NURS 230 Maternal-Child Nursing Exam 3: Questions & Answers: 100% Verified:
Updated A+ Score Solution Guide
(Part 1)
Q1. The nurse has administered a prescribed analgesic to a preschool child. Which action should
the nurse take to assess the effectiveness of this medication?
• A. Ask the child to point to a numeric pain scale
• B. Use the Wong-Baker pain scale
• C. Ask the mother if she thinks the analgesic is working
• D. Assess for changes in the child's vital signs
Answer: B
Rationale: The Wong-Baker (faces) scale is the standard developmentally-appropriate
self-report tool for preschool children aged 3–7.
Q2. The nurse is caring for a child in middle school who is hospitalized. When developing a plan
of care, the nurse should consider that children in this age group:
• A. Are increasingly aware of disappointments in life
• B. Are unable to see things from any perspective other than their own
• C. Think in abstract terms and can deal with uncertainty
• D. Are anxious about missing interactions with friends
Answer: D
Rationale: For hospitalized school-aged and adolescent children, peer relationships are
paramount, and isolation from friends is a primary source of anxiety.
Q3. The nurse is caring for a group of toddlers and is developing a plan for age-appropriate play
activities during hospitalization. Which play activity should the nurse include?
• A. Letting the toddlers race toy cars against each other
• B. Giving the toddlers dress-up clothes for a play
• C. Allowing the toddlers to complete a puzzle together
, • D. Offering each toddler a ball to roll around
Answer: D
Rationale: Toddlers naturally engage in parallel play, meaning they play side-by-side
with similar toys independently without cooperative interaction.
Q4. The nurse is working in an emergency triage area where a parent brings in a child and
states, "I think she got into my mother's medicine." After determining the medication the child
ingested, which action should the nurse perform next?
• A. Notify authorities of child neglect
• B. Contact poison control
• C. Determine medication allergies
• D. Induce vomiting
Answer: B
Rationale: After identifying the ingested toxin, contacting Poison Control immediately is
the priority action before attempting any other clinical interventions.
Q5. The nurse is performing an assessment on an adolescent client. Which behavior suggests
appropriate psychosocial development in this client?
• A. Validation for socially acceptable behavior from older adults
• B. Thinks about peers' opinions of them
• C. Gets along well with others in authority
• D. Navigates away from peers and enjoys spending time with family members
Answer: B
Rationale: According to Erikson, adolescents are in the Identity vs. Role Confusion stage
and are developmentally preoccupied with peer opinions.
Q6. The nurse is performing a nutritional assessment on an adolescent client. Which client
statement best indicates that the client's diet is healthy?
, • A. I make sure to eat 2 meals daily
• B. I make sure to drink 8 ounces of milk per day
• C. We use cheese in some of our meals
• D. My parents make sure I drink 8 glasses of water daily
Answer: D
• Rationale: Drinking 8 glasses of water daily demonstrates healthy hydration; the other
selections are nutritionally insufficient.
Q7. The nurse is educating new parents about immunizations and immunity. It indicates the
need for additional teaching if a parent states:
• A. Active immunity is what my child gets from me and is short-term protection
• B. My child will be protected for life from many diseases with active immunity
• C. My child will develop active immunity by producing antibodies to specific organisms
• D. Through active immunity, my child will develop long-term protection against
organisms
Answer: A
• Rationale: Active immunity is self-produced (long-term). The immunity a baby receives
from the mother (placental transfer/colostrum) is passive, which is temporary.
Q8. The nurse has attended a conference on immunizations. Which statement by the nurse
indicates that teaching has been effective?
• A. The recommended age to begin immunizations is 1 month
• B. Oral polio vaccine is preferred over inactivated poliovirus vaccine
• C. Children who have a common cold may still receive an immunization
• D. Preterm infants should receive their primary vaccinations at birth
Answer: C
Rationale: A mild acute illness (such as a common cold or low-grade fever) is not a
contraindication for receiving scheduled immunizations.
, Q9. The school nurse is on the playground with students and observes a child watching a small
group of children playing tag. The nurse recognizes this type of play as:
• A. Parallel
• B. Associative
• C. Onlooker
• D. Assistive
Answer: C
• Rationale: Onlooker play occurs when a child observes other children playing but does
not attempt to join the activity.
Q10. The nurse has provided discharge instructions to the parents of a 3-year-old who had a
cardiac catheterization. Which statement by the parents indicates a correct understanding of
the teaching?
• A. We will encourage our child to engage in normal activity for the next several days
• B. We will refrain from removing the adhesive bandage strip when we get home
• C. Our child will need to follow a low-protein diet for the next week
• D. Our child can take a bath beginning tomorrow
Answer: B
Rationale: The original pressure dressing must remain intact immediately post-
catheterization to prevent bleeding; tub baths are restricted.
Q11. The nurse is performing a respiratory assessment of an infant. It is necessary for the nurse
to notify the primary healthcare provider (PHCP) if the nurse observes that the infant:
• A. Is using abdominal breathing
• B. Has nasal flaring
• C. Has a respiratory rate of 30
• D. Has scattered rhonchi
Updated A+ Score Solution Guide
(Part 1)
Q1. The nurse has administered a prescribed analgesic to a preschool child. Which action should
the nurse take to assess the effectiveness of this medication?
• A. Ask the child to point to a numeric pain scale
• B. Use the Wong-Baker pain scale
• C. Ask the mother if she thinks the analgesic is working
• D. Assess for changes in the child's vital signs
Answer: B
Rationale: The Wong-Baker (faces) scale is the standard developmentally-appropriate
self-report tool for preschool children aged 3–7.
Q2. The nurse is caring for a child in middle school who is hospitalized. When developing a plan
of care, the nurse should consider that children in this age group:
• A. Are increasingly aware of disappointments in life
• B. Are unable to see things from any perspective other than their own
• C. Think in abstract terms and can deal with uncertainty
• D. Are anxious about missing interactions with friends
Answer: D
Rationale: For hospitalized school-aged and adolescent children, peer relationships are
paramount, and isolation from friends is a primary source of anxiety.
Q3. The nurse is caring for a group of toddlers and is developing a plan for age-appropriate play
activities during hospitalization. Which play activity should the nurse include?
• A. Letting the toddlers race toy cars against each other
• B. Giving the toddlers dress-up clothes for a play
• C. Allowing the toddlers to complete a puzzle together
, • D. Offering each toddler a ball to roll around
Answer: D
Rationale: Toddlers naturally engage in parallel play, meaning they play side-by-side
with similar toys independently without cooperative interaction.
Q4. The nurse is working in an emergency triage area where a parent brings in a child and
states, "I think she got into my mother's medicine." After determining the medication the child
ingested, which action should the nurse perform next?
• A. Notify authorities of child neglect
• B. Contact poison control
• C. Determine medication allergies
• D. Induce vomiting
Answer: B
Rationale: After identifying the ingested toxin, contacting Poison Control immediately is
the priority action before attempting any other clinical interventions.
Q5. The nurse is performing an assessment on an adolescent client. Which behavior suggests
appropriate psychosocial development in this client?
• A. Validation for socially acceptable behavior from older adults
• B. Thinks about peers' opinions of them
• C. Gets along well with others in authority
• D. Navigates away from peers and enjoys spending time with family members
Answer: B
Rationale: According to Erikson, adolescents are in the Identity vs. Role Confusion stage
and are developmentally preoccupied with peer opinions.
Q6. The nurse is performing a nutritional assessment on an adolescent client. Which client
statement best indicates that the client's diet is healthy?
, • A. I make sure to eat 2 meals daily
• B. I make sure to drink 8 ounces of milk per day
• C. We use cheese in some of our meals
• D. My parents make sure I drink 8 glasses of water daily
Answer: D
• Rationale: Drinking 8 glasses of water daily demonstrates healthy hydration; the other
selections are nutritionally insufficient.
Q7. The nurse is educating new parents about immunizations and immunity. It indicates the
need for additional teaching if a parent states:
• A. Active immunity is what my child gets from me and is short-term protection
• B. My child will be protected for life from many diseases with active immunity
• C. My child will develop active immunity by producing antibodies to specific organisms
• D. Through active immunity, my child will develop long-term protection against
organisms
Answer: A
• Rationale: Active immunity is self-produced (long-term). The immunity a baby receives
from the mother (placental transfer/colostrum) is passive, which is temporary.
Q8. The nurse has attended a conference on immunizations. Which statement by the nurse
indicates that teaching has been effective?
• A. The recommended age to begin immunizations is 1 month
• B. Oral polio vaccine is preferred over inactivated poliovirus vaccine
• C. Children who have a common cold may still receive an immunization
• D. Preterm infants should receive their primary vaccinations at birth
Answer: C
Rationale: A mild acute illness (such as a common cold or low-grade fever) is not a
contraindication for receiving scheduled immunizations.
, Q9. The school nurse is on the playground with students and observes a child watching a small
group of children playing tag. The nurse recognizes this type of play as:
• A. Parallel
• B. Associative
• C. Onlooker
• D. Assistive
Answer: C
• Rationale: Onlooker play occurs when a child observes other children playing but does
not attempt to join the activity.
Q10. The nurse has provided discharge instructions to the parents of a 3-year-old who had a
cardiac catheterization. Which statement by the parents indicates a correct understanding of
the teaching?
• A. We will encourage our child to engage in normal activity for the next several days
• B. We will refrain from removing the adhesive bandage strip when we get home
• C. Our child will need to follow a low-protein diet for the next week
• D. Our child can take a bath beginning tomorrow
Answer: B
Rationale: The original pressure dressing must remain intact immediately post-
catheterization to prevent bleeding; tub baths are restricted.
Q11. The nurse is performing a respiratory assessment of an infant. It is necessary for the nurse
to notify the primary healthcare provider (PHCP) if the nurse observes that the infant:
• A. Is using abdominal breathing
• B. Has nasal flaring
• C. Has a respiratory rate of 30
• D. Has scattered rhonchi
