NUR106 | NUR106 Pediatric Nursing Exam 4
Version 1 | Questions with Correct Answers and
Expert Explanation for Each Question | Saint Paul’s
School of Nursing
1. A nurse is performing a rapid assessment on a toddler using the Pediatric
Assessment Triangle (PAT). Which of the following components should the nurse
evaluate first?
A. Blood pressure and heart rate
B. Temperature and oxygen saturation
C. Appearance, work of breathing, and circulation to the skin
D. Level of consciousness and pupil response
Correct Answer: C
Expert Explanation: The Pediatric Assessment Triangle is a clinical tool used to
quickly evaluate the severity of a child’s illness or injury. It consists of three pillars:
Appearance, Work of Breathing, and Circulation to the Skin. This assessment is
performed across the room without touching the patient to establish a baseline. It
helps the nurse prioritize which patients need immediate life-saving interventions.
By observing these three areas, the nurse can rapidly identify if the child is in
respiratory distress or shock.
,2. An 8-year-old child is admitted to the emergency department with signs of
hypovolemic shock. What is the standard initial fluid bolus for this pediatric patient?
A. 10 mL/kg of 0.45% normal saline
B. 20 mL/kg of an isotonic crystalloid
C. 50 mL/kg of lactated Ringer’s
D. 5 mL/kg of 5% dextrose in water
Correct Answer: B
Expert Explanation: Initial management of hypovolemic shock in pediatrics
focuses on rapid volume expansion to restore perfusion. The recommended dose is
a 20 mL/kg bolus of an isotonic crystalloid such as normal saline or lactated
Ringer’s. This volume may be repeated up to three times depending on the patient’s
clinical response. The nurse must monitor the child closely for signs of fluid
overload during this process. Restoring circulating volume is critical to preventing
end-organ damage from prolonged hypotension.
3. During a primary survey of a pediatric trauma victim, which assessment finding
requires the most immediate intervention?
A. Capillary refill of 4 seconds
B. Glasgow Coma Scale score of 12
C. Obvious fracture of the femur
,D. Absent breath sounds on the right side
Correct Answer: D
Expert Explanation: In pediatric trauma, the primary survey follows the ABCDE
sequence to address life-threatening issues systematically. Absent breath sounds
indicate a potential tension pneumothorax or airway obstruction, which takes
priority over circulation or fractures. Airway and breathing must be stabilized first
to ensure adequate oxygenation of vital organs. If the airway is not patent, all other
interventions will be ineffective in saving the patient. Therefore, addressing the
respiratory status is the highest priority in this clinical scenario.
4. What is the correct compression-to-ventilation ratio for two-rescuer infant CPR?
A. 30:2
B. 15:2
C. 3:1
D. 5:1
Correct Answer: B
Expert Explanation: The American Heart Association provides specific guidelines
for pediatric resuscitation to improve survival outcomes. For two-rescuer CPR in
infants and children, the ratio changes from 30:2 to 15:2. This change allows for
more frequent ventilations, which is necessary because most pediatric arrests are
, respiratory in origin. In a single-rescuer scenario, the ratio remains 30:2 to maintain
consistency with adult protocols. Ensuring high-quality chest compressions and
adequate ventilation is the cornerstone of effective pediatric resuscitation.
5. A 4-year-old child is brought to the ED with suspected septic shock. Which of the
following is an early sign of compensated shock in this child?
A. Hypotension
B. Bradycardia
C. Lethargy
D. Tachycardia
Correct Answer: D
Expert Explanation: Tachycardia is often the earliest sign of shock in pediatric
patients as the heart attempts to maintain cardiac output. Children have a strong
compensatory mechanism that maintains blood pressure even when they have lost
significant volume. Consequently, hypotension is a very late sign of shock and
indicates impending cardiovascular collapse. The nurse must recognize subtle
changes like increased heart rate or delayed capillary refill before the blood
pressure drops. Prompt intervention during the compensated phase significantly
improves the prognosis for the child.
Version 1 | Questions with Correct Answers and
Expert Explanation for Each Question | Saint Paul’s
School of Nursing
1. A nurse is performing a rapid assessment on a toddler using the Pediatric
Assessment Triangle (PAT). Which of the following components should the nurse
evaluate first?
A. Blood pressure and heart rate
B. Temperature and oxygen saturation
C. Appearance, work of breathing, and circulation to the skin
D. Level of consciousness and pupil response
Correct Answer: C
Expert Explanation: The Pediatric Assessment Triangle is a clinical tool used to
quickly evaluate the severity of a child’s illness or injury. It consists of three pillars:
Appearance, Work of Breathing, and Circulation to the Skin. This assessment is
performed across the room without touching the patient to establish a baseline. It
helps the nurse prioritize which patients need immediate life-saving interventions.
By observing these three areas, the nurse can rapidly identify if the child is in
respiratory distress or shock.
,2. An 8-year-old child is admitted to the emergency department with signs of
hypovolemic shock. What is the standard initial fluid bolus for this pediatric patient?
A. 10 mL/kg of 0.45% normal saline
B. 20 mL/kg of an isotonic crystalloid
C. 50 mL/kg of lactated Ringer’s
D. 5 mL/kg of 5% dextrose in water
Correct Answer: B
Expert Explanation: Initial management of hypovolemic shock in pediatrics
focuses on rapid volume expansion to restore perfusion. The recommended dose is
a 20 mL/kg bolus of an isotonic crystalloid such as normal saline or lactated
Ringer’s. This volume may be repeated up to three times depending on the patient’s
clinical response. The nurse must monitor the child closely for signs of fluid
overload during this process. Restoring circulating volume is critical to preventing
end-organ damage from prolonged hypotension.
3. During a primary survey of a pediatric trauma victim, which assessment finding
requires the most immediate intervention?
A. Capillary refill of 4 seconds
B. Glasgow Coma Scale score of 12
C. Obvious fracture of the femur
,D. Absent breath sounds on the right side
Correct Answer: D
Expert Explanation: In pediatric trauma, the primary survey follows the ABCDE
sequence to address life-threatening issues systematically. Absent breath sounds
indicate a potential tension pneumothorax or airway obstruction, which takes
priority over circulation or fractures. Airway and breathing must be stabilized first
to ensure adequate oxygenation of vital organs. If the airway is not patent, all other
interventions will be ineffective in saving the patient. Therefore, addressing the
respiratory status is the highest priority in this clinical scenario.
4. What is the correct compression-to-ventilation ratio for two-rescuer infant CPR?
A. 30:2
B. 15:2
C. 3:1
D. 5:1
Correct Answer: B
Expert Explanation: The American Heart Association provides specific guidelines
for pediatric resuscitation to improve survival outcomes. For two-rescuer CPR in
infants and children, the ratio changes from 30:2 to 15:2. This change allows for
more frequent ventilations, which is necessary because most pediatric arrests are
, respiratory in origin. In a single-rescuer scenario, the ratio remains 30:2 to maintain
consistency with adult protocols. Ensuring high-quality chest compressions and
adequate ventilation is the cornerstone of effective pediatric resuscitation.
5. A 4-year-old child is brought to the ED with suspected septic shock. Which of the
following is an early sign of compensated shock in this child?
A. Hypotension
B. Bradycardia
C. Lethargy
D. Tachycardia
Correct Answer: D
Expert Explanation: Tachycardia is often the earliest sign of shock in pediatric
patients as the heart attempts to maintain cardiac output. Children have a strong
compensatory mechanism that maintains blood pressure even when they have lost
significant volume. Consequently, hypotension is a very late sign of shock and
indicates impending cardiovascular collapse. The nurse must recognize subtle
changes like increased heart rate or delayed capillary refill before the blood
pressure drops. Prompt intervention during the compensated phase significantly
improves the prognosis for the child.
