NUR 203/NUR203 Exam 1 V2 | Pediatric Nursing
Q&A with Rationale | Fortis College
1. A nurse is assessing a 4-month-old infant during a routine checkup. Which of the following
findings should the nurse expect?
A. The infant can sit unsupported for several minutes.
B. The infant can crawl on hands and knees.
C. The infant exhibits a neat pincer grasp.
D. The infant can roll from back to side.
Correct Answer: D
Explanation: At 4 months of age, infants typically have the coordination to roll from their
back to their side. Sitting unsupported and crawling are milestones that occur later, usually
between 6 to 9 months. The pincer grasp is a fine motor skill that typically develops around
8 to 10 months.
2. According to Erikson’s theory of psychosocial development, which task is primary for an
infant (birth to 1 year)?
A. Developing a sense of autonomy.
B. Establishing a sense of trust in caregivers.
C. Learning to initiate tasks and activities.
D. Building a sense of industry and competence.
,Correct Answer: B
Explanation: The primary developmental task for an infant is Trust vs. Mistrust, where the
infant learns to rely on caregivers for basic needs. If these needs are met consistently, the
infant develops a sense of security. Failure to meet these needs leads to suspicion and
anxiety in later life stages.
3. A nurse is preparing to administer an intramuscular injection to a 10-month-old infant.
Which site is most appropriate for this patient?
A. Deltoid muscle
B. Ventrogluteal site
C. Dorsogluteal site
D. Vastus lateralis
Correct Answer: D
Explanation: The vastus lateralis is the preferred site for IM injections in infants because it
is the most developed muscle at this age. The deltoid is not recommended for infants due to
its small size and risk of nerve injury. The dorsogluteal site is avoided in pediatrics due to
proximity to the sciatic nerve and insufficient muscle mass.
4. A 2-year-old child is hospitalized and exhibits signs of the ‘despair’ stage of separation
anxiety. Which behavior should the nurse observe?
A. Crying loudly and screaming for the parents.
B. Ignoring the parents when they return to the room.
, C. Withdrawing from others and appearing sad or depressed.
D. Engaging happily with nurses and other children.
Correct Answer: C
Explanation: Despair is the second stage of separation anxiety, characterized by a
cessation of crying and a state of mourning or withdrawal. The child may refuse to eat or
play and appears disinterested in their surroundings. Crying loudly is characteristic of the
initial ‘protest’ stage.
5. A nurse is teaching parents of a toddler about the prevention of accidental poisoning.
Which instruction is most important to include?
A. Keep all medications in child-proof containers and locked cabinets.
B. Keep Ipecac syrup readily available at home.
C. Transfer toxic liquids into colorful juice bottles.
D. Store all cleaning supplies in a low, unlocked cabinet.
Correct Answer: A
Explanation: Locking cabinets is the most effective way to prevent access to harmful
substances for curious toddlers. Child-proof containers provide an extra layer of
protection, though they are not entirely ‘child-proof’. Ipecac syrup is no longer
recommended for home use due to safety concerns and potential complications.
Q&A with Rationale | Fortis College
1. A nurse is assessing a 4-month-old infant during a routine checkup. Which of the following
findings should the nurse expect?
A. The infant can sit unsupported for several minutes.
B. The infant can crawl on hands and knees.
C. The infant exhibits a neat pincer grasp.
D. The infant can roll from back to side.
Correct Answer: D
Explanation: At 4 months of age, infants typically have the coordination to roll from their
back to their side. Sitting unsupported and crawling are milestones that occur later, usually
between 6 to 9 months. The pincer grasp is a fine motor skill that typically develops around
8 to 10 months.
2. According to Erikson’s theory of psychosocial development, which task is primary for an
infant (birth to 1 year)?
A. Developing a sense of autonomy.
B. Establishing a sense of trust in caregivers.
C. Learning to initiate tasks and activities.
D. Building a sense of industry and competence.
,Correct Answer: B
Explanation: The primary developmental task for an infant is Trust vs. Mistrust, where the
infant learns to rely on caregivers for basic needs. If these needs are met consistently, the
infant develops a sense of security. Failure to meet these needs leads to suspicion and
anxiety in later life stages.
3. A nurse is preparing to administer an intramuscular injection to a 10-month-old infant.
Which site is most appropriate for this patient?
A. Deltoid muscle
B. Ventrogluteal site
C. Dorsogluteal site
D. Vastus lateralis
Correct Answer: D
Explanation: The vastus lateralis is the preferred site for IM injections in infants because it
is the most developed muscle at this age. The deltoid is not recommended for infants due to
its small size and risk of nerve injury. The dorsogluteal site is avoided in pediatrics due to
proximity to the sciatic nerve and insufficient muscle mass.
4. A 2-year-old child is hospitalized and exhibits signs of the ‘despair’ stage of separation
anxiety. Which behavior should the nurse observe?
A. Crying loudly and screaming for the parents.
B. Ignoring the parents when they return to the room.
, C. Withdrawing from others and appearing sad or depressed.
D. Engaging happily with nurses and other children.
Correct Answer: C
Explanation: Despair is the second stage of separation anxiety, characterized by a
cessation of crying and a state of mourning or withdrawal. The child may refuse to eat or
play and appears disinterested in their surroundings. Crying loudly is characteristic of the
initial ‘protest’ stage.
5. A nurse is teaching parents of a toddler about the prevention of accidental poisoning.
Which instruction is most important to include?
A. Keep all medications in child-proof containers and locked cabinets.
B. Keep Ipecac syrup readily available at home.
C. Transfer toxic liquids into colorful juice bottles.
D. Store all cleaning supplies in a low, unlocked cabinet.
Correct Answer: A
Explanation: Locking cabinets is the most effective way to prevent access to harmful
substances for curious toddlers. Child-proof containers provide an extra layer of
protection, though they are not entirely ‘child-proof’. Ipecac syrup is no longer
recommended for home use due to safety concerns and potential complications.
