1. A nurse is assessing a 6-month-old infant during a routine health visit. Which finding
requires the most immediate follow-up?
A. Stranger anxiety when the nurse approaches
B. Rolls from abdomen to back
C. Persistent head lag when pulled to a sitting position
D. Reaches for a toy placed nearby
Answer: C
EXPLANATION: Persistent head lag at 6 months may indicate delayed neuromuscular
development and requires further evaluation.
2. The nurse is preparing to administer an intramuscular medication to a 2-month-old
infant. Which site is preferred?
A. Vastus lateralis
B. Dorsogluteal
C. Deltoid
D. Ventrogluteal
Answer: A
EXPLANATION: The vastus lateralis is the preferred intramuscular injection site for infants
because it provides adequate muscle mass and avoids major nerves.
3. A hospitalized toddler becomes upset when the parent leaves the room. Which nursing
intervention best supports the child's developmental needs?
A. Explain that the parent will return after the procedure
B. Encourage the child to remain alone to promote independence
C. Tell the child that crying is inappropriate
D. Provide consistent routines and allow a familiar object for comfort
Answer: D
EXPLANATION: Toddlers benefit from predictable routines and transitional objects when
separated from caregivers.
4. A nurse is teaching parents about safe sleep for a healthy infant. Which instruction is
most appropriate?
A. Place the infant prone after feeding
B. Place the infant supine on a firm sleep surface
,C. Use pillows to prevent positional changes
D. Allow the infant to sleep in the parent's bed
Answer: B
EXPLANATION: Infants should be placed on their backs on a firm, flat sleep surface without
loose bedding or soft objects to reduce sleep-related injury risk.
5. A 4-year-old hospitalized child believes illness occurred because the child was “bad.”
Which response by the nurse is most appropriate?
A. “You should not think about that.”
B. “Your parents can explain why you became sick.”
C. “Being sick is not a punishment for something you did.”
D. “Most children your age think the same way.”
Answer: C
EXPLANATION: Preschoolers may use magical thinking and believe illness is punishment. The
nurse should provide simple reassurance without reinforcing the misconception.
6. Which assessment finding is most concerning in a child with suspected dehydration?
A. Capillary refill of 4 seconds
B. Mild thirst
C. Moist mucous membranes
D. Urine output of 2 mL/kg/hr
Answer: A
EXPLANATION: Delayed capillary refill suggests reduced peripheral perfusion and may indicate
significant dehydration.
7. A nurse is caring for a child with acute gastroenteritis. Which finding best indicates that
fluid replacement is effective?
A. Increased thirst
B. Continued vomiting
C. Increasing lethargy
D. Urine output improves and mucous membranes become moist
Answer: D
EXPLANATION: Improved urine output and mucous membrane moisture indicate restoration of
circulating volume and hydration.
8. A child with asthma suddenly develops severe respiratory distress and markedly
diminished breath sounds. What should the nurse recognize?
A. The asthma attack is resolving
B. The child may have minimal air movement and impending respiratory failure
C. The child is experiencing mild bronchospasm
D. The finding is expected after bronchodilator therapy
,Answer: B
EXPLANATION: A “silent chest” or markedly diminished air movement during severe asthma
indicates critical airflow obstruction and requires immediate intervention.
9. Which position is generally most appropriate for a child experiencing acute respiratory
distress?
A. Flat supine
B. Trendelenburg
C. Upright or semi-Fowler position
D. Prone with the head turned
Answer: C
EXPLANATION: Upright positioning promotes lung expansion and reduces the work of
breathing.
10. A child with croup has a barking cough and inspiratory stridor. Which action should
the nurse take first?
A. Keep the child calm and minimize agitation
B. Inspect the throat with a tongue blade
C. Encourage vigorous coughing
D. Place the child flat in bed
Answer: A
EXPLANATION: Agitation can worsen upper-airway obstruction in croup. Keeping the child calm
is an immediate nursing priority.
11. A child is suspected of having epiglottitis. Which intervention should the nurse avoid?
A. Maintaining airway equipment nearby
B. Allowing the child to remain in a position of comfort
C. Providing oxygen as prescribed
D. Inspecting the throat with a tongue blade
Answer: D
EXPLANATION: Throat manipulation can trigger sudden airway obstruction in suspected
epiglottitis and should be avoided.
12. A nurse is teaching parents about using a metered-dose inhaler with a spacer for a
school-age child. Which instruction is correct?
A. The child should inhale rapidly after activation
B. The child should exhale fully before inhaling the medication
C. The spacer eliminates the need for inhalation
D. The child should immediately repeat every dose without waiting
Answer: B
EXPLANATION: Exhaling before inhalation and then slowly inhaling through the spacer
improves medication deposition in the lower airways.
, 13. Which finding is characteristic of increased work of breathing in an infant?
A. Nasal flaring
B. Warm hands
C. Regular respiratory pattern
D. Quiet sleep
Answer: A
EXPLANATION: Nasal flaring is a compensatory response indicating increased respiratory effort
in infants.
14. A child with cystic fibrosis is prescribed pancreatic enzymes. When should the nurse
instruct the family to administer them?
A. Only at bedtime
B. One hour after meals
C. With meals and snacks
D. Only when abdominal pain occurs
Answer: C
EXPLANATION: Pancreatic enzymes should be taken with meals and snacks to aid digestion and
absorption of nutrients.
15. Which dietary intervention is appropriate for a child with cystic fibrosis?
A. Restrict fat intake severely
B. Provide a high-calorie, high-protein diet
C. Limit sodium under all circumstances
D. Encourage fasting during respiratory infections
Answer: B
EXPLANATION: Children with cystic fibrosis have increased nutritional requirements and
generally benefit from calorie-dense, high-protein nutrition with appropriate enzyme
replacement.
16. A child with pneumonia is receiving antibiotics. Which finding best suggests
improvement?
A. Increasing respiratory rate
B. Decreased oxygen saturation
C. Increasing cyanosis
D. Reduced work of breathing and improved oxygenation
Answer: D
EXPLANATION: Reduced respiratory effort and improved oxygenation indicate that gas
exchange and respiratory status are improving.
17. A nurse is assessing a child with suspected bacterial meningitis. Which finding is most
concerning?
A. Increased appetite
requires the most immediate follow-up?
A. Stranger anxiety when the nurse approaches
B. Rolls from abdomen to back
C. Persistent head lag when pulled to a sitting position
D. Reaches for a toy placed nearby
Answer: C
EXPLANATION: Persistent head lag at 6 months may indicate delayed neuromuscular
development and requires further evaluation.
2. The nurse is preparing to administer an intramuscular medication to a 2-month-old
infant. Which site is preferred?
A. Vastus lateralis
B. Dorsogluteal
C. Deltoid
D. Ventrogluteal
Answer: A
EXPLANATION: The vastus lateralis is the preferred intramuscular injection site for infants
because it provides adequate muscle mass and avoids major nerves.
3. A hospitalized toddler becomes upset when the parent leaves the room. Which nursing
intervention best supports the child's developmental needs?
A. Explain that the parent will return after the procedure
B. Encourage the child to remain alone to promote independence
C. Tell the child that crying is inappropriate
D. Provide consistent routines and allow a familiar object for comfort
Answer: D
EXPLANATION: Toddlers benefit from predictable routines and transitional objects when
separated from caregivers.
4. A nurse is teaching parents about safe sleep for a healthy infant. Which instruction is
most appropriate?
A. Place the infant prone after feeding
B. Place the infant supine on a firm sleep surface
,C. Use pillows to prevent positional changes
D. Allow the infant to sleep in the parent's bed
Answer: B
EXPLANATION: Infants should be placed on their backs on a firm, flat sleep surface without
loose bedding or soft objects to reduce sleep-related injury risk.
5. A 4-year-old hospitalized child believes illness occurred because the child was “bad.”
Which response by the nurse is most appropriate?
A. “You should not think about that.”
B. “Your parents can explain why you became sick.”
C. “Being sick is not a punishment for something you did.”
D. “Most children your age think the same way.”
Answer: C
EXPLANATION: Preschoolers may use magical thinking and believe illness is punishment. The
nurse should provide simple reassurance without reinforcing the misconception.
6. Which assessment finding is most concerning in a child with suspected dehydration?
A. Capillary refill of 4 seconds
B. Mild thirst
C. Moist mucous membranes
D. Urine output of 2 mL/kg/hr
Answer: A
EXPLANATION: Delayed capillary refill suggests reduced peripheral perfusion and may indicate
significant dehydration.
7. A nurse is caring for a child with acute gastroenteritis. Which finding best indicates that
fluid replacement is effective?
A. Increased thirst
B. Continued vomiting
C. Increasing lethargy
D. Urine output improves and mucous membranes become moist
Answer: D
EXPLANATION: Improved urine output and mucous membrane moisture indicate restoration of
circulating volume and hydration.
8. A child with asthma suddenly develops severe respiratory distress and markedly
diminished breath sounds. What should the nurse recognize?
A. The asthma attack is resolving
B. The child may have minimal air movement and impending respiratory failure
C. The child is experiencing mild bronchospasm
D. The finding is expected after bronchodilator therapy
,Answer: B
EXPLANATION: A “silent chest” or markedly diminished air movement during severe asthma
indicates critical airflow obstruction and requires immediate intervention.
9. Which position is generally most appropriate for a child experiencing acute respiratory
distress?
A. Flat supine
B. Trendelenburg
C. Upright or semi-Fowler position
D. Prone with the head turned
Answer: C
EXPLANATION: Upright positioning promotes lung expansion and reduces the work of
breathing.
10. A child with croup has a barking cough and inspiratory stridor. Which action should
the nurse take first?
A. Keep the child calm and minimize agitation
B. Inspect the throat with a tongue blade
C. Encourage vigorous coughing
D. Place the child flat in bed
Answer: A
EXPLANATION: Agitation can worsen upper-airway obstruction in croup. Keeping the child calm
is an immediate nursing priority.
11. A child is suspected of having epiglottitis. Which intervention should the nurse avoid?
A. Maintaining airway equipment nearby
B. Allowing the child to remain in a position of comfort
C. Providing oxygen as prescribed
D. Inspecting the throat with a tongue blade
Answer: D
EXPLANATION: Throat manipulation can trigger sudden airway obstruction in suspected
epiglottitis and should be avoided.
12. A nurse is teaching parents about using a metered-dose inhaler with a spacer for a
school-age child. Which instruction is correct?
A. The child should inhale rapidly after activation
B. The child should exhale fully before inhaling the medication
C. The spacer eliminates the need for inhalation
D. The child should immediately repeat every dose without waiting
Answer: B
EXPLANATION: Exhaling before inhalation and then slowly inhaling through the spacer
improves medication deposition in the lower airways.
, 13. Which finding is characteristic of increased work of breathing in an infant?
A. Nasal flaring
B. Warm hands
C. Regular respiratory pattern
D. Quiet sleep
Answer: A
EXPLANATION: Nasal flaring is a compensatory response indicating increased respiratory effort
in infants.
14. A child with cystic fibrosis is prescribed pancreatic enzymes. When should the nurse
instruct the family to administer them?
A. Only at bedtime
B. One hour after meals
C. With meals and snacks
D. Only when abdominal pain occurs
Answer: C
EXPLANATION: Pancreatic enzymes should be taken with meals and snacks to aid digestion and
absorption of nutrients.
15. Which dietary intervention is appropriate for a child with cystic fibrosis?
A. Restrict fat intake severely
B. Provide a high-calorie, high-protein diet
C. Limit sodium under all circumstances
D. Encourage fasting during respiratory infections
Answer: B
EXPLANATION: Children with cystic fibrosis have increased nutritional requirements and
generally benefit from calorie-dense, high-protein nutrition with appropriate enzyme
replacement.
16. A child with pneumonia is receiving antibiotics. Which finding best suggests
improvement?
A. Increasing respiratory rate
B. Decreased oxygen saturation
C. Increasing cyanosis
D. Reduced work of breathing and improved oxygenation
Answer: D
EXPLANATION: Reduced respiratory effort and improved oxygenation indicate that gas
exchange and respiratory status are improving.
17. A nurse is assessing a child with suspected bacterial meningitis. Which finding is most
concerning?
A. Increased appetite
