Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
Author(s)Linda Anne Silvestri; Angela Silvestri
TEST BANK
Pediatric Nursing — 20 NCLEX-Style Questions
Question 1 — Growth & Development (Infant)
A 9-month-old infant is brought to the clinic by a parent who
reports the infant has not begun pulling to stand and has
limited pincer grasp. Which statement by the nurse is most
appropriate?
A. “This is typical — most infants don’t pull to stand until 15
months.”
B. “At 9 months we expect some pulling to stand and a
developing pincer grasp; let’s do a brief developmental
screen.”
C. “You should stop giving solid foods; they slow motor
development.”
D. “This delay is caused by too much tummy time; reduce it.”
,Answer: B
Rationale — correct (B): At 9 months many infants are
pulling to stand and beginning to develop a crude to refined
pincer grasp. The nurse’s response is evidence-based, non-
alarmist, and triggers an appropriate developmental
screening and possible referral — consistent with family-
centered care and early identification of developmental
delays.
Rationale — incorrect:
• A: Incorrect — pulling to stand by ~9–10 months is
common; stating 15 months is inaccurate and delays
evaluation.
• C: Incorrect — no evidence that solids cause delayed
motor skills; this is not an appropriate intervention.
• D: Incorrect — tummy time supports motor development;
reducing it would not improve milestones.
Question 2 — Respiratory (Bronchiolitis / RSV)
A 6-month-old infant admitted with bronchiolitis has
frequent wheezes, nasal flaring, retractions, and oxygen
saturation (SpO₂) 89% on room air. Which nursing action
takes priority?
A. Administer nebulized albuterol STAT.
B. Provide humidified oxygen to maintain SpO₂ ≥ 92%.
,C. Start oral antibiotics for presumed secondary infection.
D. Position supine with head flat to facilitate comfort.
Answer: B
Rationale — correct (B): Respiratory support and maintaining
adequate oxygenation is the immediate priority in
bronchiolitis. For infants with SpO₂ below target (commonly ≥
90–92% depending on policy), provide supplemental
humidified oxygen and monitoring. This addresses the
immediate safety need (oxygenation) before other
interventions.
Rationale — incorrect:
• A: Incorrect — bronchodilators like albuterol may be tried
selectively but are not universally effective in RSV
bronchiolitis and not the first priority when SpO₂ is low.
• C: Incorrect — routine antibiotics are not indicated for viral
bronchiolitis unless there is proven bacterial
superinfection.
• D: Incorrect — supine with head flat is not ideal if
respiratory distress is present; semi-upright positioning
often aids respiratory effort. Also, safety practice is to
maintain appropriate positioning and airway patency.
(Clinical note: facility protocols may set SpO₂ targets; verify
local policy.)
, Question 3 — Cardiac (Congenital Heart Defect: Tetralogy of
Fallot)
A 4-month-old with tetralogy of Fallot becomes suddenly
cyanotic and irritable while crying. The nurse observes a
period of deepening cyanosis and decreased responsiveness.
What is the best immediate nursing action?
A. Offer a pacifier to calm the infant.
B. Place the infant in a knee-to-chest position (or simulate in
older infant) and administer oxygen.
C. Give morphine IM and hold feeding.
D. Start IV antibiotics and prepare for surgery.
Answer: B
Rationale — correct (B): In a hypercyanotic (“Tet”) spell,
immediate interventions aim to increase systemic vascular
resistance and decrease right-to-left shunt (knee-to-chest
positioning in infants achieves this), provide oxygen, and give
calm measures. These actions rapidly improve oxygenation
and are life-saving.
Rationale — incorrect:
• A: Incorrect — a pacifier may help soothe but is insufficient
in a hypercyanotic episode.
• C: Incorrect — morphine IV may be used in some
protocols, but IM is not appropriate (delayed absorption)
and holding feeding alone is not the primary immediate
action.
Examination
9th Edition
Author(s)Linda Anne Silvestri; Angela Silvestri
TEST BANK
Pediatric Nursing — 20 NCLEX-Style Questions
Question 1 — Growth & Development (Infant)
A 9-month-old infant is brought to the clinic by a parent who
reports the infant has not begun pulling to stand and has
limited pincer grasp. Which statement by the nurse is most
appropriate?
A. “This is typical — most infants don’t pull to stand until 15
months.”
B. “At 9 months we expect some pulling to stand and a
developing pincer grasp; let’s do a brief developmental
screen.”
C. “You should stop giving solid foods; they slow motor
development.”
D. “This delay is caused by too much tummy time; reduce it.”
,Answer: B
Rationale — correct (B): At 9 months many infants are
pulling to stand and beginning to develop a crude to refined
pincer grasp. The nurse’s response is evidence-based, non-
alarmist, and triggers an appropriate developmental
screening and possible referral — consistent with family-
centered care and early identification of developmental
delays.
Rationale — incorrect:
• A: Incorrect — pulling to stand by ~9–10 months is
common; stating 15 months is inaccurate and delays
evaluation.
• C: Incorrect — no evidence that solids cause delayed
motor skills; this is not an appropriate intervention.
• D: Incorrect — tummy time supports motor development;
reducing it would not improve milestones.
Question 2 — Respiratory (Bronchiolitis / RSV)
A 6-month-old infant admitted with bronchiolitis has
frequent wheezes, nasal flaring, retractions, and oxygen
saturation (SpO₂) 89% on room air. Which nursing action
takes priority?
A. Administer nebulized albuterol STAT.
B. Provide humidified oxygen to maintain SpO₂ ≥ 92%.
,C. Start oral antibiotics for presumed secondary infection.
D. Position supine with head flat to facilitate comfort.
Answer: B
Rationale — correct (B): Respiratory support and maintaining
adequate oxygenation is the immediate priority in
bronchiolitis. For infants with SpO₂ below target (commonly ≥
90–92% depending on policy), provide supplemental
humidified oxygen and monitoring. This addresses the
immediate safety need (oxygenation) before other
interventions.
Rationale — incorrect:
• A: Incorrect — bronchodilators like albuterol may be tried
selectively but are not universally effective in RSV
bronchiolitis and not the first priority when SpO₂ is low.
• C: Incorrect — routine antibiotics are not indicated for viral
bronchiolitis unless there is proven bacterial
superinfection.
• D: Incorrect — supine with head flat is not ideal if
respiratory distress is present; semi-upright positioning
often aids respiratory effort. Also, safety practice is to
maintain appropriate positioning and airway patency.
(Clinical note: facility protocols may set SpO₂ targets; verify
local policy.)
, Question 3 — Cardiac (Congenital Heart Defect: Tetralogy of
Fallot)
A 4-month-old with tetralogy of Fallot becomes suddenly
cyanotic and irritable while crying. The nurse observes a
period of deepening cyanosis and decreased responsiveness.
What is the best immediate nursing action?
A. Offer a pacifier to calm the infant.
B. Place the infant in a knee-to-chest position (or simulate in
older infant) and administer oxygen.
C. Give morphine IM and hold feeding.
D. Start IV antibiotics and prepare for surgery.
Answer: B
Rationale — correct (B): In a hypercyanotic (“Tet”) spell,
immediate interventions aim to increase systemic vascular
resistance and decrease right-to-left shunt (knee-to-chest
positioning in infants achieves this), provide oxygen, and give
calm measures. These actions rapidly improve oxygenation
and are life-saving.
Rationale — incorrect:
• A: Incorrect — a pacifier may help soothe but is insufficient
in a hypercyanotic episode.
• C: Incorrect — morphine IV may be used in some
protocols, but IM is not appropriate (delayed absorption)
and holding feeding alone is not the primary immediate
action.
