,NUR254/NUR 254 Exam 3 | Maternal & Pediatric
Nursing | Galen College of Nursing | 26/27|Q&A (PDF)
1. A 4-year-old child is admitted to the pediatric unit for a surgical procedure. Which action by the
nurse best demonstrates the principles of family-centered care?
A) Asking the parents to leave the room during the physical assessment
B) Providing the child with a detailed written explanation of the procedure
C) Encouraging the parents to stay with the child and participate in care decisions
D) Limiting visitation to designated hours to maintain a structured environment
Correct Answer: Encouraging the parents to stay with the child and participate in care decisions
Rationale: Family-centered care recognizes the family as the constant in the child's life and
encourages active participation in care and decision-making. Excluding parents or limiting their
involvement is contrary to this philosophy. Written explanations are more appropriate for school-age
children who can read, while preschoolers benefit from play and simple demonstrations.
2. The nurse is assessing the developmental milestones of a 10-month-old infant. Which finding would
be a cause for concern?
A) The infant can pull to a standing position
B) The infant uses a pincer grasp to pick up small objects
C) The infant can say "mama" and "dada" specifically
D) The infant cannot sit without support
Correct Answer: The infant cannot sit without support
Rationale: By 9 months, most infants can sit without support. Failure to achieve this milestone by 10
months warrants further developmental screening. Pulling to stand, using a pincer grasp, and saying
"mama" and "dada" specifically are all expected milestones for a 10-month-old.
3. The nurse is educating the parents of a toddler about appropriate play activities. Which activity is
most developmentally appropriate for a 2-year-old?
,A) Playing a board game with simple rules
B) Building with large, colorful blocks
C) Engaging in cooperative play with multiple peers
D) Completing a complex jigsaw puzzle
Correct Answer: Building with large, colorful blocks
Rationale: Toddlers engage in solitary and parallel play and enjoy activities that involve large motor
skills and simple manipulation. Large blocks are safe and developmentally appropriate. Board games
and cooperative play are more suitable for older children, and complex puzzles exceed the cognitive
and fine motor skills of a toddler.
4. The nurse is caring for a hospitalized 6-year-old child. Which statement by the nurse best supports
the child's psychosocial development according to Erikson?
A) Let's play a game of checkers while we wait for your medicine
B) I will help you tie your shoes so we can go for a walk
C) You can choose which sticker you would like after your bath
D) It is time for your shot now, and we will do it quickly
Correct Answer: You can choose which sticker you would like after your bath
Rationale: School-age children (6-12 years) are in Erikson's stage of industry vs. inferiority, where they
seek to demonstrate competence and receive recognition for their accomplishments. Allowing the
child to make a simple choice fosters a sense of control and achievement. Offering to help with a task,
while kind, does not directly promote industry.
5. A nurse is assessing a 3-year-old child during a well-child visit. Which developmental milestone
should the nurse expect the child to have achieved?
A) Tying shoelaces
B) Riding a tricycle
C) Reading simple words
D) Drawing a person with six body parts
, Correct Answer: Riding a tricycle
Rationale: A 3-year-old typically can ride a tricycle, demonstrating gross motor skill development.
Tying shoelaces and reading are skills of a much older child. Drawing a person with multiple body
parts is a milestone for a 5-year-old.
6. The nurse is preparing to administer a scheduled immunization to a 2-month-old infant. The infant's
parent expresses concern about pain. Which non-pharmacologic intervention should the nurse
implement?
A) Apply a warm compress to the injection site
B) Administer oral acetaminophen 30 minutes before the injection
C) Offer the infant a pacifier dipped in sucrose solution
D) Apply EMLA cream to the site 1 hour before the injection
Correct Answer: Offer the infant a pacifier dipped in sucrose solution
Rationale: For infants, non-pharmacologic pain management includes sucrose solution, non-nutritive
sucking (pacifier), and swaddling. EMLA cream requires a longer application time (60 minutes) and is a
topical anesthetic, which is a pharmacologic intervention. Acetaminophen is also pharmacologic, and
warm compresses are not typically used for immunization pain.
7. The nurse is caring for a 2-year-old child who is prescribed digoxin. The child's apical pulse is 98
beats per minute. Which action should the nurse take?
A) Administer the digoxin as prescribed
B) Hold the dose and notify the healthcare provider
C) Administer half the prescribed dose
D) Recheck the pulse in 30 minutes
Correct Answer: Administer the digoxin as prescribed
Nursing | Galen College of Nursing | 26/27|Q&A (PDF)
1. A 4-year-old child is admitted to the pediatric unit for a surgical procedure. Which action by the
nurse best demonstrates the principles of family-centered care?
A) Asking the parents to leave the room during the physical assessment
B) Providing the child with a detailed written explanation of the procedure
C) Encouraging the parents to stay with the child and participate in care decisions
D) Limiting visitation to designated hours to maintain a structured environment
Correct Answer: Encouraging the parents to stay with the child and participate in care decisions
Rationale: Family-centered care recognizes the family as the constant in the child's life and
encourages active participation in care and decision-making. Excluding parents or limiting their
involvement is contrary to this philosophy. Written explanations are more appropriate for school-age
children who can read, while preschoolers benefit from play and simple demonstrations.
2. The nurse is assessing the developmental milestones of a 10-month-old infant. Which finding would
be a cause for concern?
A) The infant can pull to a standing position
B) The infant uses a pincer grasp to pick up small objects
C) The infant can say "mama" and "dada" specifically
D) The infant cannot sit without support
Correct Answer: The infant cannot sit without support
Rationale: By 9 months, most infants can sit without support. Failure to achieve this milestone by 10
months warrants further developmental screening. Pulling to stand, using a pincer grasp, and saying
"mama" and "dada" specifically are all expected milestones for a 10-month-old.
3. The nurse is educating the parents of a toddler about appropriate play activities. Which activity is
most developmentally appropriate for a 2-year-old?
,A) Playing a board game with simple rules
B) Building with large, colorful blocks
C) Engaging in cooperative play with multiple peers
D) Completing a complex jigsaw puzzle
Correct Answer: Building with large, colorful blocks
Rationale: Toddlers engage in solitary and parallel play and enjoy activities that involve large motor
skills and simple manipulation. Large blocks are safe and developmentally appropriate. Board games
and cooperative play are more suitable for older children, and complex puzzles exceed the cognitive
and fine motor skills of a toddler.
4. The nurse is caring for a hospitalized 6-year-old child. Which statement by the nurse best supports
the child's psychosocial development according to Erikson?
A) Let's play a game of checkers while we wait for your medicine
B) I will help you tie your shoes so we can go for a walk
C) You can choose which sticker you would like after your bath
D) It is time for your shot now, and we will do it quickly
Correct Answer: You can choose which sticker you would like after your bath
Rationale: School-age children (6-12 years) are in Erikson's stage of industry vs. inferiority, where they
seek to demonstrate competence and receive recognition for their accomplishments. Allowing the
child to make a simple choice fosters a sense of control and achievement. Offering to help with a task,
while kind, does not directly promote industry.
5. A nurse is assessing a 3-year-old child during a well-child visit. Which developmental milestone
should the nurse expect the child to have achieved?
A) Tying shoelaces
B) Riding a tricycle
C) Reading simple words
D) Drawing a person with six body parts
, Correct Answer: Riding a tricycle
Rationale: A 3-year-old typically can ride a tricycle, demonstrating gross motor skill development.
Tying shoelaces and reading are skills of a much older child. Drawing a person with multiple body
parts is a milestone for a 5-year-old.
6. The nurse is preparing to administer a scheduled immunization to a 2-month-old infant. The infant's
parent expresses concern about pain. Which non-pharmacologic intervention should the nurse
implement?
A) Apply a warm compress to the injection site
B) Administer oral acetaminophen 30 minutes before the injection
C) Offer the infant a pacifier dipped in sucrose solution
D) Apply EMLA cream to the site 1 hour before the injection
Correct Answer: Offer the infant a pacifier dipped in sucrose solution
Rationale: For infants, non-pharmacologic pain management includes sucrose solution, non-nutritive
sucking (pacifier), and swaddling. EMLA cream requires a longer application time (60 minutes) and is a
topical anesthetic, which is a pharmacologic intervention. Acetaminophen is also pharmacologic, and
warm compresses are not typically used for immunization pain.
7. The nurse is caring for a 2-year-old child who is prescribed digoxin. The child's apical pulse is 98
beats per minute. Which action should the nurse take?
A) Administer the digoxin as prescribed
B) Hold the dose and notify the healthcare provider
C) Administer half the prescribed dose
D) Recheck the pulse in 30 minutes
Correct Answer: Administer the digoxin as prescribed
