PNR 204/PNR204 Exam 1 V3 | Pediatric Nursing
Q&A with Rationale | Fortis College
1. A nurse is caring for a 4-year-old child following surgery. Which pain assessment tool
should the nurse use to determine the child’s level of pain?
A. FLACC scale
B. Numerical scale (0-10)
C. CRIES scale
D. Wong-Baker FACES scale
Correct Answer: D
Explanation: The Wong-Baker FACES scale is appropriate for children as young as 3 years
old because it uses visual depictions of pain levels. Children at this developmental stage
cannot yet conceptualize numerical values for pain. This tool allows the child to point to the
face that best represents their current state of discomfort.
2. According to Erikson’s theory of psychosocial development, which task should a nurse
expect a toddler (1 to 3 years old) to be working on?
A. Trust vs. Mistrust
B. Industry vs. Inferiority
C. Initiative vs. Guilt
D. Autonomy vs. Shame and Doubt
,Correct Answer: D
Explanation: The toddler stage is characterized by the struggle for autonomy vs. shame
and doubt. Children during this time are learning to express their independence through
choices like food and clothing. If they are constantly criticized or restricted, they may
develop a sense of shame regarding their abilities.
3. A mother of a 6-month-old infant expresses concern that her child cannot sit up without
support yet. What is the most appropriate response by the nurse?
A. This is normal, as infants typically master sitting unsupported between 6 to 8 months.
B. Most infants do not sit up unsupported until about 8 months of age.
C. This is a serious developmental delay and requires immediate referral.
D. You should begin physical therapy exercises to strengthen the core.
Correct Answer: A
Explanation: Sitting alone without support is a milestone usually achieved between 6 and
8 months of age. At 6 months, many infants can sit with support or only for brief moments
alone. The nurse should reassure the parent that the child is within the expected
developmental range.
4. Which of the following is the priority assessment when a nurse is examining a child with
suspected epiglottitis?
A. Inspecting the throat with a tongue blade
B. Obtaining a throat culture
, C. Assessing for drooling and agitation
D. Checking the child’s height and weight
Correct Answer: C
Explanation: Drooling, agitation, and a ‘tripod’ position are classic signs of epiglottitis,
which is a medical emergency. The nurse must never use a tongue blade or attempt a throat
culture because this could trigger a laryngospasm and complete airway obstruction.
Airway maintenance is the absolute priority for these patients.
5. When administering an intramuscular injection to a 10-month-old infant, which site is
preferred?
A. Deltoid muscle
B. Vastus lateralis muscle
C. Dorsogluteal muscle
D. Ventrogluteal muscle
Correct Answer: B
Explanation: The vastus lateralis is the preferred site for IM injections in infants because it
is the most developed muscle mass at this age. The deltoid is not sufficiently developed
until the child is older, usually around 18 months or once they are walking. Using the
vastus lateralis avoids major nerves and blood vessels.
Q&A with Rationale | Fortis College
1. A nurse is caring for a 4-year-old child following surgery. Which pain assessment tool
should the nurse use to determine the child’s level of pain?
A. FLACC scale
B. Numerical scale (0-10)
C. CRIES scale
D. Wong-Baker FACES scale
Correct Answer: D
Explanation: The Wong-Baker FACES scale is appropriate for children as young as 3 years
old because it uses visual depictions of pain levels. Children at this developmental stage
cannot yet conceptualize numerical values for pain. This tool allows the child to point to the
face that best represents their current state of discomfort.
2. According to Erikson’s theory of psychosocial development, which task should a nurse
expect a toddler (1 to 3 years old) to be working on?
A. Trust vs. Mistrust
B. Industry vs. Inferiority
C. Initiative vs. Guilt
D. Autonomy vs. Shame and Doubt
,Correct Answer: D
Explanation: The toddler stage is characterized by the struggle for autonomy vs. shame
and doubt. Children during this time are learning to express their independence through
choices like food and clothing. If they are constantly criticized or restricted, they may
develop a sense of shame regarding their abilities.
3. A mother of a 6-month-old infant expresses concern that her child cannot sit up without
support yet. What is the most appropriate response by the nurse?
A. This is normal, as infants typically master sitting unsupported between 6 to 8 months.
B. Most infants do not sit up unsupported until about 8 months of age.
C. This is a serious developmental delay and requires immediate referral.
D. You should begin physical therapy exercises to strengthen the core.
Correct Answer: A
Explanation: Sitting alone without support is a milestone usually achieved between 6 and
8 months of age. At 6 months, many infants can sit with support or only for brief moments
alone. The nurse should reassure the parent that the child is within the expected
developmental range.
4. Which of the following is the priority assessment when a nurse is examining a child with
suspected epiglottitis?
A. Inspecting the throat with a tongue blade
B. Obtaining a throat culture
, C. Assessing for drooling and agitation
D. Checking the child’s height and weight
Correct Answer: C
Explanation: Drooling, agitation, and a ‘tripod’ position are classic signs of epiglottitis,
which is a medical emergency. The nurse must never use a tongue blade or attempt a throat
culture because this could trigger a laryngospasm and complete airway obstruction.
Airway maintenance is the absolute priority for these patients.
5. When administering an intramuscular injection to a 10-month-old infant, which site is
preferred?
A. Deltoid muscle
B. Vastus lateralis muscle
C. Dorsogluteal muscle
D. Ventrogluteal muscle
Correct Answer: B
Explanation: The vastus lateralis is the preferred site for IM injections in infants because it
is the most developed muscle mass at this age. The deltoid is not sufficiently developed
until the child is older, usually around 18 months or once they are walking. Using the
vastus lateralis avoids major nerves and blood vessels.
