NURSING 4710 Adolescent 1 – Comprehensive Exam
Questions with Correct Answers and Detailed
Rationales 2026
Question 1
Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea
that has lasted for 2 days. On assessment, the nurse detects dry mucous membranes
and lethargy. What other finding suggests a fluid volume deficit?
A. Bulging fontanel
B. A sunken fontanel
C. Increased tears
D. Bounding pulse
Answer: B. A sunken fontanel
Rationale: In an infant, signs of fluid volume deficit (dehydration) include sunken
fontanels, increased pulse rate, and decreased blood pressure. The kidneys
conserve water, resulting in concentrated urine with high specific gravity.
Question 2
A mother of a hospitalized infant appears anxious and displays anger with the staff.
Which response is most appropriate?
A. “Why are you so angry with us?”
B. “Other staff members don’t want to talk to you.”
C. “You seem upset. Having your child hospitalized must be difficult.”
D. “You need to calm down for your baby’s sake.”
Answer: C. “You seem upset. Having your child hospitalized must be
difficult.”
Rationale: Acknowledging the mother’s feelings and recognizing the difficulty of
coping with a hospitalized child allows her to express her feelings. The other
responses are not therapeutic and may escalate anxiety.
Question 3
An infant who has been in foster care since birth requires a blood transfusion. Who
,is authorized to give written, informed consent for the procedure?
A. The biological mother
B. The foster mother
C. The social worker
D. The nurse manager
Answer: B. The foster mother
Rationale: When children are minors and not emancipated, their parents or
designated legal guardians are responsible for consent. The foster mother is the
legal guardian in this scenario.
Question 4
The most appropriate toys to give to a 5-month-old infant are:
A. Soft, washable toys
B. Plastic cars with small parts
C. Puzzles with small pieces
D. Stuffed animals with button eyes
Answer: A. Soft, washable toys
Rationale: Soft, washable toys are safe for infants who place everything in their
mouths. Small parts or detachable eyes pose aspiration hazards.
Question 5
Which serum electrolyte findings should the nurse expect in an infant with
persistent vomiting?
A. K⁺ 4.5, Cl⁻ 105, Na⁺ 140
B. K⁺ 5.2, Cl⁻ 110, Na⁺ 150
C. K⁺ 3.2, Cl⁻ 92, Na⁺ 120
D. K⁺ 4.0, Cl⁻ 100, Na⁺ 135
Answer: C. K⁺ 3.2, Cl⁻ 92, Na⁺ 120
Rationale: Persistent vomiting leads to loss of gastric fluid (sodium, chloride,
water) and potassium shifts, causing hypokalemia, hypochloremia, and
hyponatremia.
,Question 6
The physician suspects tracheoesophageal fistula in a 1-day-old neonate. Which
nursing intervention is most appropriate?
A. Feed glucose water every 2 hours
B. Elevate the neonate’s head and give nothing by mouth
C. Position the neonate supine after feedings
D. Encourage breastfeeding immediately
Answer: B. Elevate the neonate’s head and give nothing by mouth
Rationale: Risk of aspiration requires head elevation and NPO status. Regular
suctioning maintains airway patency.
Question 7
An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing
action is most appropriate?
A. Encourage the infant to hold the bottle
B. Maintain a consistent, structured environment
C. Confine the infant to bed rest
D. Rotate caregivers frequently
Answer: B. Maintain a consistent, structured environment
Rationale: A consistent, structured environment reinforces a caring feeding
environment. Minimizing caregiver changes promotes consistency.
Question 8
When teaching a group of parents about the potential for febrile seizures in
children, which fact should the nurse include?
A. The seizures occur as the fever rises
B. Febrile seizures usually occur after the fever breaks
C. Febrile seizures are caused by a brain tumor
D. Febrile seizures only occur in children over 5 years
Answer: A. The seizures occur as the fever rises
Rationale: Febrile seizures commonly occur during the rapid rise in temperature,
typically in children aged 6 months to 5 years.
, Question 9
An infant is being treated at home for bronchiolitis. What should the nurse teach
the parent about home care? (Select all that apply)
A. Offer large amounts of fluids infrequently
B. Offer small amounts of fluids frequently
C. Watch for difficulty breathing
D. Keep the infant in a warm, humidified environment
E. Administer over-the-counter cough suppressants
Answer: B, C, D
Rationale: Frequent small feedings prevent fatigue; monitoring for respiratory
distress is essential; warm humidified air helps loosen secretions. Cough
suppressants are not recommended for infants.
Question 10
A 2-month-old infant is brought to the emergency department with a fever of 39°C
(102.2°F). The infant is irritable and has a bulging fontanel. Which action should
the nurse take first?
A. Administer acetaminophen
B. Notify the healthcare provider immediately
C. Offer the infant a bottle
D. Sponge the infant with cool water
Answer: B. Notify the healthcare provider immediately
Rationale: A bulging fontanel in a febrile infant may indicate meningitis or
increased intracranial pressure, requiring prompt medical evaluation.
Question 11
A nurse is assessing a 4-month-old infant. Which finding indicates normal
development?
A. Rolls from back to side
B. Sits without support
C. Crawls on hands and knees
D. Walks with assistance
Answer: A. Rolls from back to side
Rationale: Rolling over typically develops around 4-6 months; sitting without
Questions with Correct Answers and Detailed
Rationales 2026
Question 1
Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea
that has lasted for 2 days. On assessment, the nurse detects dry mucous membranes
and lethargy. What other finding suggests a fluid volume deficit?
A. Bulging fontanel
B. A sunken fontanel
C. Increased tears
D. Bounding pulse
Answer: B. A sunken fontanel
Rationale: In an infant, signs of fluid volume deficit (dehydration) include sunken
fontanels, increased pulse rate, and decreased blood pressure. The kidneys
conserve water, resulting in concentrated urine with high specific gravity.
Question 2
A mother of a hospitalized infant appears anxious and displays anger with the staff.
Which response is most appropriate?
A. “Why are you so angry with us?”
B. “Other staff members don’t want to talk to you.”
C. “You seem upset. Having your child hospitalized must be difficult.”
D. “You need to calm down for your baby’s sake.”
Answer: C. “You seem upset. Having your child hospitalized must be
difficult.”
Rationale: Acknowledging the mother’s feelings and recognizing the difficulty of
coping with a hospitalized child allows her to express her feelings. The other
responses are not therapeutic and may escalate anxiety.
Question 3
An infant who has been in foster care since birth requires a blood transfusion. Who
,is authorized to give written, informed consent for the procedure?
A. The biological mother
B. The foster mother
C. The social worker
D. The nurse manager
Answer: B. The foster mother
Rationale: When children are minors and not emancipated, their parents or
designated legal guardians are responsible for consent. The foster mother is the
legal guardian in this scenario.
Question 4
The most appropriate toys to give to a 5-month-old infant are:
A. Soft, washable toys
B. Plastic cars with small parts
C. Puzzles with small pieces
D. Stuffed animals with button eyes
Answer: A. Soft, washable toys
Rationale: Soft, washable toys are safe for infants who place everything in their
mouths. Small parts or detachable eyes pose aspiration hazards.
Question 5
Which serum electrolyte findings should the nurse expect in an infant with
persistent vomiting?
A. K⁺ 4.5, Cl⁻ 105, Na⁺ 140
B. K⁺ 5.2, Cl⁻ 110, Na⁺ 150
C. K⁺ 3.2, Cl⁻ 92, Na⁺ 120
D. K⁺ 4.0, Cl⁻ 100, Na⁺ 135
Answer: C. K⁺ 3.2, Cl⁻ 92, Na⁺ 120
Rationale: Persistent vomiting leads to loss of gastric fluid (sodium, chloride,
water) and potassium shifts, causing hypokalemia, hypochloremia, and
hyponatremia.
,Question 6
The physician suspects tracheoesophageal fistula in a 1-day-old neonate. Which
nursing intervention is most appropriate?
A. Feed glucose water every 2 hours
B. Elevate the neonate’s head and give nothing by mouth
C. Position the neonate supine after feedings
D. Encourage breastfeeding immediately
Answer: B. Elevate the neonate’s head and give nothing by mouth
Rationale: Risk of aspiration requires head elevation and NPO status. Regular
suctioning maintains airway patency.
Question 7
An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing
action is most appropriate?
A. Encourage the infant to hold the bottle
B. Maintain a consistent, structured environment
C. Confine the infant to bed rest
D. Rotate caregivers frequently
Answer: B. Maintain a consistent, structured environment
Rationale: A consistent, structured environment reinforces a caring feeding
environment. Minimizing caregiver changes promotes consistency.
Question 8
When teaching a group of parents about the potential for febrile seizures in
children, which fact should the nurse include?
A. The seizures occur as the fever rises
B. Febrile seizures usually occur after the fever breaks
C. Febrile seizures are caused by a brain tumor
D. Febrile seizures only occur in children over 5 years
Answer: A. The seizures occur as the fever rises
Rationale: Febrile seizures commonly occur during the rapid rise in temperature,
typically in children aged 6 months to 5 years.
, Question 9
An infant is being treated at home for bronchiolitis. What should the nurse teach
the parent about home care? (Select all that apply)
A. Offer large amounts of fluids infrequently
B. Offer small amounts of fluids frequently
C. Watch for difficulty breathing
D. Keep the infant in a warm, humidified environment
E. Administer over-the-counter cough suppressants
Answer: B, C, D
Rationale: Frequent small feedings prevent fatigue; monitoring for respiratory
distress is essential; warm humidified air helps loosen secretions. Cough
suppressants are not recommended for infants.
Question 10
A 2-month-old infant is brought to the emergency department with a fever of 39°C
(102.2°F). The infant is irritable and has a bulging fontanel. Which action should
the nurse take first?
A. Administer acetaminophen
B. Notify the healthcare provider immediately
C. Offer the infant a bottle
D. Sponge the infant with cool water
Answer: B. Notify the healthcare provider immediately
Rationale: A bulging fontanel in a febrile infant may indicate meningitis or
increased intracranial pressure, requiring prompt medical evaluation.
Question 11
A nurse is assessing a 4-month-old infant. Which finding indicates normal
development?
A. Rolls from back to side
B. Sits without support
C. Crawls on hands and knees
D. Walks with assistance
Answer: A. Rolls from back to side
Rationale: Rolling over typically develops around 4-6 months; sitting without
