1 Exampromax - Stuvia US 2025/2026
NCLEX Pediatrics Questions and Correct Detailed
Answers (Verified Answers) ||Already Graded
A+||Newest Version
Which of the following is the most appropriate location for assessing the
pulse of an infant who is less than 1 year old?
1. Radial
2. Carotid
*3. Brachial*
4. Popliteal
*Rationale:* To assess a pulse in an infant (i.e., a child <1 year old), the
pulse is checked at the brachial artery. The infant's relatively short, fat neck
makes palpation of the carotid artery difficult. The popliteal and radial
Exampromax - Stuvia US
pulses are also difficult to palpate in an infant.
Approved By:
A nurse is teaching cardiopulmonary resuscitation to a group of nursing
students. The nurse asks a student to describe the reason why blind finger
sweeps are avoided in infants. The nurse determines that the student
understands the reason if the student makes which statement?
1. "The object may have been swallowed."
2. "The infant may bite down on the finger"
3. "The mouth is too small to see the object."
*4. "The object may be forced back further into the throat."*
*Rationale:* Blind finger sweeps are not recommended for infants and
children because of the risk of forcing the object further down into the
airway. Options 1, 2, and 3 are not related directly to the subject of the
question.
A nurse is collecting data about a child who has been admitted to the
hospital with a diagnosis of seizures. The nurse checks for causes of the
seizure activity by:
1. Testing the child's urine for specific gravity
2. Asking the child what happens during a seizure
3. Obtaining a family history of psychiatric illness
, 2 Exampromax - Stuvia US 2025/2026
*4. Obtaining a history regarding factors that may occur before the seizure
activity*
*Rationale:* Fever and infections increase the body's metabolic rate. This
can cause seizure activity among children who are less than 5-years-old.
Dehydration and electrolyte imbalance can also contribute to the
occurrence of a seizure. Falls can cause head injuries, which would increase
intracranial pressure or cerebral edema. Some medications could cause
seizures. Specific gravity would not be a reliable test, because it varies,
depending on the existing condition. Psychiatric illness has no impact on
seizure occurrence or cause. Children do not remember what happened
during the seizure itself.
A child has a basilar skull fracture. Which of the following health care
provider's prescriptions should the nurse question?
1. Restrict fluid intake.
Exampromax - Stuvia US
2. Insert an indwelling urinary catheter.
Approved By:
3. Keep an intravenous (IV) line patent.
*4. Suction via the nasotracheal route as needed.*
*Rationale:* Nasotracheal suctioning is contraindicated in a child with a
basilar skull fracture. Because of the location of the injury, the suction
catheter may be introduced into the brain. Fluids are restricted to prevent
fluid overload. The child may require a urinary catheter for the accurate
monitoring of intake and output. An IV line is maintained to administer
fluids or medications, if necessary.
Which of the following represents a primary characteristic of autism?
1. Normal social play
2. Consistent imitation of others' actions
*3. Lack of social interaction and awareness*
4. Normal verbal and nonverbal communication
, 3 Exampromax - Stuvia US 2025/2026
*Rationale:* Autism is a severe form of an autism spectrum disorder. A
primary characteristic is a lack of social interaction and awareness. Social
behaviors in autism include a lack of or an abnormal imitation of others'
actions and a lack of or abnormal social play. Additional characteristics
include a lack of or impaired verbal communication and markedly
abnormal nonverbal communication.
A nurse is assisting with data collection from an infant who has been
diagnosed with hydrocephalus. If the infant's level of consciousness
diminishes, a priority intervention is:
1. Taking the apical pulse
2. Taking the blood pressure
3. Testing the urine for protein
*4. Palpating the anterior fontanel*
Exampromax - Stuvia US
*Rationale:* A full or bulging anterior fontanel indicates an increase in
Approved By:
cerebrospinal fluid collection in the cerebral ventricle. Apical pulse and
blood pressure changes and proteinuria are not specifically associated with
increasing cerebrospinal fluid in the brain tissue in an infant.
A mother arrives at the emergency department with her 5-year-old child and
states that the child fell off a bunk bed. A head injury is suspected, and a
nurse is monitoring the child continuously for signs of increased intracranial
pressure (ICP). Which of the following is a late sign of increased ICP in this
child?
1. Nausea
*2. Bradycardia*
3. Bulging fontanel
4. Dilated scalp veins
*Rationale:* Late signs of increased ICP include a significant decrease in
the level of consciousness, bradycardia, and fixed and dilated pupils.
Nausea is an early sign of increased ICP. A bulging fontanel and dilated
scalp veins are early signs of increased ICP and would be noted in an infant
rather than in a 5-year-old child.
A child has been diagnosed with Reye's syndrome. The nurse understands
that a major symptom associated with Reye's syndrome is:
, 4 Exampromax - Stuvia US 2025/2026
*1. Persistent vomiting*
2. Protein in the urine
3. Symptoms of hyperglycemia
4. A history of a Staphylococcus infection
*Rationale:* Persistent vomiting is a major symptom that is associated with
increased intracranial pressure (ICP). Options 2, 3, and 4 are incorrect.
Protein is not present in the urine. Reye's syndrome is related to a history of
viral infections, and hypoglycemia is a symptom of this disease.
A nurse is developing a plan of care for a child who is at risk for seizures.
Which interventions apply if the child has a seizure? *Select all that apply.*
*1. Time the seizure.*
2. Restrain the child.
Exampromax - Stuvia US
*3. Stay with the child.*
4. Place the child in a prone position.
Approved By:
*5. Move furniture away from the child.*
6. Insert a padded tongue blade into the child's mouth.
*Rationale:* During a seizure, the child is placed on his or her side in a
lateral position. This type of positioning will prevent aspiration, because
saliva will drain out of the corner of the child's mouth. The child is not
restrained, because this could cause injury. The nurse would loosen clothing
around the child's neck and ensure a patent airway. Nothing is placed into
the child's mouth during a seizure, because this action may cause injury to
the child's mouth, gums, or teeth. The nurse would stay with the child to
reduce the risk of injury and allow for the observation and timing of the
seizure.
The appropriate child position after a tonsillectomy is which of the
following?
1. Supine position
*2. Side-lying position*
3. High Fowler's position
4. Trendelenburg's position
NCLEX Pediatrics Questions and Correct Detailed
Answers (Verified Answers) ||Already Graded
A+||Newest Version
Which of the following is the most appropriate location for assessing the
pulse of an infant who is less than 1 year old?
1. Radial
2. Carotid
*3. Brachial*
4. Popliteal
*Rationale:* To assess a pulse in an infant (i.e., a child <1 year old), the
pulse is checked at the brachial artery. The infant's relatively short, fat neck
makes palpation of the carotid artery difficult. The popliteal and radial
Exampromax - Stuvia US
pulses are also difficult to palpate in an infant.
Approved By:
A nurse is teaching cardiopulmonary resuscitation to a group of nursing
students. The nurse asks a student to describe the reason why blind finger
sweeps are avoided in infants. The nurse determines that the student
understands the reason if the student makes which statement?
1. "The object may have been swallowed."
2. "The infant may bite down on the finger"
3. "The mouth is too small to see the object."
*4. "The object may be forced back further into the throat."*
*Rationale:* Blind finger sweeps are not recommended for infants and
children because of the risk of forcing the object further down into the
airway. Options 1, 2, and 3 are not related directly to the subject of the
question.
A nurse is collecting data about a child who has been admitted to the
hospital with a diagnosis of seizures. The nurse checks for causes of the
seizure activity by:
1. Testing the child's urine for specific gravity
2. Asking the child what happens during a seizure
3. Obtaining a family history of psychiatric illness
, 2 Exampromax - Stuvia US 2025/2026
*4. Obtaining a history regarding factors that may occur before the seizure
activity*
*Rationale:* Fever and infections increase the body's metabolic rate. This
can cause seizure activity among children who are less than 5-years-old.
Dehydration and electrolyte imbalance can also contribute to the
occurrence of a seizure. Falls can cause head injuries, which would increase
intracranial pressure or cerebral edema. Some medications could cause
seizures. Specific gravity would not be a reliable test, because it varies,
depending on the existing condition. Psychiatric illness has no impact on
seizure occurrence or cause. Children do not remember what happened
during the seizure itself.
A child has a basilar skull fracture. Which of the following health care
provider's prescriptions should the nurse question?
1. Restrict fluid intake.
Exampromax - Stuvia US
2. Insert an indwelling urinary catheter.
Approved By:
3. Keep an intravenous (IV) line patent.
*4. Suction via the nasotracheal route as needed.*
*Rationale:* Nasotracheal suctioning is contraindicated in a child with a
basilar skull fracture. Because of the location of the injury, the suction
catheter may be introduced into the brain. Fluids are restricted to prevent
fluid overload. The child may require a urinary catheter for the accurate
monitoring of intake and output. An IV line is maintained to administer
fluids or medications, if necessary.
Which of the following represents a primary characteristic of autism?
1. Normal social play
2. Consistent imitation of others' actions
*3. Lack of social interaction and awareness*
4. Normal verbal and nonverbal communication
, 3 Exampromax - Stuvia US 2025/2026
*Rationale:* Autism is a severe form of an autism spectrum disorder. A
primary characteristic is a lack of social interaction and awareness. Social
behaviors in autism include a lack of or an abnormal imitation of others'
actions and a lack of or abnormal social play. Additional characteristics
include a lack of or impaired verbal communication and markedly
abnormal nonverbal communication.
A nurse is assisting with data collection from an infant who has been
diagnosed with hydrocephalus. If the infant's level of consciousness
diminishes, a priority intervention is:
1. Taking the apical pulse
2. Taking the blood pressure
3. Testing the urine for protein
*4. Palpating the anterior fontanel*
Exampromax - Stuvia US
*Rationale:* A full or bulging anterior fontanel indicates an increase in
Approved By:
cerebrospinal fluid collection in the cerebral ventricle. Apical pulse and
blood pressure changes and proteinuria are not specifically associated with
increasing cerebrospinal fluid in the brain tissue in an infant.
A mother arrives at the emergency department with her 5-year-old child and
states that the child fell off a bunk bed. A head injury is suspected, and a
nurse is monitoring the child continuously for signs of increased intracranial
pressure (ICP). Which of the following is a late sign of increased ICP in this
child?
1. Nausea
*2. Bradycardia*
3. Bulging fontanel
4. Dilated scalp veins
*Rationale:* Late signs of increased ICP include a significant decrease in
the level of consciousness, bradycardia, and fixed and dilated pupils.
Nausea is an early sign of increased ICP. A bulging fontanel and dilated
scalp veins are early signs of increased ICP and would be noted in an infant
rather than in a 5-year-old child.
A child has been diagnosed with Reye's syndrome. The nurse understands
that a major symptom associated with Reye's syndrome is:
, 4 Exampromax - Stuvia US 2025/2026
*1. Persistent vomiting*
2. Protein in the urine
3. Symptoms of hyperglycemia
4. A history of a Staphylococcus infection
*Rationale:* Persistent vomiting is a major symptom that is associated with
increased intracranial pressure (ICP). Options 2, 3, and 4 are incorrect.
Protein is not present in the urine. Reye's syndrome is related to a history of
viral infections, and hypoglycemia is a symptom of this disease.
A nurse is developing a plan of care for a child who is at risk for seizures.
Which interventions apply if the child has a seizure? *Select all that apply.*
*1. Time the seizure.*
2. Restrain the child.
Exampromax - Stuvia US
*3. Stay with the child.*
4. Place the child in a prone position.
Approved By:
*5. Move furniture away from the child.*
6. Insert a padded tongue blade into the child's mouth.
*Rationale:* During a seizure, the child is placed on his or her side in a
lateral position. This type of positioning will prevent aspiration, because
saliva will drain out of the corner of the child's mouth. The child is not
restrained, because this could cause injury. The nurse would loosen clothing
around the child's neck and ensure a patent airway. Nothing is placed into
the child's mouth during a seizure, because this action may cause injury to
the child's mouth, gums, or teeth. The nurse would stay with the child to
reduce the risk of injury and allow for the observation and timing of the
seizure.
The appropriate child position after a tonsillectomy is which of the
following?
1. Supine position
*2. Side-lying position*
3. High Fowler's position
4. Trendelenburg's position
