|Rationales
1. At what age does an infant’s birth weight typically double?
A. 4 months
B. 9 months
C. 6 months
D. 12 months
Answer: C
Rationale: Birth weight usually doubles by 6 months of age and triples by 1 year of age.
2. The nurse is assessing a 4-month-old infant. Which fontanel should be closed
by this age?
A. Anterior fontanel
B. Posterior fontanel
C. Frontal fontanel
D. Mastoid fontanel
Answer: B
Rationale: The posterior fontanel typically closes by 2 to 3 months of age, while the
anterior fontanel closes between 12 and 18 months.
,3. A child with Tetralogy of Fallot becomes cyanotic and dyspneic. Which
position should the nurse place the child in?
A. Knee-chest
B. Supine
C. High Fowler’s
D. Side-lying
Answer: A
Rationale: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt and improves oxygenation during a ‘tet’ spell.
4. Which clinical manifestation is a hallmark sign of pyloric stenosis?
A. Currant jelly-like stools
B. Projectile vomiting
C. Ribbon-like stools
D. Bile-stained emesis
Answer: B
Rationale: Projectile vomiting after feeding is the classic sign of hypertrophic pyloric
stenosis due to the obstruction at the gastric outlet.
5. When teaching parents about dietary management for a child with Cystic
Fibrosis, the nurse should emphasize:
A. High calorie, high protein diet
B. Low calorie, low protein diet
C. Fluid restriction to reduce secretions
D. Low sodium intake
Answer: A
Rationale: Children with CF require a high-calorie, high-protein diet to compensate for
malabsorption and increased metabolic needs.
, 6. A toddler is admitted with suspected intussusception. Which type of stool
does the nurse expect to observe?
A. Steatorrhea
B. Currant jelly stool
C. Hard, marble-like stool
D. Melena
Answer: B
Rationale: Intussusception causes intestinal obstruction and ischemia, leading to stools
mixed with blood and mucus, often described as ‘currant jelly’ stools.
7. What is the priority nursing intervention for a child diagnosed with
Epiglottitis?
A. Examine the throat with a tongue blade
B. Obtain a throat culture
C. Maintain a patent airway
D. Apply a warm compress to the neck
Answer: C
Rationale: Epiglottitis is a medical emergency. Airway maintenance is the priority. Throat
examination or cultures can trigger laryngospasm and total airway obstruction.
8. Which of the following is a common symptom of Digoxin toxicity in a child?
A. Tachycardia
B. Hyperactivity
C. Hypertension
D. Vomiting
Answer: D
Rationale: In children, vomiting is a common early sign of Digoxin toxicity. Bradycardia is
also a significant indicator.