NSG 434 Final Exam V2 | NSG 434 Nursing Care of
the Childrearing Family | Actual Q&A with
Rationale (NSG434 Final Exam) | Grand Canyon
University
1. A nurse is assessing a 9-month-old infant during a well-child visit. According to Erikson’s
stages of psychosocial development, which task should the nurse identify as the primary
focus for this age group?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Initiative vs. Guilt
D. Industry vs. Inferiority
Correct Answer: A
Explanation: The primary psychosocial task for an infant from birth to 1 year is Trust
vs. Mistrust. The infant learns to trust that their basic needs for nourishment and affection
will be met by caregivers. If these needs are not consistently met, the infant may develop a
sense of mistrust in others and the environment.
2. A nurse is evaluating an infant diagnosed with Tetralogy of Fallot. Which clinical
manifestations should the nurse expect to observe? Select all that apply.
A. Cyanosis that increases with crying
B. Systolic murmur
,C. Clubbing of the fingers and toes
D. Hypercyanotic (Tet) spells
E. Polycythemia
F. Bounding peripheral pulses
Correct Answer: A, B, C, D, E
Explanation: Tetralogy of Fallot consists of four defects: pulmonary stenosis, VSD,
overriding aorta, and right ventricular hypertrophy. Common signs include cyanosis due to
right-to-left shunting and a systolic murmur. Chronic hypoxia leads to clubbing and
polycythemia, while Tet spells occur during periods of agitation. Bounding pulses are more
characteristic of a Patent Ductus Arteriosus (PDA).
3. A 3-year-old child is brought to the emergency department with a sudden onset of high
fever, drooling, and an anxious appearance. The child is sitting in a ‘tripod’ position. What is
the priority nursing action?
A. Examine the throat using a tongue depressor
B. Obtain a throat culture for Streptococcus
C. Keep the child calm and avoid invasive procedures
D. Administer an oral antipyretic immediately
Correct Answer: C
,Explanation: These symptoms are classic signs of epiglottitis, which is a medical
emergency. Examining the throat with a tongue depressor can cause complete airway
obstruction due to laryngospasm. The priority is to keep the child calm and notify the
provider for immediate airway management.
4. The nurse is providing education to the parents of a child newly diagnosed with Cystic
Fibrosis (CF). Which information regarding the pathophysiology of the disease should be
included?
A. CF is an autosomal dominant disorder affecting endocrine glands.
B. The condition primarily affects the cardiovascular system and heart valves.
C. Increased mucus viscosity leads to obstruction in the respiratory and GI tracts.
D. Affected children have decreased sodium and chloride levels in their sweat.
Correct Answer: C
Explanation: Cystic Fibrosis is an autosomal recessive disorder characterized by a
mutation in the CFTR protein. This leads to the production of thick, tenacious mucus that
obstructs the bronchioles and pancreatic ducts. The diagnosis is confirmed via a sweat
chloride test where levels are elevated, not decreased.
5. A nurse is caring for a newborn suspected of having Hirschsprung disease. Which
assessment finding is most suggestive of this condition?
A. Currant jelly-like stools
B. Projectile vomiting containing bile
, C. Failure to pass meconium within the first 24 to 48 hours
D. Palpable olive-shaped mass in the epigastrium
Correct Answer: C
Explanation: Hirschsprung disease involves a lack of ganglion cells in the distal colon,
preventing peristalsis. The cardinal sign in neonates is the failure to pass meconium within
the first 48 hours of life. Other symptoms include abdominal distention and ribbon-like,
foul-smelling stools.
6. A 4-week-old infant is admitted for suspected hypertrophic pyloric stenosis. Which finding
should the nurse anticipate during the physical examination?
A. Sausage-shaped mass in the upper right quadrant
B. Right-sided abdominal mass that feels like an olive
C. Tender, board-like abdomen
D. Visible peristaltic waves from right to left
Correct Answer: B
Explanation: Pyloric stenosis is characterized by hypertrophy of the pyloric sphincter,
leading to obstruction. An olive-shaped mass is typically palpable in the epigastrium just to
the right of the midline. Projectile, non-bilious vomiting is another hallmark sign of this
condition.
the Childrearing Family | Actual Q&A with
Rationale (NSG434 Final Exam) | Grand Canyon
University
1. A nurse is assessing a 9-month-old infant during a well-child visit. According to Erikson’s
stages of psychosocial development, which task should the nurse identify as the primary
focus for this age group?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Initiative vs. Guilt
D. Industry vs. Inferiority
Correct Answer: A
Explanation: The primary psychosocial task for an infant from birth to 1 year is Trust
vs. Mistrust. The infant learns to trust that their basic needs for nourishment and affection
will be met by caregivers. If these needs are not consistently met, the infant may develop a
sense of mistrust in others and the environment.
2. A nurse is evaluating an infant diagnosed with Tetralogy of Fallot. Which clinical
manifestations should the nurse expect to observe? Select all that apply.
A. Cyanosis that increases with crying
B. Systolic murmur
,C. Clubbing of the fingers and toes
D. Hypercyanotic (Tet) spells
E. Polycythemia
F. Bounding peripheral pulses
Correct Answer: A, B, C, D, E
Explanation: Tetralogy of Fallot consists of four defects: pulmonary stenosis, VSD,
overriding aorta, and right ventricular hypertrophy. Common signs include cyanosis due to
right-to-left shunting and a systolic murmur. Chronic hypoxia leads to clubbing and
polycythemia, while Tet spells occur during periods of agitation. Bounding pulses are more
characteristic of a Patent Ductus Arteriosus (PDA).
3. A 3-year-old child is brought to the emergency department with a sudden onset of high
fever, drooling, and an anxious appearance. The child is sitting in a ‘tripod’ position. What is
the priority nursing action?
A. Examine the throat using a tongue depressor
B. Obtain a throat culture for Streptococcus
C. Keep the child calm and avoid invasive procedures
D. Administer an oral antipyretic immediately
Correct Answer: C
,Explanation: These symptoms are classic signs of epiglottitis, which is a medical
emergency. Examining the throat with a tongue depressor can cause complete airway
obstruction due to laryngospasm. The priority is to keep the child calm and notify the
provider for immediate airway management.
4. The nurse is providing education to the parents of a child newly diagnosed with Cystic
Fibrosis (CF). Which information regarding the pathophysiology of the disease should be
included?
A. CF is an autosomal dominant disorder affecting endocrine glands.
B. The condition primarily affects the cardiovascular system and heart valves.
C. Increased mucus viscosity leads to obstruction in the respiratory and GI tracts.
D. Affected children have decreased sodium and chloride levels in their sweat.
Correct Answer: C
Explanation: Cystic Fibrosis is an autosomal recessive disorder characterized by a
mutation in the CFTR protein. This leads to the production of thick, tenacious mucus that
obstructs the bronchioles and pancreatic ducts. The diagnosis is confirmed via a sweat
chloride test where levels are elevated, not decreased.
5. A nurse is caring for a newborn suspected of having Hirschsprung disease. Which
assessment finding is most suggestive of this condition?
A. Currant jelly-like stools
B. Projectile vomiting containing bile
, C. Failure to pass meconium within the first 24 to 48 hours
D. Palpable olive-shaped mass in the epigastrium
Correct Answer: C
Explanation: Hirschsprung disease involves a lack of ganglion cells in the distal colon,
preventing peristalsis. The cardinal sign in neonates is the failure to pass meconium within
the first 48 hours of life. Other symptoms include abdominal distention and ribbon-like,
foul-smelling stools.
6. A 4-week-old infant is admitted for suspected hypertrophic pyloric stenosis. Which finding
should the nurse anticipate during the physical examination?
A. Sausage-shaped mass in the upper right quadrant
B. Right-sided abdominal mass that feels like an olive
C. Tender, board-like abdomen
D. Visible peristaltic waves from right to left
Correct Answer: B
Explanation: Pyloric stenosis is characterized by hypertrophy of the pyloric sphincter,
leading to obstruction. An olive-shaped mass is typically palpable in the epigastrium just to
the right of the midline. Projectile, non-bilious vomiting is another hallmark sign of this
condition.
