PNR 204/PNR204 Final Exam V2 | Pediatric
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a 4-year-old child during a well-child visit. According to Erikson’s stages
of psychosocial development, which task should the nurse expect the child to be working on?
A. Autonomy vs. Shame and Doubt
B. Trust vs. Mistrust
C. Initiative vs. Guilt
D. Industry vs. Inferiority
Correct Answer: C
Explanation: Preschool-aged children (3 to 6 years) are in the stage of Initiative vs. Guilt
where they explore their environment and develop a sense of purpose. Failure to allow this
exploration may lead to a sense of guilt. Autonomy vs. Shame is the toddler stage, and
Industry vs. Inferiority belongs to school-aged children.
2. A nurse is providing discharge instructions to the parents of an infant following a cleft lip
repair. Which of the following instructions should the nurse include?
A. Clean the suture line with full-strength hydrogen peroxide.
B. Place the infant in the prone position for sleep.
C. Use a standard bottle nipple for feedings immediately.
D. Apply a thin layer of antibiotic ointment to the suture line as prescribed.
,Correct Answer: D
Explanation: Postoperative care for cleft lip repair focuses on protecting the site and
preventing infection. Antibiotic ointment is often applied to keep the site clean and moist to
minimize scarring. Infants should be placed in an upright or side-lying position, not prone,
to avoid rubbing the suture line.
3. A 10-month-old infant is brought to the clinic for a routine check-up. The nurse notes the
infant can sit unsupported and pick up small objects using a pincer grasp. Which
developmental category does this fall under?
A. Fine motor skills
B. Gross motor skills
C. Cognitive development
D. Social-emotional development
Correct Answer: A
Explanation: The pincer grasp is a hallmark of fine motor development occurring around 8
to 10 months of age. It involves the coordination of small muscles in the hands and fingers.
Gross motor skills involve larger movements like sitting or walking, while fine motor skills
involve precise manual tasks.
4. A nurse is caring for a child with suspected epiglottitis. Which of the following actions is the
priority for the nurse to take?
A. Obtain a throat culture to identify the pathogen.
, B. Perform a physical assessment using a tongue depressor.
C. Prepare for immediate nasotracheal intubation or tracheostomy.
D. Apply a warm compress to the child’s neck.
Correct Answer: C
Explanation: Epiglottitis is a medical emergency that can lead to rapid airway obstruction.
The nurse’s priority is to maintain airway patency, often requiring emergency equipment
at the bedside. Throat cultures and the use of tongue depressors are strictly
contraindicated as they can trigger a laryngospasm and total airway closure.
5. Which of the following findings should the nurse expect when assessing a child with
Tetralogy of Fallot?
A. Bounding peripheral pulses
B. Low hematocrit levels
C. Clubbing of the fingers
D. Bradycardia
Correct Answer: C
Explanation: Tetralogy of Fallot is a cyanotic heart defect that results in chronic hypoxia.
Chronic hypoxia leads to polycythemia (high RBCs) and finger clubbing as the body
attempts to compensate for low oxygen levels. Bounding pulses are more common in
Patent Ductus Arteriosus (PDA).
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a 4-year-old child during a well-child visit. According to Erikson’s stages
of psychosocial development, which task should the nurse expect the child to be working on?
A. Autonomy vs. Shame and Doubt
B. Trust vs. Mistrust
C. Initiative vs. Guilt
D. Industry vs. Inferiority
Correct Answer: C
Explanation: Preschool-aged children (3 to 6 years) are in the stage of Initiative vs. Guilt
where they explore their environment and develop a sense of purpose. Failure to allow this
exploration may lead to a sense of guilt. Autonomy vs. Shame is the toddler stage, and
Industry vs. Inferiority belongs to school-aged children.
2. A nurse is providing discharge instructions to the parents of an infant following a cleft lip
repair. Which of the following instructions should the nurse include?
A. Clean the suture line with full-strength hydrogen peroxide.
B. Place the infant in the prone position for sleep.
C. Use a standard bottle nipple for feedings immediately.
D. Apply a thin layer of antibiotic ointment to the suture line as prescribed.
,Correct Answer: D
Explanation: Postoperative care for cleft lip repair focuses on protecting the site and
preventing infection. Antibiotic ointment is often applied to keep the site clean and moist to
minimize scarring. Infants should be placed in an upright or side-lying position, not prone,
to avoid rubbing the suture line.
3. A 10-month-old infant is brought to the clinic for a routine check-up. The nurse notes the
infant can sit unsupported and pick up small objects using a pincer grasp. Which
developmental category does this fall under?
A. Fine motor skills
B. Gross motor skills
C. Cognitive development
D. Social-emotional development
Correct Answer: A
Explanation: The pincer grasp is a hallmark of fine motor development occurring around 8
to 10 months of age. It involves the coordination of small muscles in the hands and fingers.
Gross motor skills involve larger movements like sitting or walking, while fine motor skills
involve precise manual tasks.
4. A nurse is caring for a child with suspected epiglottitis. Which of the following actions is the
priority for the nurse to take?
A. Obtain a throat culture to identify the pathogen.
, B. Perform a physical assessment using a tongue depressor.
C. Prepare for immediate nasotracheal intubation or tracheostomy.
D. Apply a warm compress to the child’s neck.
Correct Answer: C
Explanation: Epiglottitis is a medical emergency that can lead to rapid airway obstruction.
The nurse’s priority is to maintain airway patency, often requiring emergency equipment
at the bedside. Throat cultures and the use of tongue depressors are strictly
contraindicated as they can trigger a laryngospasm and total airway closure.
5. Which of the following findings should the nurse expect when assessing a child with
Tetralogy of Fallot?
A. Bounding peripheral pulses
B. Low hematocrit levels
C. Clubbing of the fingers
D. Bradycardia
Correct Answer: C
Explanation: Tetralogy of Fallot is a cyanotic heart defect that results in chronic hypoxia.
Chronic hypoxia leads to polycythemia (high RBCs) and finger clubbing as the body
attempts to compensate for low oxygen levels. Bounding pulses are more common in
Patent Ductus Arteriosus (PDA).
