NUR231 Exam 4 V1 | NUR 231
Childbearing & Child Caring Family Exam
Q&A | Galen College of Nursing
1. A 10-month-old infant is hospitalized. Which behavior should the nurse identify as the
‘protest’ stage of separation anxiety?
A. The infant is quiet, withdrawn, and appears sad.
B. The infant is indifferent to the mother’s return.
C. The infant cries loudly and pushes the nurse away.
D. The infant interacts happily with strangers.
Answer: C
Rationale: In the protest stage, infants cry, scream, and search for their parents while
rejecting others. This phase is characterized by an active physical response to separation.
This analysis highlights that understanding developmental stages is critical for pediatric
assessment and family-centered care planning.
2. Which clinical finding is most characteristic of a child diagnosed with intussusception?
A. Ribbon-like stools
B. Projectile vomiting
C. Currant jelly-like stools
D. Visible peristaltic waves
,Answer: C
Rationale: Intussusception causes intestinal obstruction and ischemia, leading to the
passage of ‘currant jelly’ stools which contain blood and mucus. This is a medical
emergency that requires immediate intervention to prevent necrosis. Nursing management
involves monitoring for bowel perforation and preparing for an air or saline enema.
3. A child with cystic fibrosis is prescribed pancreatic enzymes. When should the nurse
instruct the parents to administer them?
A. Two hours after eating
B. Once daily in the morning
C. Only when the child has fatty stools
D. Before every meal and snack
Answer: D
Rationale: Pancreatic enzymes must be taken with all meals and snacks to facilitate the
digestion and absorption of nutrients. Cystic fibrosis causes thick mucus to block the
pancreatic ducts, preventing natural enzymes from reaching the duodenum. Effective
enzyme replacement therapy is essential for preventing malnutrition and growth failure.
4. A toddler is suspected of having epiglottitis. Which nursing action is contraindicated?
A. Allowing the child to sit in a tripod position
B. Administering humidified oxygen
, C. Starting an intravenous line
D. Assessing the throat with a tongue depressor
Answer: D
Rationale: Examining the throat with a tongue depressor can cause laryngospasm and
total airway obstruction in a child with epiglottitis. The priority is to keep the child calm
and prepare for emergency intubation. This condition is a life-threatening emergency
caused by bacterial infection of the epiglottis.
5. A school-age child is being treated for nephrotic syndrome. Which assessment finding
should the nurse prioritize?
A. Severe proteinuria
B. Hypotension
C. Gross hematuria
D. Weight loss
Answer: A
Rationale: Nephrotic syndrome is characterized by massive proteinuria,
hypoalbuminemia, and edema. The nurse should monitor daily weights and urine protein
levels closely. Managing fluid balance and preventing infection are the primary goals for
this patient population.
Childbearing & Child Caring Family Exam
Q&A | Galen College of Nursing
1. A 10-month-old infant is hospitalized. Which behavior should the nurse identify as the
‘protest’ stage of separation anxiety?
A. The infant is quiet, withdrawn, and appears sad.
B. The infant is indifferent to the mother’s return.
C. The infant cries loudly and pushes the nurse away.
D. The infant interacts happily with strangers.
Answer: C
Rationale: In the protest stage, infants cry, scream, and search for their parents while
rejecting others. This phase is characterized by an active physical response to separation.
This analysis highlights that understanding developmental stages is critical for pediatric
assessment and family-centered care planning.
2. Which clinical finding is most characteristic of a child diagnosed with intussusception?
A. Ribbon-like stools
B. Projectile vomiting
C. Currant jelly-like stools
D. Visible peristaltic waves
,Answer: C
Rationale: Intussusception causes intestinal obstruction and ischemia, leading to the
passage of ‘currant jelly’ stools which contain blood and mucus. This is a medical
emergency that requires immediate intervention to prevent necrosis. Nursing management
involves monitoring for bowel perforation and preparing for an air or saline enema.
3. A child with cystic fibrosis is prescribed pancreatic enzymes. When should the nurse
instruct the parents to administer them?
A. Two hours after eating
B. Once daily in the morning
C. Only when the child has fatty stools
D. Before every meal and snack
Answer: D
Rationale: Pancreatic enzymes must be taken with all meals and snacks to facilitate the
digestion and absorption of nutrients. Cystic fibrosis causes thick mucus to block the
pancreatic ducts, preventing natural enzymes from reaching the duodenum. Effective
enzyme replacement therapy is essential for preventing malnutrition and growth failure.
4. A toddler is suspected of having epiglottitis. Which nursing action is contraindicated?
A. Allowing the child to sit in a tripod position
B. Administering humidified oxygen
, C. Starting an intravenous line
D. Assessing the throat with a tongue depressor
Answer: D
Rationale: Examining the throat with a tongue depressor can cause laryngospasm and
total airway obstruction in a child with epiglottitis. The priority is to keep the child calm
and prepare for emergency intubation. This condition is a life-threatening emergency
caused by bacterial infection of the epiglottis.
5. A school-age child is being treated for nephrotic syndrome. Which assessment finding
should the nurse prioritize?
A. Severe proteinuria
B. Hypotension
C. Gross hematuria
D. Weight loss
Answer: A
Rationale: Nephrotic syndrome is characterized by massive proteinuria,
hypoalbuminemia, and edema. The nurse should monitor daily weights and urine protein
levels closely. Managing fluid balance and preventing infection are the primary goals for
this patient population.
