NUR 203/NUR203 Final Exam V2 | Pediatric
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a 4-year-old child’s growth and development. According to Erikson,
which developmental stage is this child currently in?
A. Initiative vs. Guilt
B. Autonomy vs. Shame and Doubt
C. Industry vs. Inferiority
D. Trust vs. Mistrust
Correct Answer: A
Explanation: According to Erikson’s stages of psychosocial development, preschool-aged
children (3 to 6 years) are in the stage of Initiative vs. Guilt. During this period, children
begin to assert power and control over the world through directing play and other social
interactions. If they are discouraged from doing so, they may develop a sense of guilt
regarding their desires and actions.
2. A 10-month-old infant is brought to the clinic for a well-child checkup. Which
developmental milestone should the nurse expect the infant to have achieved?
A. Using a neat pincer grasp
B. Walking without assistance
C. Speaking in 3-word sentences
,D. Stacking a tower of six blocks
Correct Answer: A
Explanation: By 10 months of age, an infant typically demonstrates a neat pincer grasp,
which involves using the thumb and index finger to pick up small objects. Walking
independently is usually achieved around 12 to 15 months, and block stacking of that
complexity occurs much later in toddlerhood. Assessing fine motor skills like the pincer
grasp is essential to track neurological and physical maturation.
3. A nurse is caring for a toddler with suspected epiglottitis. Which of the following provider
orders should the nurse question?
A. Keep the child in an upright position
B. Obtain a throat culture
C. Monitor oxygen saturation continuously
D. Maintain intravenous access
Correct Answer: B
Explanation: In a child with suspected epiglottitis, any attempt to visualize or culture the
throat using a tongue depressor or swab is strictly contraindicated. Such actions can trigger
immediate laryngospasm and complete airway obstruction, which is a life-threatening
emergency. The nurse must prioritize keeping the child calm and prepared for emergency
intubation if necessary.
,4. A 6-year-old is hospitalized with acute glomerulonephritis. Which assessment finding is
most characteristic of this condition?
A. Periorbital edema and tea-colored urine
B. Generalized hypotension
C. Increased urine output and clear urine
D. Weight loss and dehydration
Correct Answer: A
Explanation: Acute glomerulonephritis is often characterized by periorbital edema,
hypertension, and hematuria, which gives the urine a smoky or tea-colored appearance.
This condition typically follows a streptococcal infection of the throat or skin. Monitoring
blood pressure and daily weights is critical due to the potential for fluid overload and renal
insufficiency.
5. A nurse is teaching parents of a child with Tetralogy of Fallot about ‘tet spells.’ What
should the nurse instruct the parents to do first during an acute cyanotic episode?
A. Administer a dose of digoxin
B. Call 911 immediately
C. Place the child in a knee-chest position
D. Start chest compressions
Correct Answer: C
, Explanation: The knee-chest position is the initial priority intervention because it
increases systemic vascular resistance, which helps reduce the right-to-left shunt and
improves oxygenation. This position forces more blood through the pulmonary artery to
the lungs. Parents should be taught this maneuver as a primary home-care intervention for
cyanotic episodes.
6. A 2-year-old child is diagnosed with Hirschsprung disease. Which clinical manifestation is
commonly associated with this diagnosis?
A. Ribbon-like, foul-smelling stools
B. Currant jelly-like stools
C. Projectile vomiting after feedings
D. Acute right lower quadrant pain
Correct Answer: A
Explanation: Hirschsprung disease involves a lack of ganglion cells in the colon, leading to
poor motility and mechanical obstruction. This results in the characteristic ‘ribbon-like’ or
pellet-shaped stools as waste passes through the narrow affected area. Currant jelly stools
are more indicative of intussusception, whereas projectile vomiting suggests pyloric
stenosis.
7. Which vaccine is typically administered for the first time at the 12-to-15-month-old well-
child visit?
A. Hepatitis B
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a 4-year-old child’s growth and development. According to Erikson,
which developmental stage is this child currently in?
A. Initiative vs. Guilt
B. Autonomy vs. Shame and Doubt
C. Industry vs. Inferiority
D. Trust vs. Mistrust
Correct Answer: A
Explanation: According to Erikson’s stages of psychosocial development, preschool-aged
children (3 to 6 years) are in the stage of Initiative vs. Guilt. During this period, children
begin to assert power and control over the world through directing play and other social
interactions. If they are discouraged from doing so, they may develop a sense of guilt
regarding their desires and actions.
2. A 10-month-old infant is brought to the clinic for a well-child checkup. Which
developmental milestone should the nurse expect the infant to have achieved?
A. Using a neat pincer grasp
B. Walking without assistance
C. Speaking in 3-word sentences
,D. Stacking a tower of six blocks
Correct Answer: A
Explanation: By 10 months of age, an infant typically demonstrates a neat pincer grasp,
which involves using the thumb and index finger to pick up small objects. Walking
independently is usually achieved around 12 to 15 months, and block stacking of that
complexity occurs much later in toddlerhood. Assessing fine motor skills like the pincer
grasp is essential to track neurological and physical maturation.
3. A nurse is caring for a toddler with suspected epiglottitis. Which of the following provider
orders should the nurse question?
A. Keep the child in an upright position
B. Obtain a throat culture
C. Monitor oxygen saturation continuously
D. Maintain intravenous access
Correct Answer: B
Explanation: In a child with suspected epiglottitis, any attempt to visualize or culture the
throat using a tongue depressor or swab is strictly contraindicated. Such actions can trigger
immediate laryngospasm and complete airway obstruction, which is a life-threatening
emergency. The nurse must prioritize keeping the child calm and prepared for emergency
intubation if necessary.
,4. A 6-year-old is hospitalized with acute glomerulonephritis. Which assessment finding is
most characteristic of this condition?
A. Periorbital edema and tea-colored urine
B. Generalized hypotension
C. Increased urine output and clear urine
D. Weight loss and dehydration
Correct Answer: A
Explanation: Acute glomerulonephritis is often characterized by periorbital edema,
hypertension, and hematuria, which gives the urine a smoky or tea-colored appearance.
This condition typically follows a streptococcal infection of the throat or skin. Monitoring
blood pressure and daily weights is critical due to the potential for fluid overload and renal
insufficiency.
5. A nurse is teaching parents of a child with Tetralogy of Fallot about ‘tet spells.’ What
should the nurse instruct the parents to do first during an acute cyanotic episode?
A. Administer a dose of digoxin
B. Call 911 immediately
C. Place the child in a knee-chest position
D. Start chest compressions
Correct Answer: C
, Explanation: The knee-chest position is the initial priority intervention because it
increases systemic vascular resistance, which helps reduce the right-to-left shunt and
improves oxygenation. This position forces more blood through the pulmonary artery to
the lungs. Parents should be taught this maneuver as a primary home-care intervention for
cyanotic episodes.
6. A 2-year-old child is diagnosed with Hirschsprung disease. Which clinical manifestation is
commonly associated with this diagnosis?
A. Ribbon-like, foul-smelling stools
B. Currant jelly-like stools
C. Projectile vomiting after feedings
D. Acute right lower quadrant pain
Correct Answer: A
Explanation: Hirschsprung disease involves a lack of ganglion cells in the colon, leading to
poor motility and mechanical obstruction. This results in the characteristic ‘ribbon-like’ or
pellet-shaped stools as waste passes through the narrow affected area. Currant jelly stools
are more indicative of intussusception, whereas projectile vomiting suggests pyloric
stenosis.
7. Which vaccine is typically administered for the first time at the 12-to-15-month-old well-
child visit?
A. Hepatitis B
