The parents ask what complication is most common. The
nurse should respond:
,A) Hydrocephalus recurrence due to shunt obstruction
B) Infection of the shunt
C) Over-drainage of CSF
D) Seizures
AnswerB
Rationale: Shunt infections are the most common and severe
complication of VP shunts, occurring most often within the first few
months after placement. Obstruction is also common, but infection
is the primary life-threatening complication parents must monitor
for (fever, lethargy, irritability).
153. Which of the following children is at the highest risk for
developing bronchiolitis?
A) A 3-year-old child with asthma
B) A 6-month-old infant born prematurely
C) A 10-year-old child with cystic fibrosis
D) A 5-year-old child with a heart murmur
AnswerB
Rationale: Bronchiolitis, primarily caused by RSV, most commonly
affects infants under 2 years old, with the peak severity in infants
aged 2 to 6 months. Premature infants and those with congenital
heart or lung disease are at the highest risk for severe disease.
154. A nurse is assessing a child with suspected Wilms tumor
(nephroblastoma). What is the priority nursing instruction to the
parents upon admission?
A) "Do not allow your child to eat solid foods."
B) "Do not palpate your child's abdomen."
, C) "Keep your child on strict bed rest."
D) "Monitor your child's urine for protein."
AnswerB
Rationale: Wilms tumor is a highly vascular kidney tumor. Palpating
the abdomen can cause the tumor capsule to rupture, seeding
cancer cells into the abdomen. A sign is often placed on the bed
warning against abdominal palpation.
155. A 2-year-old child is diagnosed with tetralogy of Fallot. The
nurse understands that this condition consists of four defects.
Which of the following is NOT one of the four defects?
A) Ventricular septal defect (VSD)
B) Pulmonary stenosis
C) Right ventricular hypertrophy
D) Patent ductus arteriosus (PDA)
AnswerD
Rationale: Tetralogy of Fallot includes four defects: 1) VSD, 2)
Pulmonary stenosis, 3) Overriding aorta, and 4) Right ventricular
hypertrophy. PDA is a separate congenital heart defect, not part of
Tetralogy of Fallot.
156. A nurse is teaching a parent about caring for a child with
conjunctivitis. Which statement by the parent indicates a need for
further teaching?
A) "I will wash my hands frequently."
B) "I will use separate towels for my child."
C) "I will clean the crusted discharge with a warm, damp cloth."
