, NSG 434 Final Exam – Nursing Care of
Children – Actual Questions & Answers
(GCU) 100% Guarantee Pass
Question 1: The nurse is assessing a 6-month-old infant. Which method should the
nurse use to obtain an accurate temperature?
A. Oral temperature
B. Tympanic temperature
C. Axillary or rectal temperature
D. Temporal artery temperature
Answer: C
Rationale: For infants up to 2 years of age, axillary or rectal temperatures are
recommended. Rectal temperature is the most accurate for core temperature (normal
37-37.5°C; neonates 36.5-37.6°C). Oral temperatures are not reliable until the child can
hold the thermometer under the tongue (typically >5 years) .
Question 2: The nurse is assessing a 1-year-old infant's pulse. Which site should the
nurse use to obtain the most accurate measurement?
A. Radial pulse
B. Apical pulse
C. Brachial pulse
D. Femoral pulse
Answer: B
Rationale: The apical pulse, heard through a stethoscope at the apex of the heart, is the
most reliable pulse measurement in infants and young children (birth-2 years). The
brachial pulse is commonly used in infants, but the apical pulse provides the most
accurate assessment of cardiac function .
,Question 3: The nurse is assessing a 3-day-old neonate. The posterior fontanel is
palpable. Which action should the nurse take?
A. Notify the healthcare provider immediately
B. Document this as a normal finding
C. Prepare for a neurological consult
D. Reassess in 2 weeks
Answer: B
Rationale: The posterior fontanel typically closes at 2-3 months of age. A palpable
posterior fontanel in a 3-day-old neonate is a normal finding. The anterior fontanel
closes at 12-18 months .
Question 4: The nurse is assessing a 2-year-old child's blood pressure. Which factor is
most important for obtaining an accurate reading?
A. Using a small cuff to ensure a reading
B. Taking blood pressure in the lower extremity
C. Using a cuff that covers 40% of the arm circumference
D. Taking blood pressure while the child is crying
Answer: C
Rationale: Correct cuff size is essential for accurate blood pressure measurement. The
cuff bladder width should be approximately 40% of the arm circumference at the
midpoint. Using a cuff that is too small will result in falsely elevated readings .
Question 5: The nurse is assessing an infant's ear alignment. The normal alignment of
the pinna should be:
A. 5 degrees from vertical
B. 10 degrees from vertical
C. 15 degrees from vertical
D. 20 degrees from vertical
Answer: B
, Rationale: The pinna of the ear should align at approximately 10 degrees from vertical.
An angle greater than 10-15 degrees may indicate a congenital anomaly or syndrome
and requires further evaluation .
Question 6: The nurse is assessing a 4-year-old child's vision. The nurse notes that the
child has strabismus. Which complication is the nurse most concerned about?
A. Myopia
B. Amblyopia
C. Hyperopia
D. Astigmatism
Answer: B
Rationale: Strabismus (eye deviation) can lead to amblyopia (permanent blindness in
the affected eye) if not corrected by 4-6 years of age. The brain "turns off" the visual
input from the deviated eye to avoid double vision, resulting in permanent vision loss .
Question 7: The nurse is assessing a 9-month-old infant's growth. Which milestone
indicates normal development?
A. Sits with support only
B. Sits alone without support
C. Rolls from front to back only
D. Pulls to stand
Answer: B
Rationale: Infants typically sit alone without support at 8 months of age. Rolling over
occurs at 4-6 months. Pulling to stand occurs at 9-10 months. Sitting with support is
appropriate at 6 months .
Question 8: The nurse is assessing a 15-month-old toddler's fine motor development.
Which skill should the nurse expect?
Children – Actual Questions & Answers
(GCU) 100% Guarantee Pass
Question 1: The nurse is assessing a 6-month-old infant. Which method should the
nurse use to obtain an accurate temperature?
A. Oral temperature
B. Tympanic temperature
C. Axillary or rectal temperature
D. Temporal artery temperature
Answer: C
Rationale: For infants up to 2 years of age, axillary or rectal temperatures are
recommended. Rectal temperature is the most accurate for core temperature (normal
37-37.5°C; neonates 36.5-37.6°C). Oral temperatures are not reliable until the child can
hold the thermometer under the tongue (typically >5 years) .
Question 2: The nurse is assessing a 1-year-old infant's pulse. Which site should the
nurse use to obtain the most accurate measurement?
A. Radial pulse
B. Apical pulse
C. Brachial pulse
D. Femoral pulse
Answer: B
Rationale: The apical pulse, heard through a stethoscope at the apex of the heart, is the
most reliable pulse measurement in infants and young children (birth-2 years). The
brachial pulse is commonly used in infants, but the apical pulse provides the most
accurate assessment of cardiac function .
,Question 3: The nurse is assessing a 3-day-old neonate. The posterior fontanel is
palpable. Which action should the nurse take?
A. Notify the healthcare provider immediately
B. Document this as a normal finding
C. Prepare for a neurological consult
D. Reassess in 2 weeks
Answer: B
Rationale: The posterior fontanel typically closes at 2-3 months of age. A palpable
posterior fontanel in a 3-day-old neonate is a normal finding. The anterior fontanel
closes at 12-18 months .
Question 4: The nurse is assessing a 2-year-old child's blood pressure. Which factor is
most important for obtaining an accurate reading?
A. Using a small cuff to ensure a reading
B. Taking blood pressure in the lower extremity
C. Using a cuff that covers 40% of the arm circumference
D. Taking blood pressure while the child is crying
Answer: C
Rationale: Correct cuff size is essential for accurate blood pressure measurement. The
cuff bladder width should be approximately 40% of the arm circumference at the
midpoint. Using a cuff that is too small will result in falsely elevated readings .
Question 5: The nurse is assessing an infant's ear alignment. The normal alignment of
the pinna should be:
A. 5 degrees from vertical
B. 10 degrees from vertical
C. 15 degrees from vertical
D. 20 degrees from vertical
Answer: B
, Rationale: The pinna of the ear should align at approximately 10 degrees from vertical.
An angle greater than 10-15 degrees may indicate a congenital anomaly or syndrome
and requires further evaluation .
Question 6: The nurse is assessing a 4-year-old child's vision. The nurse notes that the
child has strabismus. Which complication is the nurse most concerned about?
A. Myopia
B. Amblyopia
C. Hyperopia
D. Astigmatism
Answer: B
Rationale: Strabismus (eye deviation) can lead to amblyopia (permanent blindness in
the affected eye) if not corrected by 4-6 years of age. The brain "turns off" the visual
input from the deviated eye to avoid double vision, resulting in permanent vision loss .
Question 7: The nurse is assessing a 9-month-old infant's growth. Which milestone
indicates normal development?
A. Sits with support only
B. Sits alone without support
C. Rolls from front to back only
D. Pulls to stand
Answer: B
Rationale: Infants typically sit alone without support at 8 months of age. Rolling over
occurs at 4-6 months. Pulling to stand occurs at 9-10 months. Sitting with support is
appropriate at 6 months .
Question 8: The nurse is assessing a 15-month-old toddler's fine motor development.
Which skill should the nurse expect?
