, NSG 434 Exam 1-3 – Nursing Care of
Children – Actual Questions & Answers
(GCU) 100% Guarantee Pass
Question 1: The parent of a 9-month-old infant reports that the infant has developed a
fear of strangers. How should the nurse respond?
A. "This behavior indicates a lack of appropriate bonding with you."
B. "Stranger anxiety is a normal developmental milestone at this age."
C. "You should avoid leaving the infant with anyone else until this passes."
D. "This is a sign of an anxiety disorder requiring referral."
Answer: B
Rationale: Stranger anxiety typically emerges between 6 and 9 months of age and
reflects healthy attachment. It is not a sign of disorder or poor bonding .
Question 2: A nurse is performing a physical assessment on 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 .
Question 3: 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. The brachial pulse is
commonly used in infants, but the apical pulse provides the most accurate assessment
of cardiac function .
Question 4: 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 5: 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 6: The nurse is counting the respiratory rate of a 3-month-old infant. Which
approach is most appropriate?
A. Count for 15 seconds and multiply by 4
B. Count for 30 seconds and multiply by 2
C. Count for a full 60 seconds
D. Observe chest movements only
Answer: C
Rationale: In infants, respiratory movements are often irregular. The nurse should count
for a full 60 seconds for accuracy. Respirations in infants are primarily diaphragmatic, so
the nurse should observe abdominal movements .
Question 7: The nurse is comparing radial and femoral pulses on a 1-month-old infant.
Which finding would be concerning?
A. Radial and femoral pulses are equal in strength
B. Radial pulse is weaker than femoral pulse
C. Femoral pulse is weaker than radial pulse
D. Pulses are palpable bilaterally
Answer: C
Rationale: The nurse should compare radial and femoral pulses at least once during
infancy to detect possible coarctation of the aorta, which presents with weak or absent
femoral pulses and strong radial pulses .
Question 8: The nurse is assessing a 6-week-old infant's head. Which finding indicates
the need for further evaluation?
Children – Actual Questions & Answers
(GCU) 100% Guarantee Pass
Question 1: The parent of a 9-month-old infant reports that the infant has developed a
fear of strangers. How should the nurse respond?
A. "This behavior indicates a lack of appropriate bonding with you."
B. "Stranger anxiety is a normal developmental milestone at this age."
C. "You should avoid leaving the infant with anyone else until this passes."
D. "This is a sign of an anxiety disorder requiring referral."
Answer: B
Rationale: Stranger anxiety typically emerges between 6 and 9 months of age and
reflects healthy attachment. It is not a sign of disorder or poor bonding .
Question 2: A nurse is performing a physical assessment on 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 .
Question 3: 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. The brachial pulse is
commonly used in infants, but the apical pulse provides the most accurate assessment
of cardiac function .
Question 4: 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 5: 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 6: The nurse is counting the respiratory rate of a 3-month-old infant. Which
approach is most appropriate?
A. Count for 15 seconds and multiply by 4
B. Count for 30 seconds and multiply by 2
C. Count for a full 60 seconds
D. Observe chest movements only
Answer: C
Rationale: In infants, respiratory movements are often irregular. The nurse should count
for a full 60 seconds for accuracy. Respirations in infants are primarily diaphragmatic, so
the nurse should observe abdominal movements .
Question 7: The nurse is comparing radial and femoral pulses on a 1-month-old infant.
Which finding would be concerning?
A. Radial and femoral pulses are equal in strength
B. Radial pulse is weaker than femoral pulse
C. Femoral pulse is weaker than radial pulse
D. Pulses are palpable bilaterally
Answer: C
Rationale: The nurse should compare radial and femoral pulses at least once during
infancy to detect possible coarctation of the aorta, which presents with weak or absent
femoral pulses and strong radial pulses .
Question 8: The nurse is assessing a 6-week-old infant's head. Which finding indicates
the need for further evaluation?
