BSN Pediatric Nursing 1 — Questions and Answers
Question 1: A 2-year-old child is brought to the clinic for a well-child visit. Which developmental milestone should the nurse expect this child to have achieved?
- Walks up stairs alternating feet
- Uses a vocabulary of at least 50 words and 2-word phrases (Correct answer)
- Rides a tricycle
- Draws a person with 6 parts
Correct answer: Uses a vocabulary of at least 50 words and 2-word phrases
By age 2, children typically have a vocabulary of at least 50 words and can combine two words together, which is a key language milestone for this age group.
Question 2: The nurse is reviewing the immunization record of a 12-month-old infant. Which vaccine is recommended for the first time at 12 months of age per the CDC schedule?
- Hepatitis B (HepB)
- Varicella (VAR) (Correct answer)
- Inactivated Poliovirus (IPV)
- Rotavirus (RV)
Correct answer: Varicella (VAR)
The varicella (chickenpox) vaccine is first administered at 12–15 months, making it appropriate for a 12-month-old's immunization schedule.
Question 3: The nurse is assessing a 6-month-old infant. Which finding is expected and considered normal for this age?
- Presence of the Moro reflex
- Disappearance of the anterior fontanelle
- Ability to sit without support
- Doubling of birth weight (Correct answer)
Correct answer: Doubling of birth weight
Infants typically double their birth weight by 4–6 months, making this a normal and expected finding at the 6-month well-child visit.
Question 4: A nurse is assessing a febrile 3-year-old with a temperature of 39.5°C (103.1°F). Which initial nursing action is most appropriate?
- Apply a cooling blanket immediately
- Administer acetaminophen per protocol (Correct answer)
- Obtain blood cultures before any intervention
- Restrict oral fluids to prevent vomiting
Correct answer: Administer acetaminophen per protocol
Administering antipyretics such as acetaminophen per protocol is the priority intervention to safely reduce fever and improve the child's comfort.
Question 5: When using the FACES pain rating scale to assess pain in a 4-year-old, the nurse understands that this scale is appropriate because:
- Children this age can reliably report a numeric pain score
- It does not require verbal communication from the child
- It uses facial expressions that children can match to their own feeling (Correct answer)
- It is the most accurate scale for all age groups
Correct answer: It uses facial expressions that children can match to their own feeling
The FACES scale uses pictorial facial expressions that young children can cognitively match to how they are feeling, making it developmentally appropriate for preschoolers.
Question 6: A child weighing 20 kg requires IV fluid maintenance. Using the Holliday-Segar method, what is the correct daily fluid maintenance requirement?
- 1,000 mL/day
- 1,500 mL/day (Correct answer)
- 1,800 mL/day
- 2,000 mL/day
Correct answer: 1,500 mL/day
The Holliday-Segar method calculates: 100 mL/kg for the first 10 kg + 50 mL/kg for the next 10 kg = 1,000 + 500 = 1,500 mL/day for a 20 kg child.
Question 7: The nurse is caring for an infant with suspected intussusception. Which clinical finding is most characteristic of this condition?
- Projectile vomiting after feeding
- Currant jelly-like stools (Correct answer)
- Ribbon-like stools
- Bile-stained emesis with abdominal distension
Correct answer: Currant jelly-like stools
Currant jelly-like stools (a mixture of blood and mucus) are a hallmark sign of intussusception caused by mucosal sloughing from the telescoped bowel segment.
BSN Pediatric Nursing 1
A 2-year-old child is brought to the clinic for a well-child visit.
Which developmental milestone should the nurse expect this child to have achieved?