NUR 254 Final Exam: Pediatrics - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is assessing a 6-month-old infant. Which developmental milestone should the nurse expect the
infant to have achieved?
A. Rolling from back to abdomen
B. Sitting steadily without support
C. Walking while holding onto furniture
D. Using a neat pincer grasp
Correct Answer: A
Rationale: By 6 months of age, infants should be able to roll over from their back to their abdomen.
Sitting steadily without support typically occurs around 8 months. Walking while holding onto furniture
and the pincer grasp are milestones seen later in the first year. Assessing these milestones helps the
nurse evaluate neurological and motor development. Early identification of delays is essential for prompt
intervention and support.
2. A toddler is admitted with a diagnosis of intussusception. Which clinical manifestation should the nurse
expect to observe?
A. Projectile vomiting after feedings
B. Ribbon-like, foul-smelling stools
C. Currant jelly-like stools
D. Pain localized in the lower right quadrant
Correct Answer: C
,Rationale: Intussusception is characterized by the telescoping of one portion of the intestine into
another. This often results in stools that contain blood and mucus, described as currant jelly-like.
Projectile vomiting is more indicative of pyloric stenosis rather than intussusception. Ribbon-like stools
are a classic sign of Hirschsprung disease. Managing this condition is critical to prevent bowel ischemia
and perforation.
3. A nurse is caring for a child with Tetralogy of Fallot who begins to have a hypercyanotic ‘Tet’ spell. What
is the priority nursing action?
A. Administer 100% oxygen via mask
B. Administer morphine sulfate intravenously
C. Place the child in the knee-chest position
D. Prepare for immediate surgical intervention
Correct Answer: C
Rationale: The knee-chest position increases systemic vascular resistance and decreases right-to-left
shunting. This action helps to improve oxygenation to the lungs and vital organs during a spell. While
oxygen and morphine are used, positioning is the immediate first step. It is a non-invasive maneuver that
provides rapid relief in many cases. The nurse must remain calm to reduce the child’s anxiety and oxygen
demand.
4. Which assessment finding is most indicative of worsening condition in a child with epiglottitis?
A. Drooling and inability to swallow
B. Presence of a barking, brassy cough
C. Increased wheezing during expiration
D. Decreased heart rate and lethargy
, Correct Answer: A
Rationale: Epiglottitis is a medical emergency that can lead to rapid airway obstruction. Drooling occurs
because the child cannot swallow secretions due to severe throat pain and swelling. A barking cough is
characteristic of croup, not epiglottitis. Absence of spontaneous cough and the presence of the ‘tripod
position’ are also key indicators. Nurses should never attempt to visualize the throat as it may cause total
occlusion.
5. A school-age child is being treated for Nephrotic Syndrome. Which clinical finding should the nurse
expect?
A. Gross hematuria and hypertension
B. Low serum cholesterol levels
C. Increased urinary output and weight loss
D. Severe proteinuria and generalized edema
Correct Answer: D
Rationale: Nephrotic syndrome is characterized by massive proteinuria due to increased glomerular
permeability. This loss of protein leads to hypoalbuminemia and subsequent shift of fluid into the tissues,
causing edema. Hematuria and hypertension are more common in acute glomerulonephritis. Cholesterol
levels are typically elevated, not low, in this condition. Monitoring daily weights and abdominal girth is
essential for managing fluid status.
6. When administering Digoxin to an infant, which heart rate would require the nurse to withhold the
medication?
A. Less than 110 beats/min
B. Less than 90 beats/min
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is assessing a 6-month-old infant. Which developmental milestone should the nurse expect the
infant to have achieved?
A. Rolling from back to abdomen
B. Sitting steadily without support
C. Walking while holding onto furniture
D. Using a neat pincer grasp
Correct Answer: A
Rationale: By 6 months of age, infants should be able to roll over from their back to their abdomen.
Sitting steadily without support typically occurs around 8 months. Walking while holding onto furniture
and the pincer grasp are milestones seen later in the first year. Assessing these milestones helps the
nurse evaluate neurological and motor development. Early identification of delays is essential for prompt
intervention and support.
2. A toddler is admitted with a diagnosis of intussusception. Which clinical manifestation should the nurse
expect to observe?
A. Projectile vomiting after feedings
B. Ribbon-like, foul-smelling stools
C. Currant jelly-like stools
D. Pain localized in the lower right quadrant
Correct Answer: C
,Rationale: Intussusception is characterized by the telescoping of one portion of the intestine into
another. This often results in stools that contain blood and mucus, described as currant jelly-like.
Projectile vomiting is more indicative of pyloric stenosis rather than intussusception. Ribbon-like stools
are a classic sign of Hirschsprung disease. Managing this condition is critical to prevent bowel ischemia
and perforation.
3. A nurse is caring for a child with Tetralogy of Fallot who begins to have a hypercyanotic ‘Tet’ spell. What
is the priority nursing action?
A. Administer 100% oxygen via mask
B. Administer morphine sulfate intravenously
C. Place the child in the knee-chest position
D. Prepare for immediate surgical intervention
Correct Answer: C
Rationale: The knee-chest position increases systemic vascular resistance and decreases right-to-left
shunting. This action helps to improve oxygenation to the lungs and vital organs during a spell. While
oxygen and morphine are used, positioning is the immediate first step. It is a non-invasive maneuver that
provides rapid relief in many cases. The nurse must remain calm to reduce the child’s anxiety and oxygen
demand.
4. Which assessment finding is most indicative of worsening condition in a child with epiglottitis?
A. Drooling and inability to swallow
B. Presence of a barking, brassy cough
C. Increased wheezing during expiration
D. Decreased heart rate and lethargy
, Correct Answer: A
Rationale: Epiglottitis is a medical emergency that can lead to rapid airway obstruction. Drooling occurs
because the child cannot swallow secretions due to severe throat pain and swelling. A barking cough is
characteristic of croup, not epiglottitis. Absence of spontaneous cough and the presence of the ‘tripod
position’ are also key indicators. Nurses should never attempt to visualize the throat as it may cause total
occlusion.
5. A school-age child is being treated for Nephrotic Syndrome. Which clinical finding should the nurse
expect?
A. Gross hematuria and hypertension
B. Low serum cholesterol levels
C. Increased urinary output and weight loss
D. Severe proteinuria and generalized edema
Correct Answer: D
Rationale: Nephrotic syndrome is characterized by massive proteinuria due to increased glomerular
permeability. This loss of protein leads to hypoalbuminemia and subsequent shift of fluid into the tissues,
causing edema. Hematuria and hypertension are more common in acute glomerulonephritis. Cholesterol
levels are typically elevated, not low, in this condition. Monitoring daily weights and abdominal girth is
essential for managing fluid status.
6. When administering Digoxin to an infant, which heart rate would require the nurse to withhold the
medication?
A. Less than 110 beats/min
B. Less than 90 beats/min
