NUR231 Exam 4 V2 | NUR 231
Childbearing & Child Caring Family Exam
Q&A | Galen College of Nursing
1. A 4-year-old child is admitted with suspected bacterial meningitis. Which clinical
manifestation should the nurse prioritize for immediate assessment?
A. Bulging fontanels
B. Positive Kernig sign
C. Nuchal rigidity
D. Maculopapular rash
Answer: C
Rationale: Nuchal rigidity is a hallmark sign of meningeal irritation in older children.
While Kernig sign is also relevant, nuchal rigidity often presents earlier and is a critical
physical finding. Bulging fontanels are only seen in infants before the sutures close.
2. A nurse is calculating the maintenance fluid rate for a child weighing 22 kg. According to
the Holliday-Segar formula, what is the hourly rate in mL/hr?
A. 60 mL/hr
B. 70 mL/hr
C. 55 mL/hr
,D. 64 mL/hr
Answer: D
Rationale: For the first 10 kg: 1000 mL. For the next 10 kg (up to 20 kg): 500 mL. For the
remaining 2 kg: 20 mL/kg = 40 mL. Total 24-hour fluid = 1540 mL. =
approximately 64 mL/hr.
3. Which pain assessment tool is most appropriate for a 2-month-old infant post-surgery?
A. FACES scale
B. Visual Analog Scale (VAS)
C. Numeric Rating Scale
D. FLACC scale
Answer: D
Rationale: The FLACC scale (Face, Legs, Activity, Cry, Consolability) is an observational
tool used for infants and non-verbal children to assess pain intensity based on behavioral
cues.
4. A nurse notices a circular burn on a toddler’s buttocks during a routine exam. What is the
priority nursing action?
A. Apply antibiotic ointment to the burn
B. Ask the parents if they use cigarettes
C. Report the finding to the proper authorities
, D. Document the size and location of the burn
Answer: C
Rationale: Circular burns are highly suspicious for cigarette burns, a form of physical
abuse. Nurses are mandated reporters and must report any suspicion of child abuse
immediately to child protective services or designated authorities.
5. A child is diagnosed with Autism Spectrum Disorder (ASD). Which intervention should the
nurse include in the plan of care to promote safety?
A. Maintain a consistent daily routine and schedule
B. Provide a high-stimulation environment to encourage interaction
C. Allow the child to explore the hospital unit freely
D. Use complex, multi-step instructions for tasks
Answer: A
Rationale: Children with ASD often thrive on routine and predictability. Minimizing
changes in their schedule helps reduce anxiety and behavioral outbursts, promoting a safer
environment.
6. A 10-month-old infant is admitted with severe dehydration due to gastroenteritis. Which
finding would indicate that the treatment is effective?
A. Specific gravity of 1.035
B. Capillary refill of 4 seconds
Childbearing & Child Caring Family Exam
Q&A | Galen College of Nursing
1. A 4-year-old child is admitted with suspected bacterial meningitis. Which clinical
manifestation should the nurse prioritize for immediate assessment?
A. Bulging fontanels
B. Positive Kernig sign
C. Nuchal rigidity
D. Maculopapular rash
Answer: C
Rationale: Nuchal rigidity is a hallmark sign of meningeal irritation in older children.
While Kernig sign is also relevant, nuchal rigidity often presents earlier and is a critical
physical finding. Bulging fontanels are only seen in infants before the sutures close.
2. A nurse is calculating the maintenance fluid rate for a child weighing 22 kg. According to
the Holliday-Segar formula, what is the hourly rate in mL/hr?
A. 60 mL/hr
B. 70 mL/hr
C. 55 mL/hr
,D. 64 mL/hr
Answer: D
Rationale: For the first 10 kg: 1000 mL. For the next 10 kg (up to 20 kg): 500 mL. For the
remaining 2 kg: 20 mL/kg = 40 mL. Total 24-hour fluid = 1540 mL. =
approximately 64 mL/hr.
3. Which pain assessment tool is most appropriate for a 2-month-old infant post-surgery?
A. FACES scale
B. Visual Analog Scale (VAS)
C. Numeric Rating Scale
D. FLACC scale
Answer: D
Rationale: The FLACC scale (Face, Legs, Activity, Cry, Consolability) is an observational
tool used for infants and non-verbal children to assess pain intensity based on behavioral
cues.
4. A nurse notices a circular burn on a toddler’s buttocks during a routine exam. What is the
priority nursing action?
A. Apply antibiotic ointment to the burn
B. Ask the parents if they use cigarettes
C. Report the finding to the proper authorities
, D. Document the size and location of the burn
Answer: C
Rationale: Circular burns are highly suspicious for cigarette burns, a form of physical
abuse. Nurses are mandated reporters and must report any suspicion of child abuse
immediately to child protective services or designated authorities.
5. A child is diagnosed with Autism Spectrum Disorder (ASD). Which intervention should the
nurse include in the plan of care to promote safety?
A. Maintain a consistent daily routine and schedule
B. Provide a high-stimulation environment to encourage interaction
C. Allow the child to explore the hospital unit freely
D. Use complex, multi-step instructions for tasks
Answer: A
Rationale: Children with ASD often thrive on routine and predictability. Minimizing
changes in their schedule helps reduce anxiety and behavioral outbursts, promoting a safer
environment.
6. A 10-month-old infant is admitted with severe dehydration due to gastroenteritis. Which
finding would indicate that the treatment is effective?
A. Specific gravity of 1.035
B. Capillary refill of 4 seconds
