NR328/NR 328 Final Exam V1 | Pediatric Nursing
Q&A with Rationale | Chamberlain University
1. A nurse is assessing a 3-year-old child for pain using the FLACC scale. The child is crying
steadily, kicking their legs, and is difficult to console. Which score should the nurse
document?
A. 6
B. 3
C. 9
D. 10
Correct Answer: A
Explanation: The FLACC scale evaluates Face, Legs, Activity, Cry, and Consolability, with
each category scored from 0 to 2. In this scenario, steady crying earns 2 points, kicking legs
earns 2 points, and being difficult to console earns 2 points, totaling 6. This tool is
specifically designed for non-verbal children or those who cannot self-report pain
accurately.
2. Which developmental milestone is expected for a 4-month-old infant during a well-child
checkup?
A. Sitting upright without support
B. Using a pincer grasp
,C. Rolling from back to side
D. Creeping on hands and knees
Correct Answer: C
Explanation: A 4-month-old infant is expected to roll from their back to their side and can
typically roll from front to back. Sitting without support usually occurs around 6 to 8
months, while the pincer grasp is a fine motor skill seen at 9 months. Understanding these
milestones is critical for the nurse to identify potential developmental delays early.
3. A nurse is caring for a toddler with suspected epiglottitis. Which action is the priority for
the nurse to take?
A. Obtain a throat culture to identify the pathogen
B. Prepare for immediate endotracheal intubation
C. Visualize the airway using a tongue depressor
D. Place the child in a supine position
Correct Answer: B
Explanation: Epiglottitis is a medical emergency that can lead to sudden, total airway
obstruction. The nurse must never use a tongue depressor or attempt a throat culture as
this can trigger a laryngospasm. Preparation for intubation or tracheostomy is the priority
to ensure airway patency while keeping the child calm in an upright position.
, 4. A 10-year-old child with Type 1 Diabetes Mellitus presents with a blood glucose of 58
mg/dL. Which of the following is the most appropriate initial intervention?
A. Administer 15g of simple carbohydrates like orange juice
B. Give a subcutaneous injection of regular insulin
C. Provide a snack consisting of complex carbohydrates and protein
D. Administer intravenous glucagon immediately
Correct Answer: A
Explanation: Hypoglycemia in a conscious child is managed by the 15/15 rule, starting
with 15 grams of fast-acting simple carbohydrates. After 15 minutes, the blood glucose
should be rechecked to ensure it has risen above 70 mg/dL. Once the level is stable, a
complex carbohydrate and protein snack can be given to maintain the blood sugar level.
5. A nurse is providing teaching to the parents of an infant with Cystic Fibrosis. Which
instruction regarding pancreatic enzyme replacement should be included?
A. Administer the enzymes once daily in the morning
B. Give the enzymes with every meal and snack
C. Crush the enteric-coated beads if the infant cannot swallow them
D. Mix the enzymes with hot formula for better absorption
Correct Answer: B
Q&A with Rationale | Chamberlain University
1. A nurse is assessing a 3-year-old child for pain using the FLACC scale. The child is crying
steadily, kicking their legs, and is difficult to console. Which score should the nurse
document?
A. 6
B. 3
C. 9
D. 10
Correct Answer: A
Explanation: The FLACC scale evaluates Face, Legs, Activity, Cry, and Consolability, with
each category scored from 0 to 2. In this scenario, steady crying earns 2 points, kicking legs
earns 2 points, and being difficult to console earns 2 points, totaling 6. This tool is
specifically designed for non-verbal children or those who cannot self-report pain
accurately.
2. Which developmental milestone is expected for a 4-month-old infant during a well-child
checkup?
A. Sitting upright without support
B. Using a pincer grasp
,C. Rolling from back to side
D. Creeping on hands and knees
Correct Answer: C
Explanation: A 4-month-old infant is expected to roll from their back to their side and can
typically roll from front to back. Sitting without support usually occurs around 6 to 8
months, while the pincer grasp is a fine motor skill seen at 9 months. Understanding these
milestones is critical for the nurse to identify potential developmental delays early.
3. A nurse is caring for a toddler with suspected epiglottitis. Which action is the priority for
the nurse to take?
A. Obtain a throat culture to identify the pathogen
B. Prepare for immediate endotracheal intubation
C. Visualize the airway using a tongue depressor
D. Place the child in a supine position
Correct Answer: B
Explanation: Epiglottitis is a medical emergency that can lead to sudden, total airway
obstruction. The nurse must never use a tongue depressor or attempt a throat culture as
this can trigger a laryngospasm. Preparation for intubation or tracheostomy is the priority
to ensure airway patency while keeping the child calm in an upright position.
, 4. A 10-year-old child with Type 1 Diabetes Mellitus presents with a blood glucose of 58
mg/dL. Which of the following is the most appropriate initial intervention?
A. Administer 15g of simple carbohydrates like orange juice
B. Give a subcutaneous injection of regular insulin
C. Provide a snack consisting of complex carbohydrates and protein
D. Administer intravenous glucagon immediately
Correct Answer: A
Explanation: Hypoglycemia in a conscious child is managed by the 15/15 rule, starting
with 15 grams of fast-acting simple carbohydrates. After 15 minutes, the blood glucose
should be rechecked to ensure it has risen above 70 mg/dL. Once the level is stable, a
complex carbohydrate and protein snack can be given to maintain the blood sugar level.
5. A nurse is providing teaching to the parents of an infant with Cystic Fibrosis. Which
instruction regarding pancreatic enzyme replacement should be included?
A. Administer the enzymes once daily in the morning
B. Give the enzymes with every meal and snack
C. Crush the enteric-coated beads if the infant cannot swallow them
D. Mix the enzymes with hot formula for better absorption
Correct Answer: B
