NUR 231 Exam 4 Actual Exam V2 | NUR 231 Childbearing & Child
Caring Family (NUR231 Exam 4) | Galen College of Nursing
1. A 4-year-old child returns to the unit following a tonsillectomy. Which of the following
assessment findings would be the nurse’s priority concern?
A. Refusal to drink orange juice
B. Frequent swallowing and clearing of the throat
C. Complaints of a sore throat and ear pain
D. The presence of dried dark brown blood on the tongue
Answer: B
Rationale: Frequent swallowing or clearing of the throat is a primary sign of active
bleeding in a post-tonsillectomy patient. This requires immediate notification of the
surgeon to prevent further hemorrhage. Early detection of bleeding is critical for airway
management and hemodynamic stability in pediatric patients.
2. A nurse is providing care for a toddler hospitalized with high fever and suspected bacterial
meningitis. Which of the following actions should the nurse prioritize?
A. Initiate droplet precautions immediately
B. Obtain a stool culture for pathogens
C. Prepare the child for a chest X-ray
D. Administer an oral dose of acetaminophen
Answer: A
Rationale: Bacterial meningitis is highly contagious and droplet precautions must be
implemented immediately to prevent transmission. Fever management is important, but
isolation protocols take precedence to protect other patients and staff. The nurse must
maintain these precautions for at least 24 hours after antibiotics have begun.
3. A 2-year-old is admitted with acute larynogotracheobronchitis (croup). Which of the
following clinical manifestations should the nurse expect to find during the assessment?
A. Productive cough and expiratory wheezing
B. High fever, drooling, and tripod positioning
C. Barky, brassy cough and inspiratory stridor
D. Persistent barking cough that improves with warm air
Answer: C
,Rationale: Croup typically presents with a characteristic barky cough and inspiratory
stridor due to upper airway narrowing. Unlike epiglottitis, croup symptoms often worsen
at night and may improve with exposure to cool mist or cold air. The nurse should focus on
monitoring the respiratory effort and hydration status of the child.
4. The nurse is evaluating a 10-month-old infant for developmental milestones. Which finding
suggests a potential developmental delay?
A. The infant does not have a crude pincer grasp
B. The infant is unable to stand alone
C. The infant is unable to walk with one hand held
D. The infant uses a pincer grasp to pick up small objects
Answer: A
Rationale: By 8 to 10 months, an infant should have developed a crude pincer grasp, and
by 11 to 12 months, a neat pincer grasp. Standing alone and walking with support are
common around 11 to 12 months, so these are not delays at 10 months. Assessing fine
motor skills helps nurses identify neurological or motor development issues early.
5. A nurse is teaching parents of a child with Sickle Cell Anemia about managing a vaso-
occlusive crisis at home. What instruction is most important?
A. Restrict fluid intake to prevent fluid overload
B. Encourage increased fluid intake to maintain hydration
C. Apply cold compresses to painful joints
D. Administer aspirin for pain management
Answer: B
Rationale: Hydration is the most vital intervention to reduce blood viscosity and prevent
further sickling of red blood cells. Cold compresses should be avoided as they cause
vasoconstriction, which can worsen the crisis. Pain management is central, but hydration
directly addresses the underlying cause of the vaso-occlusive event.
6. Which assessment finding in an infant with Tetralogy of Fallot should lead the nurse to
suspect a hypercyanotic (‘tet’) spell?
A. Bradypnea and flushed skin
B. Sudden onset of cyanosis and gasping respirations
C. Bounding peripheral pulses and hypertension
D. Increased urine output and peripheral edema
Answer: B
, Rationale: Hypercyanotic spells are characterized by a sudden increase in cyanosis,
irritability, and respiratory distress. These spells often occur during crying, feeding, or
defecation when oxygen demand increases. The nurse should immediately place the infant
in a knee-chest position to increase systemic vascular resistance.
7. A nurse is caring for a 7-year-old child with Type 1 Diabetes Mellitus. The child is sweating,
shaky, and feels weak after physical education class. What is the priority nursing action?
A. Call the primary healthcare provider immediately
B. Administer 15 grams of fast-acting carbohydrates
C. Give the child an injection of rapid-acting insulin
D. Check the child’s blood glucose level
Answer: D
Rationale: In a clinical setting, checking blood glucose is the first step to confirm
hypoglycemia before treatment. If checking the glucose would delay treatment
significantly, the nurse should treat for hypoglycemia empirically. Following the ‘15-15
rule’ with fast-acting carbs is the standard treatment once the low sugar is verified.
8. A mother brings her 3-year-old to the clinic for a well-child checkup. Which of Erikson’s
developmental stages is most characteristic of this age group?
A. Trust vs. Mistrust
B. Initiative vs. Guilt
C. Autonomy vs. Shame and Doubt
D. Industry vs. Inferiority
Answer: C
Rationale: The toddler stage (ages 1-3) is defined by Erikson as Autonomy vs. Shame and
Doubt. Children this age are learning to do things for themselves and establish
independence. Nurses can support this by offering simple choices, such as which sticker the
child wants after a procedure.
9. The nurse is preparing to administer Digoxin to an infant. Which finding should cause the
nurse to withhold the medication?
A. Apical pulse of 85 beats per minute
B. Apical pulse of 110 beats per minute
C. Potassium level of 4.5 mEq/L
D. The infant ate 2 hours ago
Answer: A
Caring Family (NUR231 Exam 4) | Galen College of Nursing
1. A 4-year-old child returns to the unit following a tonsillectomy. Which of the following
assessment findings would be the nurse’s priority concern?
A. Refusal to drink orange juice
B. Frequent swallowing and clearing of the throat
C. Complaints of a sore throat and ear pain
D. The presence of dried dark brown blood on the tongue
Answer: B
Rationale: Frequent swallowing or clearing of the throat is a primary sign of active
bleeding in a post-tonsillectomy patient. This requires immediate notification of the
surgeon to prevent further hemorrhage. Early detection of bleeding is critical for airway
management and hemodynamic stability in pediatric patients.
2. A nurse is providing care for a toddler hospitalized with high fever and suspected bacterial
meningitis. Which of the following actions should the nurse prioritize?
A. Initiate droplet precautions immediately
B. Obtain a stool culture for pathogens
C. Prepare the child for a chest X-ray
D. Administer an oral dose of acetaminophen
Answer: A
Rationale: Bacterial meningitis is highly contagious and droplet precautions must be
implemented immediately to prevent transmission. Fever management is important, but
isolation protocols take precedence to protect other patients and staff. The nurse must
maintain these precautions for at least 24 hours after antibiotics have begun.
3. A 2-year-old is admitted with acute larynogotracheobronchitis (croup). Which of the
following clinical manifestations should the nurse expect to find during the assessment?
A. Productive cough and expiratory wheezing
B. High fever, drooling, and tripod positioning
C. Barky, brassy cough and inspiratory stridor
D. Persistent barking cough that improves with warm air
Answer: C
,Rationale: Croup typically presents with a characteristic barky cough and inspiratory
stridor due to upper airway narrowing. Unlike epiglottitis, croup symptoms often worsen
at night and may improve with exposure to cool mist or cold air. The nurse should focus on
monitoring the respiratory effort and hydration status of the child.
4. The nurse is evaluating a 10-month-old infant for developmental milestones. Which finding
suggests a potential developmental delay?
A. The infant does not have a crude pincer grasp
B. The infant is unable to stand alone
C. The infant is unable to walk with one hand held
D. The infant uses a pincer grasp to pick up small objects
Answer: A
Rationale: By 8 to 10 months, an infant should have developed a crude pincer grasp, and
by 11 to 12 months, a neat pincer grasp. Standing alone and walking with support are
common around 11 to 12 months, so these are not delays at 10 months. Assessing fine
motor skills helps nurses identify neurological or motor development issues early.
5. A nurse is teaching parents of a child with Sickle Cell Anemia about managing a vaso-
occlusive crisis at home. What instruction is most important?
A. Restrict fluid intake to prevent fluid overload
B. Encourage increased fluid intake to maintain hydration
C. Apply cold compresses to painful joints
D. Administer aspirin for pain management
Answer: B
Rationale: Hydration is the most vital intervention to reduce blood viscosity and prevent
further sickling of red blood cells. Cold compresses should be avoided as they cause
vasoconstriction, which can worsen the crisis. Pain management is central, but hydration
directly addresses the underlying cause of the vaso-occlusive event.
6. Which assessment finding in an infant with Tetralogy of Fallot should lead the nurse to
suspect a hypercyanotic (‘tet’) spell?
A. Bradypnea and flushed skin
B. Sudden onset of cyanosis and gasping respirations
C. Bounding peripheral pulses and hypertension
D. Increased urine output and peripheral edema
Answer: B
, Rationale: Hypercyanotic spells are characterized by a sudden increase in cyanosis,
irritability, and respiratory distress. These spells often occur during crying, feeding, or
defecation when oxygen demand increases. The nurse should immediately place the infant
in a knee-chest position to increase systemic vascular resistance.
7. A nurse is caring for a 7-year-old child with Type 1 Diabetes Mellitus. The child is sweating,
shaky, and feels weak after physical education class. What is the priority nursing action?
A. Call the primary healthcare provider immediately
B. Administer 15 grams of fast-acting carbohydrates
C. Give the child an injection of rapid-acting insulin
D. Check the child’s blood glucose level
Answer: D
Rationale: In a clinical setting, checking blood glucose is the first step to confirm
hypoglycemia before treatment. If checking the glucose would delay treatment
significantly, the nurse should treat for hypoglycemia empirically. Following the ‘15-15
rule’ with fast-acting carbs is the standard treatment once the low sugar is verified.
8. A mother brings her 3-year-old to the clinic for a well-child checkup. Which of Erikson’s
developmental stages is most characteristic of this age group?
A. Trust vs. Mistrust
B. Initiative vs. Guilt
C. Autonomy vs. Shame and Doubt
D. Industry vs. Inferiority
Answer: C
Rationale: The toddler stage (ages 1-3) is defined by Erikson as Autonomy vs. Shame and
Doubt. Children this age are learning to do things for themselves and establish
independence. Nurses can support this by offering simple choices, such as which sticker the
child wants after a procedure.
9. The nurse is preparing to administer Digoxin to an infant. Which finding should cause the
nurse to withhold the medication?
A. Apical pulse of 85 beats per minute
B. Apical pulse of 110 beats per minute
C. Potassium level of 4.5 mEq/L
D. The infant ate 2 hours ago
Answer: A
