NUR 230 Exam 4 V3 | NUR 230 The
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 4) | Galen
College of Nursing
1. A 4-year-old child is brought to the emergency department with a sudden onset of high
fever, drooling, and an agitated demeanor. The child is sitting in a ‘tripod’ position. Which
nursing action is the highest priority?
A. Notify the provider and prepare for immediate intubation.
B. Assess the throat using a tongue blade for inflammation.
C. Obtain a throat culture to identify the causative organism.
D. Place the child in a supine position to facilitate breathing.
Answer: A
Rationale: The clinical presentation of drooling, tripod positioning, and high fever is
indicative of acute epiglottitis, which is a medical emergency. Attempting to visualize the
throat or obtain a culture can trigger a laryngospasm and complete airway obstruction. The
priority is to maintain airway patency by keeping the child calm and preparing for
emergency airway management.
2. A nurse is caring for an infant with Tetralogy of Fallot who suddenly becomes cyanotic and
dyspneic. Which action should the nurse take first?
A. Administer 100% oxygen via a face mask.
,B. Place the infant in the knee-chest position.
C. Prepare for the administration of morphine sulfate.
D. Begin intravenous fluid resuscitation.
Answer: B
Rationale: Placing the infant in a knee-chest position is the priority intervention for a ‘tet
spell’ or hypercyanotic episode. This maneuver increases systemic vascular resistance,
which reduces the right-to-left shunt and improves pulmonary blood flow. Oxygen and
morphine are secondary treatments that follow physical positioning to alleviate the crisis.
3. Which developmental finding is most characteristic of a 24-month-old toddler according to
Erikson’s stages of psychosocial development?
A. Exhibiting ritualism and a need for routine.
B. Participating in cooperative play with peers.
C. Developing a sense of trust in caregivers.
D. Demonstrating the ability to use logical reasoning.
Answer: A
Rationale: According to Erikson, toddlers (ages 1 to 3) are in the stage of Autonomy
vs. Shame and Doubt. Ritualism and the need for a strict routine provide a sense of control
and security for the toddler as they navigate their independence. Cooperative play and
, logical reasoning are characteristics of older developmental stages, such as preschool and
school-age.
4. A school-age child with Type 1 Diabetes Mellitus presents with diaphoresis, shakiness, and
pallor. What is the most appropriate initial nursing intervention?
A. Administer 15 grams of a simple carbohydrate.
B. Provide a complex carbohydrate and protein snack.
C. Give a subcutaneous injection of regular insulin.
D. Check the blood glucose level with a glucometer.
Answer: D
Rationale: The child is exhibiting signs of hypoglycemia, but the nurse must first verify the
blood glucose level if possible to guide treatment. Once hypoglycemia is confirmed, the
‘rule of 15’ is applied by giving 15g of simple carbs. A complex carbohydrate snack should
only follow once the blood sugar has stabilized.
5. When teaching the parents of a child with Cystic Fibrosis (CF) about nutritional needs,
which instruction should the nurse include?
A. Administer pancreatic enzymes with every meal and snack.
B. Provide a low-calorie, high-protein diet.
C. Restrict dietary fats to prevent malabsorption.
D. Limit salt intake during the hot summer months.
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 4) | Galen
College of Nursing
1. A 4-year-old child is brought to the emergency department with a sudden onset of high
fever, drooling, and an agitated demeanor. The child is sitting in a ‘tripod’ position. Which
nursing action is the highest priority?
A. Notify the provider and prepare for immediate intubation.
B. Assess the throat using a tongue blade for inflammation.
C. Obtain a throat culture to identify the causative organism.
D. Place the child in a supine position to facilitate breathing.
Answer: A
Rationale: The clinical presentation of drooling, tripod positioning, and high fever is
indicative of acute epiglottitis, which is a medical emergency. Attempting to visualize the
throat or obtain a culture can trigger a laryngospasm and complete airway obstruction. The
priority is to maintain airway patency by keeping the child calm and preparing for
emergency airway management.
2. A nurse is caring for an infant with Tetralogy of Fallot who suddenly becomes cyanotic and
dyspneic. Which action should the nurse take first?
A. Administer 100% oxygen via a face mask.
,B. Place the infant in the knee-chest position.
C. Prepare for the administration of morphine sulfate.
D. Begin intravenous fluid resuscitation.
Answer: B
Rationale: Placing the infant in a knee-chest position is the priority intervention for a ‘tet
spell’ or hypercyanotic episode. This maneuver increases systemic vascular resistance,
which reduces the right-to-left shunt and improves pulmonary blood flow. Oxygen and
morphine are secondary treatments that follow physical positioning to alleviate the crisis.
3. Which developmental finding is most characteristic of a 24-month-old toddler according to
Erikson’s stages of psychosocial development?
A. Exhibiting ritualism and a need for routine.
B. Participating in cooperative play with peers.
C. Developing a sense of trust in caregivers.
D. Demonstrating the ability to use logical reasoning.
Answer: A
Rationale: According to Erikson, toddlers (ages 1 to 3) are in the stage of Autonomy
vs. Shame and Doubt. Ritualism and the need for a strict routine provide a sense of control
and security for the toddler as they navigate their independence. Cooperative play and
, logical reasoning are characteristics of older developmental stages, such as preschool and
school-age.
4. A school-age child with Type 1 Diabetes Mellitus presents with diaphoresis, shakiness, and
pallor. What is the most appropriate initial nursing intervention?
A. Administer 15 grams of a simple carbohydrate.
B. Provide a complex carbohydrate and protein snack.
C. Give a subcutaneous injection of regular insulin.
D. Check the blood glucose level with a glucometer.
Answer: D
Rationale: The child is exhibiting signs of hypoglycemia, but the nurse must first verify the
blood glucose level if possible to guide treatment. Once hypoglycemia is confirmed, the
‘rule of 15’ is applied by giving 15g of simple carbs. A complex carbohydrate snack should
only follow once the blood sugar has stabilized.
5. When teaching the parents of a child with Cystic Fibrosis (CF) about nutritional needs,
which instruction should the nurse include?
A. Administer pancreatic enzymes with every meal and snack.
B. Provide a low-calorie, high-protein diet.
C. Restrict dietary fats to prevent malabsorption.
D. Limit salt intake during the hot summer months.
