NSG3600 Exam 3 V1 | NSG 3600 Nursing
Practice – Children’s Health Exam Q&A |
Galen College of Nursing
1. A 4-month-old infant with Tetralogy of Fallot begins to cry and suddenly becomes cyanotic
with rapid breathing. Which action should the nurse take first?
A. Administer high-flow oxygen via mask
B. Assess the infant’s apical pulse and blood pressure
C. Prepare for immediate administration of morphine
D. Place the infant in the knee-chest position
Answer: D
Rationale: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt in Tetralogy of Fallot. This is the primary emergency
intervention for a ‘tet spell’ or hypercyanotic episode. Following this, oxygen and morphine
may be administered to further stabilize the infant.
2. The nurse is preparing to administer Digoxin to an 8-month-old infant. The nurse should
withhold the dose and notify the provider if the apical heart rate is below what threshold?
A. 110 beats per minute
B. 60 beats per minute
C. 70 beats per minute
,D. 90 beats per minute
Answer: D
Rationale: In infants, Digoxin is typically withheld if the apical pulse is less than 90 beats
per minute to prevent bradycardia and toxicity. For older children, the cutoff is usually 70
beats per minute, and for adults, it is 60. Accurate heart rate assessment is critical for safe
medication administration in pediatric cardiology.
3. A child is admitted with a diagnosis of Type 1 Diabetes Mellitus and is experiencing
Kussmaul respirations. The nurse understands this breathing pattern is an attempt to:
A. Increase oxygen saturation due to respiratory distress
B. Compensate for metabolic acidosis by blowing off CO2
C. Compensate for respiratory alkalosis
D. Reduce blood glucose levels through exhalation
Answer: B
Rationale: Kussmaul respirations are deep, rapid breaths that occur during Diabetic
Ketoacidosis (DKA). This pattern is a compensatory mechanism for metabolic acidosis, as
the body tries to eliminate excess carbon dioxide (an acid) to raise the blood pH. This
finding indicates a severe state of metabolic imbalance requiring immediate intervention.
4. Which developmental finding is most characteristic of a 3-year-old child diagnosed with
Autism Spectrum Disorder (ASD)?
A. Preference for imaginative play with peers
, B. Strong desire for physical touch and affection
C. Advanced language skills for their age group
D. Lack of eye contact and repetitive behaviors
Answer: D
Rationale: Children with Autism Spectrum Disorder often exhibit impaired social
interaction, which manifests as a lack of eye contact or difficulty with verbal and non-
verbal communication. Repetitive behaviors or a strict adherence to routines are also
hallmark signs of the disorder. Early identification of these symptoms is crucial for
initiating specialized developmental therapies.
5. A nurse is teaching the parents of a child with a new diagnosis of a seizure disorder. Which
instruction is most important for safety during a seizure?
A. Insert a padded tongue blade into the child’s mouth
B. Restrain the child’s limbs to prevent injury
C. Turn the child onto their side to maintain an airway
D. Administer oral seizure medication immediately
Answer: C
Rationale: During a seizure, the primary goal is to maintain a patent airway and prevent
aspiration, which is achieved by turning the child to their side. Restraining the child or
placing objects in the mouth can cause injury to the teeth, jaw, or musculoskeletal system.
Practice – Children’s Health Exam Q&A |
Galen College of Nursing
1. A 4-month-old infant with Tetralogy of Fallot begins to cry and suddenly becomes cyanotic
with rapid breathing. Which action should the nurse take first?
A. Administer high-flow oxygen via mask
B. Assess the infant’s apical pulse and blood pressure
C. Prepare for immediate administration of morphine
D. Place the infant in the knee-chest position
Answer: D
Rationale: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt in Tetralogy of Fallot. This is the primary emergency
intervention for a ‘tet spell’ or hypercyanotic episode. Following this, oxygen and morphine
may be administered to further stabilize the infant.
2. The nurse is preparing to administer Digoxin to an 8-month-old infant. The nurse should
withhold the dose and notify the provider if the apical heart rate is below what threshold?
A. 110 beats per minute
B. 60 beats per minute
C. 70 beats per minute
,D. 90 beats per minute
Answer: D
Rationale: In infants, Digoxin is typically withheld if the apical pulse is less than 90 beats
per minute to prevent bradycardia and toxicity. For older children, the cutoff is usually 70
beats per minute, and for adults, it is 60. Accurate heart rate assessment is critical for safe
medication administration in pediatric cardiology.
3. A child is admitted with a diagnosis of Type 1 Diabetes Mellitus and is experiencing
Kussmaul respirations. The nurse understands this breathing pattern is an attempt to:
A. Increase oxygen saturation due to respiratory distress
B. Compensate for metabolic acidosis by blowing off CO2
C. Compensate for respiratory alkalosis
D. Reduce blood glucose levels through exhalation
Answer: B
Rationale: Kussmaul respirations are deep, rapid breaths that occur during Diabetic
Ketoacidosis (DKA). This pattern is a compensatory mechanism for metabolic acidosis, as
the body tries to eliminate excess carbon dioxide (an acid) to raise the blood pH. This
finding indicates a severe state of metabolic imbalance requiring immediate intervention.
4. Which developmental finding is most characteristic of a 3-year-old child diagnosed with
Autism Spectrum Disorder (ASD)?
A. Preference for imaginative play with peers
, B. Strong desire for physical touch and affection
C. Advanced language skills for their age group
D. Lack of eye contact and repetitive behaviors
Answer: D
Rationale: Children with Autism Spectrum Disorder often exhibit impaired social
interaction, which manifests as a lack of eye contact or difficulty with verbal and non-
verbal communication. Repetitive behaviors or a strict adherence to routines are also
hallmark signs of the disorder. Early identification of these symptoms is crucial for
initiating specialized developmental therapies.
5. A nurse is teaching the parents of a child with a new diagnosis of a seizure disorder. Which
instruction is most important for safety during a seizure?
A. Insert a padded tongue blade into the child’s mouth
B. Restrain the child’s limbs to prevent injury
C. Turn the child onto their side to maintain an airway
D. Administer oral seizure medication immediately
Answer: C
Rationale: During a seizure, the primary goal is to maintain a patent airway and prevent
aspiration, which is achieved by turning the child to their side. Restraining the child or
placing objects in the mouth can cause injury to the teeth, jaw, or musculoskeletal system.
