PEDIATRIC NURSING ABNORMALS

REINFORCEMENT EXAM
1. Which of the following situations is most likely to produce sepsis in the neonate?
a. Maternal diabetes
c. Cesarean section
b. Prolonged rupture of membranes
d. Precipitous vaginal delivery
Answer: B, Premature Rupture of Membranes is a leading cause of newborn sepsis. After 12-24 hours of leaking
fluids, measures are taken to reduce the risk to mother and the fetus/newborn. Maternal diabetes, cesarean
section, and Precipitous vaginal delivery do not predispose to neonatal sepsis. (Pilliteri 5 th edition)
2. The nurse assesses a 1-day-old neonate. Which finding indicates that the neonate's oxygen needs are not being
met by current treatment?
a. Abdominal breathing
b. A respiratory rate of 51 breathes/ minute
c. Nasal flaring
d. Bluish discoloration of the tips of the hands and feet
Answer: C, Signs of respiratory distress include a respiratory rate above 60 breaths/minute, labored respirations,
grunting, nasal flaring, generalized cyanosis, and retractions. Abdominal breathing is a normal finding in
neonates. Acrocyanosis (a bluish tinge to the hands and feet) is normal on the 1st day after birth. (Pilliteri 5 th
edition)
3. When suctioning neonates after birth, it is essential that the nurse:
a. Suctions the cleaner nose before the mouth
b. Give the baby time to rest in between suctioning episode
c. May not be needed if baby is delivered by CS as mucus are scanty
d. Sends aspirate to the laboratory if meconeum stained
Answer: B, Give the baby time to rest in between suctioning episode. During suctioning, not only secretions are
removed but also oxygen from the airways so baby should be allowed to recover the o2 loses by allowing rest in
between every suctioning episode should not go over 10 seconds. Mouth is suctioned before the nose, babies
delivered by CS needs more suctioning because their head and neck were not benefited by milking effect of their
passage through the birth canal. Meconeum stained aspirates need not be sent to the laboratory for analysis.
(Pilliteri 5th edition)
4. Extreme hypothermia can stimulate the following responses from a neonate, most dangerous effect which is:
a. Acidosis
c. Hypoglycemia
b. Hypoxemia
d. Alkalosis
Answer A, Extreme hypothermia causes increase oxygen requirement or the alternative use of fats to produce heat
that can both contribute to acidosis and not alkalosis. Hypothermia may lead to hypoglycemia and hypoxemia.
(Pilliteri 5th edition)
5. A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse
prepares to prevent heat loss in the newborn infant resulting from evaporation by?
a. Warming the crib pad
b. Turning on the overhead radiant warmer
c. Closing the doors to the room
d. Drying the infant with a warm blanket
Answer: D, Heat is lost more rapidly from a wet skin through the process of evaporation. Warming the bed
prevents heat loss by conduction, use of radiant warmer by radiation, closing the doors of the DR to prevent draft
by convection. (Pilliteri 5th edition)
6. Why does thermoregulation a problem for neonates?
a. Their renal function is not fully developed.
b. Their small body surface area favors heat loss.
c. They have a thin layer of subcutaneous fat that provides poor insulation.
d. They maintain a flex posture that favors heat loss.
Answer: C, Infants have small amounts of subcutaneous fat. Page 177A-The maturity of the kidneys does not
affect body temperature B- Neonates have a proportionately higher body surface area. D- A flexed position
decreases heat loss. (Pilliteri 5th edition)
7. Which of the following factors makes the neonate more prone to problems of dehydration, acidosis, and
possible over hydration?
a. Placental transfer of blood is minimal.

b. Immature kidneys cannot concentrate urine.

c. Rate of fluid exchange is less than in adults
d. Rate of metabolism is less in relation to body weight
Answer: B, The immature state of the kidneys interferes with the regulatory effect that the kidneys perform in
adults. Page 177A- A minimal transfer of blood will not place the infant at risk C- The rate of fluid exchange is
seven times greater. D- Infants have twice the metabolic rate of adults. (Pilliteri 5 th edition)
8. Which of the following is important in providing a neutral thermal environment for a low birth weight infant
in an incubator?
a. Use wool blankets.
b. Avoid using disposable diapers.
c. Maintain high humidity atmosphere.
d. Closely monitor both incubator and rectal temperatures.
Answer: C, A high humidity atmosphere with in the incubator minimizes evaporative heat loss, which helps the
infant maintain a neutral thermal environment. Page 233A-Wool blankets are recommended when the infant is
removed from the incubator. B-This does not significantly affect the thermal environment. D- The infants skin
temperature is monitored to provide the neutral environment. (Pilliteri 5 th edition)
9. When caring for the neonate of a diabetic mother weighing 4.564g (10lbs, 1 ounce) who was delivered
vaginally, the nurse would assess the neonate for fracture of which of the following?
a. Clavicle
b. Skull
c. Wrist
d. Rib cage
Answer: A, Infants born to diabetic mothers tend to be larger than average, and this neonate weighs 10lbs, 1
ounce. The most common fractures are those of the clavicle and long bones, such as the femur. (Pilliteri 5 th
edition)
10. A nurse is performing an assessment on a post-term baby. Which physical characteristic would the nurse
expect to observe?
a. Vernix that covers the body in a thick layer
b. Peeling of the skin
c. Smooth soles without creases
d. Lanugo covering the entire body
Answer: B, A post term infant exhibits dry, peeling, cracked, almost leather-like skin over the body, which is
called desquamation. The pre term exhibits thick vernix covering the body, smooth sole creases, a lanugo
covering the body. (Pilliteri 5th edition)
11. Which of the following is the most appropriate nursing action when intermittently gavage-feeding a preterm
infant?
a. Allow formula to flow by gravity
b. Insert tube through nares rather than mouth
c. Avoid letting infant suck on tube
d. Apply steady pressure to syringe to deliver formula to stomach in a timely manner
Answer: A, This technique prevents introduction of too much pressure into the stomach that can promote
vomiting after feeding. Oral access not nasal is preferred because neonates are nasal breathers. Sucking during
feeding will be beneficial to promote peristalsis
12. Which of the following statements best describes the clinical manifestations of the preterm infant?
a. Head is proportionately small in relation to the body
b. Sucking reflex is absent, weak, or ineffectual
c. Thermostability is well established
d. Extremities remain in attitude of flexion
Answer: B, Feeding reflexes are still immature among preterms with inadequate amount of sucking pads. Head is
still the biggest part of the body even in preterms. With, inadequate amount of subcutaneous tissues and immature
hypothalamus, thermostability is not present. Extremities in extension posture make them unable to contain body
heat.
13. A large for gestational age infant weighing 10 pounds, 15 ounces had just been admitted to the nursery. When
performing the initial assessment the nurse should be especially alert which of the following?
a. Desquamation
b. Meconium Ileus

c. Birth Injuries
d. Jaundiced
Answer: C, Because of their large size, LGA infants frequently sustain birth trauma, such as fractured bone, skull
trauma, nerve damage, and hematoma. Desquamation is the extreme drying of the skin of a newborn specifically
on the hands and soles of the feet. Meconium ileus is the obstruction of the intestinal lumen by hardened
meconium and occurs almost exclusively in infants with cystic fibrosis. Jaundice is the yellowing of the skin
caused by the accumulation of bilirubin. (Lippincots 3 rd edition)
14. A baby boy is born 7 weeks premature. At birth, he has no spontaneous respirations nut is successfully
resuscitated. Within several hours, he develops respiratory grunting, cyanosis, tahcypnea, nasal flaring, and
retractions. Hes diagnosed with respiratory distress syndrome, intubated, and placed in a ventilator. Which
nursing action should be included in the premature babys plan of care to prevent retinopathy of prematurity?
a. Cover his eyes while receiving oxygen
b. Keep his body temperature low
c. Monitor partial pressure of oxygen (PaO2) levels
d. Humidify the oxygen
Answer: C, Monitoring PaO2 levels and reducing the oxygen concentration to keep PaO2 within normal limits
reduces the risks of retinopathy of prematurity in premature infant receiving oxygen. Covering the eyes of the
infant and humidifying the oxygen dont reduce the risk of retinopathy. Because cooling increases the risk of
acidosis, the infant should be kept warm so that his respiratory distress isnt aggravated. (Pilliteri 5 th edition)
15. The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The
parents state We are concerned about the possible occurrence of SIDS. In order to take appropriate action,
the nurse must understand:
a. The child is within the age group most susceptible to SIDS
b. The peak age for occurrence of SIDS is 8-12 months of age
c. The apnea monitor is not effective on a child in this age group
d. 95% of SIDS cases occur before 6 months of age
Answer: D, Peak age of SIDS occurrence is at 2-4 months and 95% of cases occur by age 6 months of age. It is the
leading cause of infant death from 1-12 months. Apnea monitor is still necessary at this age. (Pilliteri 5 th edition)
16. A nurse is monitoring a preterm newborn infant for signs of respiratory distress syndrome. The nurse
monitors the infant for:
a. Cyanosis, tachypnea, retractions, grunting respirations, and nasal flaring
b. Acrocyanosis, apnea, pneumothorax, and grunting
c. Barrel shaped chest, hypotension, and bradycardia
d. Acrocyanosis, emphysema, and interstitial edema
Answer: A, The newborn infant with RDS may present clinical signs of Cyanosis, tachypnea, chest wall
retractions, audible grunting respirations, and nasal flaring. Acrocyanosis is associated with immature peripheral
circulation and is not uncommon in the first few hours of life. 2, 3, 4 do not indicate clinical signs of RDS.
(Pilliteri 5th edition)
17. While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for
hyperbilirubinemia. Which of the following should be reported immediately?
a. Jaundice evident at 26 hours
b. Hematocrit of 55%
c. Serum bilirubin of 12 mg
d. Positive Coombs test
Answer: C, The elevated bilirubin is in the range that requires immediate intervention, such as phototherapy. At a
serum bilirubin of 12mg, the neonate is at risk for the development of kernikterus/ bilirubin encephalopathy. The
health care provider determines the therapy appropriate after reviewing all laboratory findings. A hematocrit level
of 55 % is expected due to increased RBC count. Jaundice at 26 hours after delivery is normal. (Pilliteri 5 th edition)
18. For which of the following mother-baby pairs should the nurse review the Coomb's test in preparation for
administering RhO (D) immune globulin within 72 hours of birth?
a. Rh negative mother with Rh positive baby
b. Rh negative mother with Rh negative baby
c. Rh positive mother with Rh positive baby
d. Rh positive mother with Rh negative baby
Answer: A, An Rh- mother who delivers an Rh+ baby may develop antibodies to the fetal red cells to which she
may be exposed during pregnancy or at placental separation. If the Coombs test is negative, no sensitization has
occurred. The RhO (D) immune globulin is given to block antibody formation in the mother.(Pilliteri 5 th edition)

19. The nurse evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding
the child has:
a. Achieved developmental milestones at an erratic rate
b. Delay in musculoskeletal development
c. Displayed difficulty with speech development
d. Delay in achievement of most developmental milestones
Answer: D, The majority of children with AIDS have neurological involvement. There is decreased growth as
evidenced by microcephaly and abnormal neurologic findings. Developmental delays are common, or after
achieving normal development, there may be loss of milestone. The other options are correct but are too specific to
be the best response. (Pilliteri 5th edition)
20. The nurse assessing a newborn infant and observes low set ears, short palpebral fissures, flat nasal bridge, and
indistinct philtrum. A priority assessment by the nurse should be to ask about:
a. ROH use during pregnancy
b. Usual nutritional intake
c. Family genetic disorder
d. Maternal and paternal ages
Answer: A, The identification of this cluster of facial characteristics is often linked to fetal ROH syndrome. Usual
nutrition intake, family genetic disorder, and maternal and paternal ages are less likely or may not predispose to
this cluster of facial characteristics. (Pilliteri 5 th edition)
21. Which of the following would indicate that the infant with tracheoesophageal fistula needs suctioning?
a. Brassy cough
b. Substernal retractions
c. Decreased activity level
d. Increased respiratory rate
Answer: B, With TEF, outflow of secretions into the larynx leads to laryngospasms. This obstruction to inspiration
stimulates the strong contraction of accessory muscles of the thorax to assist the diaphragm in breathing. This
produces substernal retractions. Brassy cough, decreased activity level, and increased respiratory rate may less
likely or may not indicate need for suctioning. (Pilliteri 5 th edition)
22. The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should
avoid:
a. Holding the infant
b. Offering pacifier
c. Providing a mobile
d. Offering sterile water
Answer: B, The nurse should avoid giving the infant a pacifier or bottle because sucking is not permitted. Holding
the infant cradled in the arms, providing a mobile, and offering sterile water using a breck feeder are permitted;
therefore, answers A, C, and D are incorrect. (Lippincotts 3 rd edition)
23. In the initial assessment, which of the following would the nurse expect a typical sign of esophageal atresia
and tracheoesophageal fistula?
a. Bloody emesis
b. Large amounts of frothy meconium
c. Diaphragmatic breathing
d. Continuous drooling
Answer: D, Esophageal atresia and TEF may occur together or separately. Esophageal atresia prevents the passage
of swallowed mucus and saliva in the stomach. After fluid has accumulated in the pouch, it flows from the mouth.
The infant drools continuously. The lack of swallowed amniotic fluid prevents the accumulation of normal
meconium; lack of stools result. Bloody emesis, large amounts of frothy meconium, and diaphragmatic breathing
are not typical signs of esophageal atresia. (Lippincotts 3 rd edition)
24. Which of the following assessment findings would lead the nurse to suspect Down Syndrome in an infant?
a. Small tongue
c. Marked motor delays
b. Lack of speech
d. Gait disability
Answer: B, Down syndrome is characterized by the following: transverse palmar crease (simian crease), separated
sagittal suture, oblique palpebral fissures, small nose, depressed nasal bridge, high arched palate, excess and lax
skin, wide spacing and plantar crease between the second and big toes, hyperextensible and lax joints, large
protruding tongue, and muscle weakness. (Lippincotts 3 rd edition)
25. The clinic nurse reviews the record of an infant seen in the clinic. The nurse notes that a diagnosis of
esophageal atresia with tracheoesophageal fistula (TEF) is suspected. Which of the following assessment
findings would not be noted in this disorder?
a. Severe projectile vomiting
b. Coughing

c. Choking
d. Cyanosis
Answer: A, Any child who exhibits the 3 Cs of coughing, choking with feedings, and cyanosis should be
suspected of TEF. Failure to pass a suction catheter or nasogastric tube at birth, excessive oral secretions,
vomiting, abdominal distention, and an airless, scaphoid abdomen (atresia without fistula) are also clinical
manifestations. (Pilliteri 5th edition)
26. A newborn diagnosed with bilateral choanal atresia is scheduled for surgery soon after delivery. The nurse
recognizes the immediate need for surgery because the newborn:
a. Will have difficulty swallowing
b. Will be unable to pass meconium
c. Will regurgitate his feedings
d. Will have unable to breathe through his nose
Answer: D, Newborns are preferential nose breathers. The newborn with choanal atresia has a bony obstruction
that blocks the passage of air through the nares. Answer A refers to esophageal atresia, answer b refers to
imperforate anus, and answer c refers to pyloric stenosis; therefore, they are incorrect. (Lippincotts 3 rd edition)
27. The nurse is aware that children born with a missing chromosome are most likely to have:
a. Cretinism
c. Down syndrome
b. Phenylketonuria
d. Turners Syndrome
Answer: D, Turners syndrome results from a missing X chromosome, these females have an XO configuration
rather than XX making the child have short stature and impairment in ovarian function resulting to sterility.
Phenylketonuria is an autosomal recessive disorder due to the absence of the liver enzyme phenylalanine
hydroxylase preventing conversion of the phenylalanine which may result to permanent damage to the brain tissue.
Down syndrome is the most frequently occurring chromosomal abnormality resulting distinct facial features and
may cause cognition problems to the child. (Pilliteri 5 th edition)
28. A characteristic abnormality in which of the following would lead the nurse to suspect that an infant has
torticollis (wry neck)
a. Quadriceps
c. Trapezius muscle
b. Cervical vertebrae
d. Sternocleidomastoid muscle
Answer: D, In wry neck, the sternocleidomastoid muscle appears contracted or shortened, and range of motion in
the neck is limited. This causes the neck to turn laterally to one side, with the chin directed to the opposite
side.Abnormalities to the quadriceps, cervical vertebrae, and trapezius muscles do lead to wry neck. (Pilliteri 5 th
edition)
29. A healthy male newborn is born via cesarean section. You are the nurse in charge. You place the newborn
under the warmer unit. In addition to routine assessments, you should closely monitor this newborn for which
of the following?
a. Unstable blood glucose
b. Respiratory distress due to lack of contractions
c. Signs of acrocyanosis
d. Temperature instability due to type of birth
Answer: B, The squeezing action of the contractions during labor enhances fetal lung maturity. Infants who aren't
subjected to contractions are at an increased risk for developing respiratory distress. The type of birth has nothing
to do with temperature or glucose stability, and acrocyanosis is a normal finding. (Pilliteri 5 th edition)
30. The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important
aspect of this care is:
a.Sedation as needed to prevent exhaustion
b.Antibiotic therapy for 10-14 days
c.Humidified air and increased oral fluids
d.Anithistamines to decrease allergic responses
Answer: C, The most important aspect of home care for a child with acute spasmodic croup is to provide
humidified air and increased oral fluids. Moisture soothes inflamed membranes. Adequate systemic hydration aids
in mucocillary clearance and keeps secretions thin, white, watery, and easily removed with minimal coughing.
(Pilliteri 5th edition)

31. The nurse is providing diet instructions to the parents of a child with cystic fibrosis. The nurse would
emphasize that the diet should be:
a. High calorie, low fat, low sodium
b. High protein, low fat, low carbohydrate
c. High protein, high calorie, unrestricted fat

d. High carbohydrate, low protein, moderate fat

Answer: C, A patient with cystic fibrosis needs a well balanced diet that is high protein, high calorie, and fats do
not need to be restricted. Low protein and calorie are not indicated to patients with cystic fibrosis. (Pilliteri 5 th
edition)
32. You are assigned to the pediatric unit of the emergency room. Which of the following is the priority
intervention for a preschool child rushed in the hospital with severe epiglottitis and a deteriorating status?
a. Administering oxygen by face mask
b. Administering parenteral antibiotics
c. Assisting with intubation
d. Monitoring the electrocardiogram for arrythmias
Answer: C, The most important intervention for a child with epiglottitis is airway management and patency.
Children are at high risk for developing abrupt airway obstruction. Intubation should be performed as soon as
possible in controlled and well managed environmentChildren need supplemental oxygen, but most are so anxious
that they will never allow a mask to stay in place. Provide humidified blow-by oxygen if possibleThe children
needs parenteral antibiotics, however the priority is airway management. The most common rhythm in this client is
sinus tachycardia related to compensation. (Pilliteri 5 th edition)
33. An emergency room nurse is caring for a child diagnosed with epiglottitis. Assessing the child, the nurse
monitors for which indication that the child may be experiencing airway obstruction?
a. The child exhibits nasal flaring and bradycardia
b. The child is leaning forward, with the chin thrust
c. The child has low grade fever and complains of a sore throat
d. The child is leaning backward, supporting himself with the hands and arms
Answer: B, Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward
while supported by arms, chin thrust out, and open mouth), nasal flaring, tachycardia, a high fever, and a sore
throat. Option D is an incorrect position. Options A and C are incorrect because epiglottitis causes high fever and
tachycardia. (Pilliteri 5th edition)
34. A nurse assessing the vital signs of a 3 year-old child hospitalized with a diagnosis of croup and notes that the
respiratory rate is 28 breathes per minute. Based on this finding, which nursing action is appropriate?
a. Reassess the respiratory rate in 15 minutes
b. Notify the doctor
c. Document the findings
d. Administer oxygen
Answer: C, The normal respiratory rate for a 3 year-old is approximately 20 to 30 breathes per minute. Because
RR is normal, option A, B, D is unnecessary actions. The nurse would document the findings. (Pilliteri 5 th edition)
35. A nurse is reviewing results of a sweat test performed on a child with cystic fibrosis. The nurse would expect
to note which of the following?
a. A sweat sodium concentration of less than 40mEq/L
b. A sweat potassium concentration of less than 40mEq/L
c. A sweat potassium concentration greater than 40mEq/L
d. A sweat chloride concentration greater than 60mEq/L
Answer: D, A consistent finding of abnormally high sodium and chloride concentration in the sweat is a unique
characteristic in the sweat of CF. Normally, the sweat chloride concentration greater than 60mEq/L is diagnostic of
CF. Potassium concentration is unrelated to the sweat test. Repeat test is done if sweat chloride levels amounts to
40Eq/L. (Pilliteri 5th edition)
36. A toddler with Cystic Fibrosis is admitted with Pneumonia. Which of the findings in the child's history is
directly related to the diagnosis of Cystic Fibrosis:
a. Developmental delay in walking
b. Tripling birth weight at one year
c. Meconium ileus
d. Two previous admissions for dehydration.
Answer: C, The increased viscosity of mucous in the GI tract is frequently responsible for development of
meconium ileus in the newborn period. Developmental delay in walking is not directly related to Cystic Fibrosis,
tripling birth weight is a normal milestone expected of all children. History of dehydration may or may not be
related to Cystic Fibrosis. (Fuer Nursing Review Practice Test)
37. An 18 month old with Tetralogy of Fallot has a "tet" spell after having an invasive procedure. To improve
the child's cardiac status which of the following interventions should the nurse do initially?
a. Place the child in a knee chest position
b. Begin chest compressions
c. Administer oxygen

d. Position with HOB elevated

Answer: A, A "tet" spell is when the child is having difficulty meeting oxygen demands. The knee chest position
reduces venous blood return from the lower extremities and increases vascular resistance to divert blood flow to
the pulmonary artery. Option B is to be initiated for cardiac arrest. Options C and D would not help to oxygenate
a child with TOF. (Fuer Nursing Review Practice Test)
38. A child, age 4, is admitted with a tentative diagnosis of congenital heart disease. When assessment reveals a
bounding radial pulse coupled with a weak femoral pulse, the nurse suspects that the child has:
a. patent ductus arteriosus.
b. coarctation of the aorta.
c. a ventricular septal defect.
d. truncus arteriosus.
Answer: B, Coarctation of the aorta causes signs of peripheral hypoperfusion, such as a weak femoral pulse and a
bounding radial pulse. These signs are not a common manifestation in patent ductus arteriosus, ventricular septal
defect, and truncus arteriosus. (Brunner and Suddarth's 9th Ed.)
39. A 10-month-old infant with tetralogy of Fallot (TOF) experiences a cyanotic episode. To improve oxygenation
during such an episode, the nurse should place the infant in which position?
a. Knee-to-chest
c. Trendelenburg's
b. Fowler's
d. Prone
Answer: A, TOF involves four defects: pulmonary stenosis, right ventricular hypertrophy, ventricular-septal
defect (VSD), and overriding aorta. Pulmonary stenosis decreases pulmonary blood flow and right-to-left
shunting via the VSD, causing unoxygenated blood to circulate. The knee-to-chest position reduces venous return
from the legs and increases systemic vascular resistance, maximizing pulmonary blood flow and improving
oxygenation status. During a cyanotic episode, the child with TOF typically assumes this position instinctively.
Fowler's, Trendelenburg's, and prone positions don't improve oxygenation. (www.nursetest.com.ph)
40. When developing the plan of care for a newly admitted 2-year-old with the diagnosis of Kawasaki disease
(KD), which of the following would be the priority?
a. Taking vital signs every 6 hours.
b. Monitoring intake and output every hour.
c. Minimizing skin discomfort.
d. Providing passive range of motion exercises
Answer: B, Cardiac status must be monitored carefully in the initial phase of KD because the child is at high risk
for congestive heart failure. Therefore, the nurse should assess the frequently for signs of congestive heart failure
(CHF), which would include respiratory distress and decreased urine output. Vital sign would be obtained more
often than every 6hours because of the risk of CHF. Although minimizing skin discomfort would be important, it
does not take priority in monitoring the childs hourly intake and output. Passive range-of-motion exercise would
be done if the child develops arthritis. (Pillitteri 3 rd edition)
41. Which of the following would the nurse expect to include in the plan of care for a child who is diagnosed with
rheumatic fever and carditis and admitted to the hospital?
a. Ensuring continuous parental presences at the childs bedside.
b. Providing the child with periods of rest.
c. Encouraging participation in age-appropriate activities.
d. Advising the child to eat as much as possible.
Answer: B, The nurse would encourage and plan to provide periods of rest for the child with rheumatic fever and
carditis to allow the heart to rest. The parents should be made to feel that they can come and go as they need to.
The child is not in critical condition, so the parents do not need to be present at the childs bedside continuously.
The child should be allowed to participate in non strenouos activities that avoid overtaxing the heart, thus
allowing the heart time to rest. There is no reason to encourage the child to eat as much a possible; in fact,
overeating should be discouraged because it taxes the heart muscle. (Pillitteri 3 rd edition)
42. The nurse is monitoring the daily weight on an infant with CHF. Which of the following alerts the nurse to
suspect fluid overload and the need to call the physician?
a.
A daily weight gain of more than 20 g in a 24-hour period
b.
A daily weight gain of more than 30 g in a 24-hour period
c.
A daily weight gain of more than 40 g in a 24-hour weight
d.
A daily weight gain of more than 50 g in a 24-hour period
Answer: D, A weight gain of more than 50 g/day may indicate fluid overload. The nurse should assess for urine
output, evaluate for evidence of facial or peripheral edema, auscultate lung sounds, thus assessments should be
reported to the physician (www.nursetest.com.ph)

43. The nurse reviews the chart of an infant admitted to the intensive care unit. The diagnosis is documented as a
left-to right cardiac shunt. Which of the following physiological alterations occurs in these conditions?
a. Blood is shunted to the left side of the heart
b. The right side of the heart functions under greater pressure than the left side
c. Oxygenated and unoxygenated blood mix
d. Oxygenated and unoxygenated blood do not mix
Answer: C, In a left-to-right cardiac shunt, blood is shunted to the right side of the heart because the left side is
normally functioning under higher pressure than the right side. This shunting allows oxygenated and
unoxygenated blood to mix. This results in increased pulmonary blood flow because the abnormal
communication or opening sends more blood to the right side of the heart (Through the opening than abnormal)
(www.nursetest.com.ph)
44. A child with tetralogy of fallot visits the clinic several weeks before the planned surgery. The nurse should
give priority attention to:
a. Assessment on oxygenation
c. Prevention of infection
b. Observation of developmental delays
d. Maintenance of adequate nutrition
Answe: A, All of the above would be important in a child with TOF. However, persistent hypoxemia causes
acidosis which further decreases pulmonary blood flow. Additionally, low oxygenation leads to the possible
development of polycythemia and resultant neurologic complications (www.nursetest.com.ph)
45. The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart disease. Which of these
is most likely to be seen with this diagnosis?
a. Several otitis media episodes in the last year
b. Weight and height in the 10th percentile since birth
c. Takes frequent rest periods while playing
d. Changing food preference and dislikes
Answer: C, Children with heart disease tend to have exercise intolerance. The child may manifest fatigue,
abdominal pain, bloating, nausea, dyspnea, orthopnea, peripheral cyanosis, cheyne strokes respirations. The
child self-limits activities which is consistent with manifestations of congenital heart disease in children. The
child is advised to take frequent rest periods while playing to reduce cardiac workload.
46. A 5 year-old is admitted to the hospital for heart surgery to repair the TOF. The nurse reviews the childs
record and notes that the child has clubbed fingers. The nurse understands that the clubbing is most likely
caused by:
a. Peripheral hypoxia
b. Delayed physical growth
c. Chronic hypertension
d. Destruction of bone marrow
Answer: A, Clubbing, a thickening or flattening of the tips of the fingers and toes, is though to occur because of
chronic tissue hypoxia and polycythemia. Clubbing is not pertaining to B, C, D. (www.nursetest.com.ph)
47. When teaching parents about sickle cell disease, the nurse should tell them that their childs anemia is caused
by:
a. Reduced oxygen capacity of cells due to lack of iron
b. An imbalance between red cell destruction and production
c. Depression of red and white cells and platelets
d. Inability of sickle shaped cells to regenerate
Answer: B, Sickle Cell anemia is an autosomal disorder affecting hemoglobin. Defective hemoglobin causes red
blood cells to become sickle cell shaped and clump together under reduced oxygen tension. Anemia results when
the rate of red cell destruction exceeds the rate of production through stimulated erythropoiesis in the bone
marrow.
48. A diagnosed of hemophilia A is confirmed in an infant. With which of the following instructions would the
nurse provide the parents as the infant becomes more mobile and starts to crawls?
a. Administer on half of a childrens aspirin for a temperature higher than 101F (38.3C).
b. Sew thick padding into the elbows and knees of the childs clothing
c. Check the color of the childs urine every day.
d. Expect the eruption of the primary teeth to produce moderate to severe bleeding.

Answer: B, As the hemophilic infants begin to acquire motor skills, the risk of bleeding increase because of falls
and bumps. Such injuries can be minimized by padding vulnerable joints. Aspirin is contraindicated because of its
antiplatelet properties, which increase infants risk of bleeding. Because genitourinary bleeding is not a typical
problem in children with hemophilia, urine testing is not indicated. Although some bleeding may occur with tooth

eruption, it does not normally cause moderate to severe bleeding episode in children with hemophilia. (Pillitteri
3rd edition)
49. A pediatric nurse is caring for a 3 year-old boy with the diagnosis of acute lymphocytic leukemia (ALL). The
child is crying and complaining that his knees hurt. Which of the following nursing intervention would be
appropriate?
a. Ask the child if he would like a baby aspirin
b. Administer acetaminophen (Tylenol) to the child
c. Apply heat to the childs knees and elevate the knees on a pillow
d. Involve the child in a diversional activity
Answer: B, Aspirin is not administered to the child with ALL because of its anticoagulant properties and because
administering aspirin could lead to bleeding in the joints. Heat also would increase the pain by increasing
circulation to the area. Diversional activities will not be effective in relieving pain.(www.nursetest.com.ph)
50. A nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that which of the
following would most likely be abnormal in this child?
a. Platelet count
b. Hematocrit level
c. Hemoglobin level
d. Partial thromboplastin time
Answer: D, Hemophilia refers to a group of bleeding disorders resulting from a deficiency of coagulation
proteins. Results of tests that measures platelet function are normal; results of tests that measure clotting factor
function may be abnormal. Therefore, abnormal laboratory results in hemophilia indicate a prolonged partial
thromboplastin time. The platelet count, hemoglobin level, and hematocrit level are normal in hemophilia.
(www.nursetest.com.ph)
51. The home care nurse is providing safety instructions to the mother of a child with hemophilia. Which of the
following instructions would the nurse provide to the mother to promote a safe environment for the child?
a. Allow the child to play indoors only and to avoid any outdoor or playgrounds
b. Place a helmet and elbow pads on the child every day as soon as the child awakens
c. Allow the child to use play equipment only when parent is present
d. Eliminate any toys with sharp edges from the childs play area.
Answer: D, The nurse should instruct the mother to remove toys with sharp edges that may cause potential injury.
Requiring that the child wear a helmet and elbow pads immediately on awakening and throughout the day is not
necessary; however, the child should wear these items during activities that could cause potential injury.
Restricting the child from outdoor play activities is not necessary. But the activities in which the child participates
should be monitored. Restriction of play is not necessary if safety measures have been implemented. (Pilliteri 5 th
edition)
52. A home care nurse instructs the mother about dietary measures for a 5 year-old with lactose intolerance. The
nurse tells the mother that it is necessary to provide which dietary supplement in the childs diet?
a. Fats
c. Protein
b. Zinc
d. Calcium
Answer: D, Lactose intolerance is the inability to tolerate lactose, the sugar found in dairy products. Removing
milk and other dairy products from the diet can provide adequate relief from symptoms. Additional dietary
changes may be required such as milk which is an excellent source of calcium.
53. A father tells the nurse that he has heard of cows milk allergy but knows nothing about cows milk sensitivity.
The nurse would explain this condition as which of the following?
a. Hereditary disorder of carbohydrate metabolism.
b. Adverse reaction to cows milk protein.
c. Acquired lactose intolerance.
d. Existence of lifelong allergy.
Answer: B, Cows milk sensitivity is an adverse local and systemic gastrointestinal reaction to cows milk
protein. This is the most common nutritional allergy in infants. Almost all sensitive children can tolerate cows
milk by 2 years of age. Lactose intolerance involves a deficiency of an enzyme lactase, which is needed for
digestion of lactose. (Pillitteri 3rd edition)

54. A parent asks the nurse about head lice (pediculosis capitis) infestation during a visit to the clinic. Which of
the following symptoms would the nurse tell the parent is most common in a child infested with head lice?
a. Itching of the scalp
b. Scalping of the hair
c. Serous weeping of the scalp surface

d. Pinpoint hemorrhagic spots on the scalp surface

Answer: A, Most common is severe itching which also occurs in other body parts. Scratch marks are almost
always found when lice are present. The scalp is the most common site of lice infestation. If the child scratches,
scaling may occur thereafter. (Pilliteri 5th edition)
55. After teaching a mother of an infant with pyloric stenosis about the disease, which of the following if stated
by the mother as a cause, indicates effective teaching?
a. An enlarged muscle below the stomach sphincter.
b. Telescoping of large bowel into the small bowel.
c. A result of giving the baby more formula than is necessary.
d. My baby taking formula too quickly.
Answer: A, Pyloric stenosis involves hypertrophy of the pylorus muscle distal to the stomach and obstruction of
the gastric outlet resulting in vomiting, metabolic acidosis, and dehydration. Telescoping of the bowel is called
intussusception. Over and underfeeding is not associated with pyloric stenosis. (Pilliteri 5 th edition)
56. When teaching a mother of an infant who has received a temporary colostomy for treatment of Hirschprungs
disease, which of the following description about the stomas appearance would the nurse include in the
teaching?
a. Becoming dark brown in 2 months
b. Staying bright red in color
c. Changing to several shades of pink
d. Turning almost purple in color
Answer: B, Typically the stoma should remain bright red in color as long as the infant has the colostomy. A darkred to purplish color may indicate impaired circulation to the stoma. (Pilliteri 5 th edition)
57. The parents of a child with colic are asked to describe the infants bowel movements. Which are the following
description would the nurse expect?
a. Soft, yellow stool
c. Ribbon-like stool
b. Frequent watery stool
d. Foul- smelling stool
Answer: A, Infants with colic usually pass normal stool typically yellowish and soft. Option B refers to diarrhea.
Option C refers to Hirschprungs disease or narrowing of the rectal sphincter. Option D is related to diet. (Pilliteri
5th edition)
58. Oral iron supplements are prescribed for the 6-year old child with IDA. The nurse instructs the mother to
administer the iron with which of the following food items?
a. Water
c. Apple juice
b. Milk
d. Orange juice
Answer: D, Vitamin C increases the absorption of iron by the body. The mother should be instructed to
administer the medication with a citrus fruit or juice high in vitamin C. (Pilliteri 5 th edition)
59. Which of the following foods would be appropriate for a 12 month-old child with celiac disease?
a. Cheerios
c. Rice cereals
b. Pancake
d. Waffles
Answer: C, The child with celiac disease should avoid foods containing wheat, oats, rye, and barley. Foods
containing rice, such as rice cereals, or corn are appropriate. Other options are either made of oats and wheat and
therefore should be avoided. (Pilliteri 5 th edition)
60. A nurse provides feeding instructions to a mother of an infant diagnosed with gastroespphageal reflux. To
assist in reducing the episodes of emesis, the nurse tells the mother:
a. Provide less frequent, larger feedings
b. Burp the infant less frequently during feedings
c. Thin the feedings by adding water to the formula
d. Thicken the feedings by adding rice cereal to the formula
Answer: D, Small, frequent feedings with frequent burping often are prescribed in the treatment of
gastroesophageal reflux. Feedings thickened with rice cereal may reduce episodes of emesis. If thickened formula
is used, cross- cutting of the nipple may be required. Other interventions will not reduce emesis. (Pilliteri 5 th
edition)

61. After hydrostatic reduction for intussusception, the nurse expects to observe which client response?
a. Severe colicky-pain vomiting
b. Currant-jelly like stools
c. Passage of barium or water-soluble contrast with stools

d. Severe abdominal distention

Answer: C, After hydrostatic reduction, the nurse observes for the passage of barium of water-soluble contrast
material with stool. Options 1 and 2 are clinical indicators of intussusception. Option D is a sign of an unresolved
gastrointestinal disorder. (Pilliteri 5th edition)
62. A child is admitted to the pediatric unit with a diagnosis of celiac disease. Based on this diagnosis, the nurse
expects that the childs stool will be:
a. Dark in color
c. Usually hard
b. Abnormally small in amount
d. Malodorous
Answer: D, The stools of a child with celiac disease are characteristically unpleasant smell, pale, large (bulky),
and soft (loose). Excessive flatus is common, and bouts of diarrhea may occur. Option A, B, C are not common
characteristics of stool in clients with celiac disease. (Pilliteri 5 th edition)
63. The parents of a child age 6 months-old report that the infant has been screaming and drawing the knees up to
the chest and has passed stools mixed with blood and mucus that are jelly-like. A nurse recognizes these
symptoms as indicative of:
a. Hirschprungs disease
c. Intussusception
b. Peritonitis
d. Appendicitis
Answer: C, The classic signs and symptoms of intussusception are acute, colicky abdominal pain with currant
jelly-like stools. Clinical manifestations of hirschprungs disease include constipation, abdominal distention,
ribbon-like stool, foul smelling stools. Peritonitis is a serious complication that may follow intestinal obstruction
and perforation. The most common symptom of appendicitis is colicky, periumbilical or lower abdominal pain in
the right quadrant. (Pilliteri 5 th edition)
64. A 2 year old diagnosed with Hirschsprung's disease is being interviewed by the nurse. During data collection,
the parents described the child's stools as "strange". Which of the following stool types would most likely fit
the parents description?
a. Light yellow, frothy and foul smelling
b. Currant jelly-like
c. Narrow and ribbon-like
d. Liquid stool
Answer: C, This finding is consistent with Hirschsprung's disease. Due to the aganglionic portion that is very
narrow and failure of the internal anal sphincter to relax the stool that passes is very narrow and may appear to
look like a long ribbon. Option A is Foul smelling stool = fat in stool, option B is currant jelly stool
intussusceptions = circulation problems, option D is liquid stool not specific may indicate pancreatitis. (Fuer
Nursing Review Practice Test)
65. Which of these statements made to the nurse by a 9 year old with acute appendicitis would require immediate
action?
a. "I am afraid to have surgery."
b. "I feel hot and thirsty."
c. "I feel better with my legs up towards my chest."
d. "My pain has gone away."
Answer: D, The classic finding when an appendix ruptures is a sudden cessation of pain. A ruptured appendix
requires immediate intervention to prevent serious complications. Options A, B and C are expected findings for a
child of this age who is diagnosed with acute peritonitis. (Fuer Nursing Review Practice Test)
66. A 4 year old with Celiac Disease is in the hospital with an exacerbation of Celiac Crisis due to improper
dietary intake. When teaching the mother the dietary restrictions for her child, which of the following foods
must be completely eliminated from the child's diet?
a. Whole milk, ice cream and cheese
b. Rice, corn and soybeans
c. Bread, oatmeal and pretzels
d. Beef, liver and veal
Answer: C, Celiac disease is caused by an intolerance to gluten, which is a protein found in wheat, oats, barley
and rye, All the foods in option C contain gluten. Option A would be eliminated if the child had a lactose
intolerance, option D would be eliminated if the child had a fat intolerance.Option B is not for clients with celiac
disease. (Fuer Nursing Review Practice Test)
67. The mother of a toddler with nephritic syndrome asks the nurse what can be done about the childs swollen
eyes. Which of the following would the nurse suggest?
a. Applying cool compress to the childs eyes
b. Elevating the head of the childs bed
c. Applying eye drops every 8 hours

d. Limiting the childs television watching

Answer: B, The childs swollen eyes are caused by fluid accumulation. Evaluating the head of the bed allows
gravity to increase the downward flow of fluids in the body away from the face. Applying cool compresses or eye
drops, or limiting television, may be comforting but will not relieve the swelling. (Pilliteri 5 th edition)
68. A nurse is performing as admission assessment on a 2 year-old child who has been diagnosed with nephritic
syndrome. The nurse knows that the most common characteristic associated with nephritic syndrome is:
a. Hypertension
b. Generalized edema
c. Increased urinary output
d. Frank, bright red blood in the urine
Answer: B, Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, hyperlipemia, or edema.
Other manifestation include weight gain, periorbital and facial edema that is most prominent in the morning, leg
ankle, labial or scrotal edema, decreased urine output and urine that is dark and frothy, abdominal swelling, and
blood pressure that is normal or slightly decreased. (Pilliteri 5 th edition)
69. The pediatric nurse admitted a child diagnosed with AGN. The diet regimen the nurse will follow for a child
with acute glomerulonephritis is
a. Give the child low sodium, low calorie diet
b. Give the child low potassium, low protein diet
c. Offer a fluid intake of 1000ml/24 hr
d. Give the child low calcium, low potassium diet
Answer: B, A diet restricted from potassium and protein and a increased calcium diet is necessary for all children
who demonstrate some degree of renal failure as a result of AGN. For severe renal failure, protein is totally
restricted. (Pilliteri 5th edition)
70. A recent history of which of the following would alert the nurse to suspect as urinary tract infection in a 2year-old child who is exhibiting fever and fussiness?
a. Abdominal pain
c. Skin rash.
b. Swollen lymph glands
d. Back pain.
Answer: A, Abdominal pain frequently accompanies urinary tract infection in children 2 years of age and older.
Other associated signs and symptoms include decreased appetite, vomiting, fever, and irritability. The presence of
swollen lymph glands (lymphadenopathy) is unrelated to urinary tract infections. Lymphadenopathy is associated
with a systemic infection or possibly cancer. Skin rash is associated with exposure to allergens or irritants (e.g,
poison ivy, harsh soaps); prolonged contact with urine (e.g., diaper dermatitis); or illness such as measles,
rheumatic fever, or juvenile rheumatoid arthritis. Flank or low back pain is associated with urinary tract infection
in children order than 2 years of age and adults.
71. A 5-year old is admitted to the hospital with a diagnosis of acute glomerulonephritis. A nursing diagnosis of
excess fluid volume would be correct if the assessment data included:
a. Dysuria, pruritus, weight loss
b. Diarrhea, polyuria weight gain
c. Hypotension tachycardia, hematuria
d. Periorbital edema, smoky urine, headaches
Answer: D, Acute glomerulonephritis involves damage to both kidneys resulting from filtration and trapping of
anti-body antigen complexes within the glomeruli. As a result, inflammatory and degenerative changes affect all
renal tissue. Acute glomeruloneritis results to periorbital edema as indicative of fluid retention. Oliguria and
hematuria will also occur due to inflamed kidneys. Smokey urine due to elevated plasma BUN and creatinine.
72. A nurse is reviewing a treatment plan with the parents of a newborn infant with hypospadias. Which statement
by the parents indicates their understanding of the plan?
a. Caution should be used when straddling the infant on a hip.
b. Vital signs should be taken daily to check for bladder infection.
c. Catheterization will be necessary when the infant does not void.
d. Circumcision has been delayed to save tissue for surgical repair.
Answer: D, Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis.
In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should
not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. Options
A, B and C are unrelated to this disorder. (www.nursetest.com.ph)
73. A nurse is caring for an infant with cryptorchidism. The nurse anticipates that the most likely diagnostic
studies to be prescribed would be those that assess:
a. Urinary function
c. DNA synthesis
b. Babinski reflex
d. Chromosomal analysis

Answer: D, Cryptorchidism (undescended testes) may occur as a result of hormone deficiency, intrinsic
abnormality of a testis, or a structural problem. Diagnostic tests for this disorder are performed to assess urinary
function and kidney function because the kidneys and testes arise from the same germ tissue. Babinski reflex
reflects neurological function. Assessing DNA synthesis and chromosomal analysis are unrelated to his disorder.
(www.nursetest.com.ph)
74. A nurse has provided discharge instructions to a mother of a 2 year-old child who had an orchiopexy to correct
cryptorchidism. Which statement by the mother of the child indicates that further teaching is necessary?
a. Ill check his temperature.
b. Ill give him medication so hell be comfortable.
c. Ill check hi voiding to be sure theres no problem.
d. Ill let him decide when to return to his play activities.
Answer: D, All vigorous activities should be restricted for 2 weeks following surgery to promote healing and
prevent injury. This will prevent dislodging of the internal sutures. Normally, 2-year-olds want to be active;
therefore, allowing the child to decide when to return to his play activities may prevent healing and cause injury.
The parent should be taught to monitor the temperature, provide analgesics as needed, and monitor the urine
output.(Pilliteri 5th edition)
75. After a surgical repair of a hypospadias, a 12-month-old child returns to the nursing unit with an intravenous
line, a urethral catheter, and a suprapubic catheter in place. Which of the following would the nurse explain to
the parents is the primary purpose for the suprapubic catheter?
a. To ensure an accurate measurement of urine output.
b. To provide an alternative urinary elimination route.
c. To provide an entry port for bladder irrigation.
d. To allow assessment for blood clots in the urine.
Answer: B, Surgical repair of a hypospadias involves use of the skin from the prepuce to extend the urethra to the
tip of the penis. An alternative urinary elimination route is needed because the surgical site needs to be kept dry,
clean, and free from the pressure of a full bladder. Pressure from the full bladder might cause fluid to leak around
the urethral catheter or possibly disrupt the delicate plastic surgery. Although the suprapubic catheter does aid in
providing an accurate measurement of urine output, its primary purpose is to provide an alternative route for
urinary elimination. After surgical repair of a hypospadias, the bladder does need to be irrigated. (Pilliteri 5 th
edition)
76. When explaining to the parents of child with hydrocele about the possible cause of this condition, the nurse
bases this explanation on the interpretation that a hydorcele is most likely the result of which of the
following?
a. Blockage of the inguinal canal that allows fluids to accumulate in the epididymis and ductus deferens
b. Failure of the upper part of the processus vaginalis to atrophy, allowing accumulation of fluids in the
testes and the periotoneal cavity
c. A patent processus vaginalis that results in the collection of fluids along the spermatic cord or tunica
vaginalis of the testes
d. An obliterated processus vaginalis that allows fluid to accumulate in the scrotal sac
Answer: C, Hydrocele is the collection of fluids in the tunica vaginalis of the testes or along the spermatic cord
that results from a patent processus vaginalis. Failure of the upper part of the processus vaginalis to atrophy
allows the accumulation of fluids in the testes and peritoneal cavity, causing inguinal hernia.
77. A pediatric nurse educator provides a teaching session to the nursing staff regarding phenylketonuria. The
nurse tells the nursing staff that:
a. Treatment includes dietary restriction of tyramine
b. PKU is an autosomal dominant disorder
c. PKU primarily affects the gastrointestinal system
d. Routine screening of all newborn infants for PKU is required
Answer: D, Phenylketonuria is an autosomal recessive disorder. Treatment includes dietary restriction of
phenylalanine intake. Phenylketonuria is a genetic disorder that results in central nervous system damage from
toxic levels of phenylalanine in the blood. Option D is the most accurate.
78. A mother brings her 3 week-old infant to a clinic for a PKU rescreening blood test. The test indicates a serum
phenylalanine level of 1mg/dl. The nurse interprets this result as:
a. Positive
c. Inconclusive
b. Negative
d. Requiring rescreening at age 6 weeks
Answer: B, Phenylketonuria is characterized by blood phenylalanine levels higher than 8 mg/dl. A normal level is
lower than 2 mg/dL. A result of 1 mg/dL is a negative test result. Phenylketonuria (PKU) testing done 48 hours
after ingestion of nutrients; infants with absence of phenylalanine will need special diet to prevent retardation.

79. The nurse educator provides a teaching session to the nursing staff of the pediatric unit regarding metabolic
disorders such as G6PD, PKU, and galactosemia. Which of the following is included in the teaching
lesson?
a. These metabolic disorders are common in the poverty line status
b. Treatment includes dietary restriction only
c. The country necessitates/ requires routine screening of all newborns for metabolic disorders
d. Metabolic disorders primarily affect the gastrointestinal system alone
Answer: C, Newborn screening is necessitated/ advised as a routine examination for all newborns to detect
metabolic disorders such as G6PD, PKU, and galactosemia. All of these tests are done to detect early possible
complications. Unearly detection causes congenital anomalies and mental retardation.
80. A 10-month-old infant with phenylketonuria (PKU) is being weaned from breast-feeding. When teaching the
parents about the proper diet for their child, the nurse should stress the importance of restricting or
eliminating:
a. vegetables
c. grains
b. meats
d. sugar
Answer: B, PKU is an inherited disorder characterized by the inability to metabolize phenylalanine, an essential
amino acid. Phenylalanine accumulating in the blood causes central nervous system damage and progressive
mental retardation. However, early detection of PKU and dietary restriction of phenylalanine can prevent disease
progression. Intake of high-protein foods, such as meats and dairy products, must be restricted because they
contain large amounts of phenylalanine. The child may consume measured amounts of vegetables, grains, and
sugar, which are low in phenylalanine. (Brunner and Suddarth's 9th Ed.)
81. The mother of a 6-week-old infant asks the nurse why her infant wasn't diagnosed earlier with congenital
hypothyroidism. What response should the nurse give?
a. "Breast-fed infants may not display symptoms until they're weaned."
b. "If you had brought your infant in for a 2-week checkup you would have been told."
c. "The diagnosis was made earlier but replacement medication won't start yet."
d. "The public health nurse was unable to locate your home."
Answer: A, Frequently, infants don't exhibit signs of congenital hypothyroidism because of the exogenous source
of thyroid hormone supplied by the maternal circulation. It may not be obvious in infants because they have a
functional remnant of the thyroid hormone. Breast-fed babies may not manifest symptoms until they're weaned.
Telling the mother she missed her 2-week checkup puts the blame on her, which isn't necessary. The other
responses aren't appropriate because the infant was breast-fed, preventing earlier diagnosis. (Brunner and
Suddarth's 9th Ed.)
82. The nurse judge that the mother understands the term cerebral palsy when she describes it as a term applied to
impaired movement resulting form which of the following?
a. Injury to the cerebrum caused by a viral infection
b. Malformed blood vessels in the ventricles caused by inheritance
c. Non progressive brain damage caused by injury
d. Inflammatory brain disease caused by metabolic imbalances
Answer: C, The term cerebral palsy refers to a group of non progressive disorders of upper motor dysfunction due
to injury. In addition, a child may have speech or ocular difficulties, seizures, hyperactivity, or cognitive
impairment. The condition of congenital malformed blood vessels in the ventricles is known as arteriovenous
malformations
83. A newborn is admitted to a special care nursery awaiting surgery for a myelomeningocele. Which of the
following nursing diagnoses would be the priority in the plan of care for this baby?
a. Altered parenting
c. Potential for infection
b. Altered skin integrity
d. Potential altered elimination
Answer: B, Skin integrity is correct because the myelomeningocele is only covered by a thin membrane and
damage to the membrane can cause severe spinal cord injury and infection. All of the other options are
appropriate concerns for a child with this condition, but are not as life threatening. Potential problems never take
priority over actual problems. (Fuer Nursing Review Practice Test)
84. An infant has undergone surgery to remove a myelomeningocele. To detect increased intracranial pressure
(ICP) as early as possible, the nurse should be alert for which of the following postoperative findings?
a. Decreased urine output
c.
Bulging fontanels
b. Increased heart rate
d.
Sunken eyeballs
Answer: C. Because an infant's fontanels remain open, the skull may expand in response to increased ICP.
Therefore, bulging fontanels are a cardinal sign of increased ICP in an infant. Decreased urine output and sunken
eyeballs indicate dehydration, not increased ICP. With increased ICP, the heart rate decreases. (Brunner and
Suddarth 9th Ed.)

85. A nurse is caring for an infant with spina bifida (meningomyelocele type) who had the gibbus (sac on the back
containing cerebrospinal fluid, the meninges, and the spinal cord) surgically removed. The nurse plans which
of the following in the postoperative period to maintain the infants safe
a. Elevating the head with the infant in the prone position
b. Covering the back dressing with a binder
c. Placing the infant in a head-down position
d. Strapping the infant in a baby seat sitting up
Answer: A. Elevating the head will decrease the chance of cerebrospinal fluid collecting in the cranial cavity. The
infant needs to be prone for several days to decrease the pressure on the surgical site on the back. Binders and a
baby seat should not be used because of the pressure they would exert on the surgical site.(Pilliteri 5 th edition)
86. When determining the parents compliance with the treatment of their toddler who has recurrent otitis media,
which of the following measures would the nurse expect the parents to describe?
a. Cleaning the childs ears with hydrogen peroxide
b. Administering continuous, small dose antibiotics
c. Instilling ear drops regularly to prevent cerumen accumulation
d. Holding the child upright when feeding with a bottle
Answer: D, Holding the child upright while feeding with a bottle will prevent pooling of formula in the
pharyngeal area. When the vacuum in the middle ear opens into the pharyngeal cavity, the formula is drawn to the
middle ear and results to inflammatory process caused by the pressure. And so minimize recurrence, you feed the
child in upright position. Cleaning the childs ear with hydrogen peroxide and instilling ear drops are not
advisable. Teach parents proper administration of antibiotics and stress importance of full course of therapy.
87. A nurse is reviewing the instillation technique for eye ointment and eye drops with the parent of a pediatric
client diagnosed with bacterial conjunctivitis. Which of the following statements, if made by the parent,
indicates that learning has taken place?
a. I will administer the eye ointment, wait 5 minutes, and then administer the eye drops.
b. I will place my child on the left side to administer drops in the right eye
c. I will have my child blink after the instillation to encourage thorough distribution of the eye drops
d. Ill be careful not to touch the eye or eyelid during drug administration
Answer: D, Eye drops should be administered before eye ointment. The child should be placed in a supine
position with neck slightly hyperextended for administration. Blinking will increase the loss of medication.
Touching the eye or eyelid during medication administration can contaminate the dropper and also can cause eye
injury.(Pilliteri 5th edition)
88. The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which
of the following is not a component of the instructions?
a. apply lotion under the brace to prevent skin breakdown
b. Avoid the use of powder because it will cake under the brace
c. Have the child wear a soft fabric under the brace
d. Encourage the child to perform prescribed exercises
Answer: A, the use of lotions or powders should be avoided as they become sticky or cake under the brace,
causing irritation. Options B, C and D are appropriate instructions to the parents of a child with a brace. (Pilliteri
5th edition)
89. Brian, a 10 month old infant, has a fractured femur. The most likely type of traction to be used would be:
a. Bucks extensions
b. Bryants traction
c. Balanced suspension traction
d. Skeletal traction
Answer: B, Traction is used to reduce the fracture or to maintain alignment of bone fragments until healing
occurs. In the case of Brian, Bryants Traction is used align fractured femurs in young children. Bryants Traction
is an example of skin traction, wherein weighs are attached to adhesive, which is applied to the skin. Bucks
Traction often used temporarily to immobilize the leg when the client fractures a hip. Balanced suspension
traction (Russell traction) used to treat fractures of the femur of an adult.

90. To prevent loss of joint function in a child with juvenile rheumatoid arthritis, the nurse should teach the
parents to avoid letting the child
a. Ride a bicycle
b. Walk to school
c. Do frequent isometric exercise

d. Watch TV for prolong period

Answer: D, Prolong sitting or lying in one position can lead to stiffness and flexions contractures and should be
avoided. This help join mobility. These promote normal function movement. These help maintain muscle
tone.A,B,C, will facilitate joint mobility, promote normal function and maintain muscle tone.(Pilliteri 5 th edition)
91. On reviewing the preliminary laboratory result for a child with osteomyelitis, which of the following findings
would lead the nurse to suspect osteomyelitis?
a. Hematocrit, 30%.
b. Erythrocyte sedimentation rate, 35 mm/hour.
c. Serum potassium concentration, 5.7 mEq/L.
d. White blood cell count, 12000?mm3.
Answer: B, In osteomyelitis, the erythrocyte sedimentation rate increase (for a child, the normal range is 0 to
13mm/hour). The erythrocyte sedimentation rate rises in the presence of sever localized or systematic
inflammation. The hematocrit level would be normal in a child with osteomyelitis. This childs hematocrit is
lower than the normal level, which typically is greater than 33%. The serum potassium concentration would be
normal in a child with osteomyelitis; in this child it is higher than the normal range of 3.5 to 5.5 mEq/L. the
leukocyte count in osteomyelitis is increased, usually 15,000 to 25,000/mm. The childs leukocyte level is low in
light of the diagnosis of osteomyelitis. Normally, the white blood cell count ranges from 5,000 to 10,000/mm.
(Pillitteri 3rd edition)
92. A mother brings her 2 week-old infant to a clinic for treatment following a diagnosis of clubfoot made at
birth. Which statement by the mother indicates a need for further teaching regarding this disorder?
a. Treatment needs to be started as soon as possible.
b. I realize my infant will require follow-up care until full grown.
c. I need to bring my infant back to the clinic in 1 month for a new cast.
d. I need to come to the clinic every week with my infant for the casting.
Answer: C, Clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot
supination, hindfoot varus, and ankle equinus; the defect may be unilateral or bilateral. Treatment for clubfoot is
started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient
correction is not achieved in 3 to 6 months, surgery usually is indicated. Because clubfoot can recur, all children
with clubfoot require long-term interval follow-up until they reach skeletal maturity to ensure an optimal
outcome.
93. A nurse is providing instructions to the parents of a child regarding the use of a brace. Which statement by the
parents indicates a need for further instructions?
a. I will encourage my child to perform prescribed exercise.
b. I will have my child wear soft fabric clothing under the brace.
c. I should apply lotion under the brace to prevent skin breakdown.
d. I should avoid the use of powder because it will cake under the brace.
Answer: The use of lotions or powders under a brace should be avoided because they can become sticky and cake
under the brace, causing irritation. Options A, C, and D are appropriate interventions in the care of a child with a
brace. (Pilliteri 5th edition)
94. The mother of a child with juvenile arthritis calls the clinic nurse because the child is experiencing a painful
exacerbation of the disease. The mother asks the nurse if the child can perform range-of-motion exercise at
this time. The appropriate nursing response is:
a. Avoid all exercise during painful periods.
b. Range-of-motion exercises must be performed every day.
c. Have the child perform simple isometric exercises during this time.
d. Administer additional pain medication before performing range-of-motion exercises.
Answer: C, During painful episodes of juvenile idiopathic arthritis, hot or cold packs and splinting and
positioning the affected joint in a neutral position help reduce the pain. Although resting the extremity is
appropriate, beginning simple isometric or tensing exercises as soon as the child is able is important. These
exercises do not involve joint movement.
95. The nurse would evaluate that the parents correctly understand the care of their infant being treated for talipes
equinovarus if the parents said which of the following?
a. We will unwrap the cast every night and massage his feet with lotion to prevent skin breakdown.
b. Well petal the cast around the baby groin to protect it from urine and bowel movements.
c. Everyday well check the babys toes for movement and color after we squeeze them.
d. Were so glad that the casts will cure his club feet.
Answer: C, Parents should be taught to assess neurovascular status of the toes because babies grow quickly and
may outgrow the casts. A The casts are not bivalved so this is not an option. Casts should remain on until
changed. B Infants usually have short leg casts, so petaling is not a priority. Casts are changed every one to two
weeks to accommodate the babys rapid growth. D This answer does not give any indication as to how the
parents will care for their infant. (NSNA NCLEX RN Review 4 th Edition, Page 929 and 943.)

96. A nurse instructs the parents of a child with leukemia regarding measures related to monitoring for infection.
Which statement, if made by the parent, indicates a need for further instructions?
a. I will take a rectal temperature daily.
b. I will inspect the skin daily for redness.
c. I will inspect the mouth daily for lesions.
d. I will perform proper hand washing techniques.
Answer: A, The risk of injury to fragile mucous membranes is so high in the child with leukemia that oral,
tympanic, or axillary temperature should be taken. Rectal abscesses can occur easily to damage rectal tissue. No
rectal temperatures should be taken. In addition, oral temperature taking should be avoided if the child has oral
ulcers. Options 2, 3, and 4 are appropriate measures to prevent infection. (Pilliteri 5 th edition)
97. During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be
most concerned about which statement by the mother?
a. My child has lost 3 pounds in the last month.
b. Urinary output seemed to be less over the past 2 days.
c. All the pants have become tight around the waist.
d. The child prefers some salty foods more than others.
Answer: C, Clothing has become tight around the waist Parents often recognize the increasing abdominal girth
first. This is an early sign of Wilm''s tumor, a malignant tumor of the kidney. Options A,B and D, are insignificant
data in relation to wilms tumor. (Pilliteri 5 th edition)
98. A nurse is performing an assessment on a 10 year-old child suspected having Hodgkins disease. The nurse
understands that which of the following assessment findings is characteristic of this disease?
a. Fever and malaise
b. Anorexia and weight loss
c. Painful, enlarged inguinal lymph nodes
d. Painless, firm, and movable adenopathy in the cervical area
Answer: D, Clinical manifestations specifically associated with Hodgkins disease include painless, firm, and
movable adenopathy in the cervical and supraclavicular areas. Hepatosplenomegaly also is noted. Although fever,
malaise, anorexia, and weight loss are associated with Hodgkins disease, these manifestations are seen in many
disorders.
99. After teaching the parents of a child newly diagnosed with leukemia about the disease, which of the following
descriptions given by the mother best indicates that she understands the nature of leukemia?
a. The disease is an infection resulting in increase white blood cell production.
b. The disease is a type of a cancer characterized by an increased in immature white blood cells.
c. The disease is an inflammation associated with enlargement of the lympnodes.
d. The disease is an allergic disorder involving increased circulating antibodies in the blood.
Answer: B, Leukemia is a neoplastic, disorder of blood-forming tissue and is characterized by proliferation of
immature white blood cells. (Pillitteri 3rd edition)
100.

When providing physical hygiene and comfort for a child with leukemia who is receiving cancer
chemotherapy, the nurse should avoid the use of:
a. Straws
c. Any powder
b. Mouthwash
d. A firm tooth brush
Answer: D, Leukemia is the most common type of childhood cancer wherein prognosis is improving. Clinical
findings for a child with leukemia include necrosis and bleeding of gums and other mucous membranes. They are
high risk for injury (including hemorrhage) related to decreased platelets. The nurse should avoid the use of
bristles for this client because it irritates and cause hemorrhage of gums.