NSG 3600 Exam 3 Actual Exam V1 | NSG 3600 Nursing Practice –
Children’s Health (NSG3600 Exam 3)
1. A 4-month-old infant is admitted with suspected Tetralogy of Fallot. Which clinical
manifestation should the nurse anticipate during the assessment?
A. Bounding peripheral pulses in upper extremities
B. Decreased breath sounds on the right side
C. A machinery-like continuous murmur
D. A harsh systolic murmur heard at the left sternal border
Answer: D
Rationale: Tetralogy of Fallot typically presents with a harsh systolic murmur due to
pulmonary stenosis and the ventricular septal defect. Bounding pulses are more
characteristic of Patent Ductus Arteriosus (PDA) or Coarctation of the Aorta. The nurse
must prioritize monitoring for hypercyanotic spells in these patients.
2. The nurse is caring for a child experiencing a ‘Tet spell.’ Which action should the nurse
perform first?
A. Administer 100% oxygen via non-rebreather mask
B. Place the child in a knee-chest position
C. Prepare for immediate administration of Morphine sulfate
D. Initiate an intravenous fluid bolus
Answer: B
Rationale: Placing the child in the knee-chest position increases systemic vascular
resistance, which helps reduce the right-to-left shunting of blood. This is the first-line
intervention to improve oxygenation during an acute hypercyanotic spell. Oxygen and
medications are secondary to this physiological maneuver.
3. A nurse is monitoring an infant receiving Digoxin for heart failure. Which sign would most
likely indicate Digoxin toxicity?
A. Vomiting unrelated to feedings
B. Heart rate of 140 beats per minute
C. Increased urinary output
D. Elevated serum potassium level
Answer: A
,Rationale: Vomiting is a classic early sign of Digoxin toxicity in infants and children.
Bradycardia, rather than tachycardia, is also a common indicator of toxic levels. The nurse
should always double-check the dose and monitor apical pulse for a full minute before
administration.
4. A 10-year-old child is diagnosed with Coarctation of the Aorta. What finding should the
nurse expect during the physical examination?
A. Severe clubbing of the fingers
B. Cyanosis of the upper extremities
C. Lower blood pressure in the arms than the legs
D. Weak or absent femoral pulses
Answer: D
Rationale: Coarctation of the Aorta involves narrowing of the lumen, which results in high
blood pressure in the upper body and low blood pressure/weak pulses in the lower body.
Nursing assessments must include four-limb blood pressure checks to identify these
discrepancies. This condition often presents with headaches or leg pain upon exertion.
5. Which intervention is considered a priority for a child in the acute phase of Kawasaki
Disease?
A. Encouraging high-impact physical activity
B. Applying warm compresses to swollen joints
C. Administering high-dose Aspirin and IVIG
D. Providing a high-protein, low-fat diet
Answer: C
Rationale: Intravenous immunoglobulin (IVIG) and high-dose aspirin are the standards of
care to prevent coronary artery aneurysms in Kawasaki Disease. The nurse must monitor
the child’s cardiac status closely during the inflammatory phase. Aspirin therapy is
continued at lower doses for its anti-platelet effects after the fever subsides.
6. A 7-year-old is admitted with suspected Rheumatic Fever. Which finding, according to the
Jones Criteria, supports this diagnosis?
A. Polyarthritis and Erythema Marginatum
B. Generalized maculopapular rash
C. Elevated white blood cell count
D. History of viral gastroenteritis
Answer: A
, Rationale: The Jones Criteria for Rheumatic Fever include major manifestations like
polyarthritis, carditis, chorea, and Erythema Marginatum. A recent Group A Beta-Hemolytic
Streptococcal infection is usually the trigger for this autoimmune response. Nurses should
assess for joint pain and subcutaneous nodules during the physical exam.
7. A nurse is caring for an infant with hydrocephalus who just underwent a
Ventriculoperitoneal (VP) shunt placement. How should the nurse position the infant
postoperatively?
A. High-Fowler’s to promote drainage
B. On the operative side to put pressure on the valve
C. Flat on the non-operative side
D. Prone with the head turned to the side
Answer: C
Rationale: The infant should be kept flat to prevent rapid fluid drainage from the brain,
which could lead to a subdural hematoma. Positioning on the non-operative side prevents
pressure on the shunt valve and site. Gradual elevation of the head of the bed is typically
ordered by the surgeon over several days.
8. A child is admitted with Bacterial Meningitis. Which nursing intervention is the most critical
during the first 24 hours?
A. Maintaining strict respiratory isolation precautions
B. Providing frequent range of motion exercises
C. Encouraging oral fluid intake to prevent dehydration
D. Increasing environmental stimulation to assess sensorium
Answer: A
Rationale: Bacterial meningitis is highly contagious and requires droplet precautions for at
least 24 hours after starting effective antibiotic therapy. The nurse must also maintain a
quiet, low-stimulus environment to prevent triggering seizures or increasing intracranial
pressure. Frequent neurological assessments are vital to detect early signs of deterioration.
9. Which assessment finding in an 8-month-old infant is the most sensitive indicator of
increased intracranial pressure (ICP)?
A. A bulging, tense fontanel
B. A decrease in systolic blood pressure
C. Constricted, pinpoint pupils
D. Increased interest in play
Children’s Health (NSG3600 Exam 3)
1. A 4-month-old infant is admitted with suspected Tetralogy of Fallot. Which clinical
manifestation should the nurse anticipate during the assessment?
A. Bounding peripheral pulses in upper extremities
B. Decreased breath sounds on the right side
C. A machinery-like continuous murmur
D. A harsh systolic murmur heard at the left sternal border
Answer: D
Rationale: Tetralogy of Fallot typically presents with a harsh systolic murmur due to
pulmonary stenosis and the ventricular septal defect. Bounding pulses are more
characteristic of Patent Ductus Arteriosus (PDA) or Coarctation of the Aorta. The nurse
must prioritize monitoring for hypercyanotic spells in these patients.
2. The nurse is caring for a child experiencing a ‘Tet spell.’ Which action should the nurse
perform first?
A. Administer 100% oxygen via non-rebreather mask
B. Place the child in a knee-chest position
C. Prepare for immediate administration of Morphine sulfate
D. Initiate an intravenous fluid bolus
Answer: B
Rationale: Placing the child in the knee-chest position increases systemic vascular
resistance, which helps reduce the right-to-left shunting of blood. This is the first-line
intervention to improve oxygenation during an acute hypercyanotic spell. Oxygen and
medications are secondary to this physiological maneuver.
3. A nurse is monitoring an infant receiving Digoxin for heart failure. Which sign would most
likely indicate Digoxin toxicity?
A. Vomiting unrelated to feedings
B. Heart rate of 140 beats per minute
C. Increased urinary output
D. Elevated serum potassium level
Answer: A
,Rationale: Vomiting is a classic early sign of Digoxin toxicity in infants and children.
Bradycardia, rather than tachycardia, is also a common indicator of toxic levels. The nurse
should always double-check the dose and monitor apical pulse for a full minute before
administration.
4. A 10-year-old child is diagnosed with Coarctation of the Aorta. What finding should the
nurse expect during the physical examination?
A. Severe clubbing of the fingers
B. Cyanosis of the upper extremities
C. Lower blood pressure in the arms than the legs
D. Weak or absent femoral pulses
Answer: D
Rationale: Coarctation of the Aorta involves narrowing of the lumen, which results in high
blood pressure in the upper body and low blood pressure/weak pulses in the lower body.
Nursing assessments must include four-limb blood pressure checks to identify these
discrepancies. This condition often presents with headaches or leg pain upon exertion.
5. Which intervention is considered a priority for a child in the acute phase of Kawasaki
Disease?
A. Encouraging high-impact physical activity
B. Applying warm compresses to swollen joints
C. Administering high-dose Aspirin and IVIG
D. Providing a high-protein, low-fat diet
Answer: C
Rationale: Intravenous immunoglobulin (IVIG) and high-dose aspirin are the standards of
care to prevent coronary artery aneurysms in Kawasaki Disease. The nurse must monitor
the child’s cardiac status closely during the inflammatory phase. Aspirin therapy is
continued at lower doses for its anti-platelet effects after the fever subsides.
6. A 7-year-old is admitted with suspected Rheumatic Fever. Which finding, according to the
Jones Criteria, supports this diagnosis?
A. Polyarthritis and Erythema Marginatum
B. Generalized maculopapular rash
C. Elevated white blood cell count
D. History of viral gastroenteritis
Answer: A
, Rationale: The Jones Criteria for Rheumatic Fever include major manifestations like
polyarthritis, carditis, chorea, and Erythema Marginatum. A recent Group A Beta-Hemolytic
Streptococcal infection is usually the trigger for this autoimmune response. Nurses should
assess for joint pain and subcutaneous nodules during the physical exam.
7. A nurse is caring for an infant with hydrocephalus who just underwent a
Ventriculoperitoneal (VP) shunt placement. How should the nurse position the infant
postoperatively?
A. High-Fowler’s to promote drainage
B. On the operative side to put pressure on the valve
C. Flat on the non-operative side
D. Prone with the head turned to the side
Answer: C
Rationale: The infant should be kept flat to prevent rapid fluid drainage from the brain,
which could lead to a subdural hematoma. Positioning on the non-operative side prevents
pressure on the shunt valve and site. Gradual elevation of the head of the bed is typically
ordered by the surgeon over several days.
8. A child is admitted with Bacterial Meningitis. Which nursing intervention is the most critical
during the first 24 hours?
A. Maintaining strict respiratory isolation precautions
B. Providing frequent range of motion exercises
C. Encouraging oral fluid intake to prevent dehydration
D. Increasing environmental stimulation to assess sensorium
Answer: A
Rationale: Bacterial meningitis is highly contagious and requires droplet precautions for at
least 24 hours after starting effective antibiotic therapy. The nurse must also maintain a
quiet, low-stimulus environment to prevent triggering seizures or increasing intracranial
pressure. Frequent neurological assessments are vital to detect early signs of deterioration.
9. Which assessment finding in an 8-month-old infant is the most sensitive indicator of
increased intracranial pressure (ICP)?
A. A bulging, tense fontanel
B. A decrease in systolic blood pressure
C. Constricted, pinpoint pupils
D. Increased interest in play
