LPN Pediatric Nursing Fundamentals 1 — Questions and Answers

Question 1: A 3-year-old child is admitted with suspected epiglottitis. Which nursing action is the priority?

Perform a throat inspection using a tongue depressor
Obtain a throat culture to identify the causative organism
Keep the child calm, do not agitate, and notify the charge nurse immediately (Correct answer)
Administer a tepid sponge bath to reduce fever

Correct answer: Keep the child calm, do not agitate, and notify the charge nurse immediately

Epiglottitis can cause complete airway obstruction. Examination of the throat with a tongue depressor can trigger laryngospasm. The priority is maintaining a calm environment and preparing for emergency airway management.

Epiglottitis is a rapidly progressive bacterial infection (Haemophilus influenzae type b) causing life-threatening supraglottic edema. Classic signs in children: high fever, drooling, dysphagia, muffled voice, stridor, and the 'tripod position' (sitting forward, neck extended). Any agitation or throat examination can trigger acute airway obstruction and death. The LPN must: keep the child calm, allow the child to remain in the position of comfort (usually sitting with parent), notify the charge nurse and provider immediately, ensure emergency airway equipment and personnel are at bedside, and do NOT lay the child down, use a tongue depressor, or start IVs until the airway is secured.

Question 2: The LPN is caring for a 2-year-old child in a mist tent. Which nursing action is most important?

Keep the tent temperature warmer than the room for comfort
Change the child's clothing and bed linens frequently to prevent hypothermia (Correct answer)
Ensure the tent remains fully sealed at all times to maintain humidity
Encourage the child to sleep in the tent without parental presence

Correct answer: Change the child's clothing and bed linens frequently to prevent hypothermia

Mist tents create a cool, moist environment that can cause hypothermia in young children. Frequent changes of wet clothing and linens are essential to maintain temperature.

Cool mist tents (croupettes) are used to deliver humidified oxygen and reduce airway secretion viscosity. The major nursing concerns are: (1) Hypothermia — cool mist makes the child's clothing, linens, and hair wet; change frequently; monitor temperature every 2–4 hours; (2) Monitor oxygen concentration inside the tent with an oxygen analyzer; (3) Observe the child through the tent wall — agitation may worsen respiratory distress; (4) Limit opening of the tent to maintain the environment. Temperature monitoring and dry linens are the priority safety interventions.

Question 3: A 7-month-old infant is brought to the emergency department. The parent reports the infant 'won't stop crying and is pulling at the right ear.' The infant has a temperature of 38.8°C (101.8°F). The LPN should expect the provider to order:

Ear drops with hydrocortisone for external otitis
Assessment for otitis media and likely antibiotic therapy (Correct answer)
Immediate CT scan of the head
Lumbar puncture to rule out meningitis

Correct answer: Assessment for otitis media and likely antibiotic therapy

Ear pulling combined with fever, irritability, and age less than 2 years are classic signs of acute otitis media (middle ear infection), treated with antibiotics in infants under 2 years.

Acute otitis media (AOM) is the most common childhood infection. In infants, signs include: fever, irritability, crying, ear pulling/rubbing, difficulty sleeping, and decreased hearing. Risk factors: bottle-feeding in supine position, daycare attendance, pacifier use. Diagnosis is by otoscopy showing a red, bulging, immobile tympanic membrane. Treatment guidelines (AAP): amoxicillin for children <2 years (no watchful waiting); older children may be observed first. The LPN should comfort the child, position with the affected ear dependent (promotes drainage), administer acetaminophen for fever, and educate parents.

Question 4: A child is admitted with suspected Reye's syndrome. Which historical finding in the chart most supports this diagnosis?

Recent vaccinations with the MMR vaccine
Aspirin use during a recent viral illness (chickenpox or influenza) (Correct answer)
Chronic ibuprofen use for juvenile arthritis
Recent streptococcal throat infection treated with penicillin

Correct answer: Aspirin use during a recent viral illness (chickenpox or influenza)

Reye's syndrome is strongly associated with aspirin (salicylate) use in children during viral illnesses, particularly varicella or influenza, causing acute hepatic encephalopathy.

Reye's syndrome is a rare but life-threatening condition characterized by acute non-inflammatory encephalopathy and liver failure. It is strongly linked to salicylate (aspirin) use in children during viral illnesses, particularly influenza B and varicella (chickenpox). The mechanism involves mitochondrial dysfunction in liver cells. Clinical progression: viral illness → vomiting and behavioral changes → neurological deterioration → coma. Laboratory findings: elevated liver enzymes, hyperammonemia, hypoglycemia. Treatment is supportive. Prevention: never give aspirin to children under 18 years for viral illness (use acetaminophen or ibuprofen instead).

Question 5: An LPN is assessing a 4-year-old with suspected intussusception. Which clinical finding is most characteristic of this condition?

Bright red blood mixed with diarrhea and fever
Episodic severe abdominal cramping with periods of normal behavior and currant jelly stools (Correct answer)
Projectile vomiting after every feeding
Diffuse abdominal rigidity and guarding without bowel sounds

Correct answer: Episodic severe abdominal cramping with periods of normal behavior and currant jelly stools

Intussusception classically presents with colicky abdominal pain (episodic with normal intervals), vomiting, and currant jelly stools (blood and mucus from intestinal ischemia).

Intussusception is the telescoping of one segment of bowel into an adjacent segment, most common in children 6 months to 3 years. Classic triad: (1) Sudden episodic severe abdominal cramping — the child screams and draws up the knees, then appears normal between episodes; (2) Vomiting; (3) Currant jelly stools (blood and mucus from mucosal sloughing). A sausage-shaped mass may be palpated in the right upper quadrant. Treatment: air or barium enema reduction (non-surgical) or surgical reduction. The LPN must report these findings urgently as intestinal ischemia and perforation can develop rapidly.

Question 6: The LPN is caring for a 6-year-old child with nephrotic syndrome. Which finding is the primary characteristic of this condition?

Hypertension and hematuria
Massive proteinuria, hypoalbuminemia, and generalized edema (anasarca) (Correct answer)
Oliguria and elevated creatinine
Polyuria and polydipsia

Correct answer: Massive proteinuria, hypoalbuminemia, and generalized edema (anasarca)

Nephrotic syndrome is defined by the triad of massive proteinuria (>3.5 g/day), hypoalbuminemia (<3 g/dL), and generalized edema from reduced oncotic pressure.

Nephrotic syndrome results from increased glomerular permeability allowing protein (mainly albumin) to leak into the urine. Consequences: proteinuria (foamy urine) → hypoalbuminemia → decreased oncotic pressure → fluid shifts to interstitial spaces → generalized edema (ascites, periorbital edema worsening with lying down, scrotal/labial edema, anasarca). Hyperlipidemia and lipiduria also occur. Hematuria and hypertension are more characteristic of nephritic syndrome. Management includes corticosteroids (prednisone is first-line), sodium restriction, diuretics, and monitoring for complications (infection, thrombosis).

Question 7: A school-age child receives a tympanostomy tube (ear tube) and is being discharged. Which instruction should the LPN include?

The child may swim freely but must avoid submerging ears in the bathtub
Keep water out of the ear with earplugs during bathing and swimming until the provider clears it (Correct answer)
The tubes will dissolve in 2 weeks — no follow-up is needed
Apply antibiotic ear drops twice daily for 6 months

Correct answer: Keep water out of the ear with earplugs during bathing and swimming until the provider clears it

Water in the ear canal can travel through the tympanostomy tube into the middle ear, causing otitis media. Earplugs or cotton with petroleum jelly protect the ear during water exposure.

Tympanostomy tubes are surgically inserted into the tympanic membrane to drain fluid and equalize middle ear pressure in children with recurrent otitis media or chronic otitis media with effusion. Post-procedure teaching: keep water out of the ears during bathing and swimming (use custom earplugs or cotton balls coated with petroleum jelly); avoid submerging the head; report any tube drainage (otorrhea) to the provider; tubes typically remain in place for 6–18 months and fall out spontaneously; follow-up appointments are required to monitor tube status and hearing. Swimming restrictions vary by provider (many allow surface swimming with earplugs).

Question 8: A 9-month-old infant is brought in for a well-child visit. Which developmental milestone would the LPN expect this infant to demonstrate?

Walking independently
Speaking 2–3 word sentences
Sitting without support and pulling to stand (Correct answer)
Building a tower of 4 blocks

Correct answer: Sitting without support and pulling to stand

By 9 months, infants should be able to sit without support (achieved by 6–7 months) and begin pulling to a standing position using furniture.

Key developmental milestones by age: 4 months: rolls front to back, laughs, tracks objects; 6 months: sits with support, transfers objects, babbles; 9 months: sits without support, pulls to stand, uses pincer grasp, says 'mama/dada' non-specifically, plays peek-a-boo, understands 'no'; 12 months: stands alone briefly, walks with support, says 1–2 words; 18 months: walks independently, uses 10–20 words; 24 months: runs, uses 2–3 word sentences, builds tower of 4 blocks. The LPN should refer delayed milestones for developmental evaluation.

Question 9: A 4-year-old child is scheduled for a tonsillectomy. Which postoperative finding requires immediate nursing action?

Complaining of a sore throat and refusing to drink
Swallowing frequently and blood-tinged saliva (Correct answer)
Temperature of 37.8°C (100°F) on postoperative day 2
Preference for cold liquids over warm ones

Correct answer: Swallowing frequently and blood-tinged saliva

Frequent swallowing after tonsillectomy is a sign of hemorrhage — the child is swallowing blood. This is a postoperative emergency requiring immediate intervention.

Post-tonsillectomy hemorrhage is the most serious complication. Primary hemorrhage occurs within 24 hours; secondary hemorrhage occurs 7–10 days postoperatively. Key bleeding signs: frequent swallowing (most subtle and important), brightening red blood in saliva, clearing the throat frequently, restlessness, tachycardia, and pallor. The LPN must notify the charge nurse and provider immediately, keep the child upright, apply ice to the neck, monitor vital signs, and establish IV access. The child should not be left alone. Sore throat, low-grade fever, and preference for cold foods are expected postoperative findings.

Question 10: A child with sickle cell disease presents with fever of 38.9°C (102°F), severe bone pain, and pallor. The LPN recognizes this as a vaso-occlusive crisis. Which intervention is the priority?

Restrict fluids to prevent fluid overload with IV hydration
Administer supplemental oxygen, IV fluids, and analgesics as ordered (Correct answer)
Apply ice packs to painful extremities to reduce sickling
Encourage bed rest and withhold all analgesics until the cause is identified

Correct answer: Administer supplemental oxygen, IV fluids, and analgesics as ordered

Vaso-occlusive crisis treatment focuses on hydration (to reduce blood viscosity), opioid analgesia (to manage severe pain), oxygen (if hypoxic), and warmth.

Vaso-occlusive (pain) crisis in sickle cell disease is caused by sickled RBCs obstructing microcirculation, causing ischemic pain. Treatment priorities: (1) Aggressive IV hydration (1.5x maintenance) to decrease blood viscosity and reduce sickling; (2) Analgesia — severe pain requires IV opioids (morphine) on a schedule, not PRN; (3) Supplemental oxygen if SpO2 <95% (hypoxia promotes sickling); (4) Warmth (cold causes vasoconstriction, worsening sickling — never use ice); (5) Monitor CBC, reticulocyte count, and vital signs. Fever in sickle cell requires blood cultures and antibiotics due to functional asplenia and infection risk.

Question 11: A 2-year-old child is brought to the clinic after ingesting an unknown amount of acetaminophen approximately 1 hour ago. The child is currently asymptomatic. The LPN should:

Reassure the parent that acetaminophen is safe and no action is needed
Advise the parent to watch for symptoms at home for 24 hours
Immediately notify the charge nurse and contact Poison Control (Correct answer)
Administer syrup of ipecac to induce vomiting

Correct answer: Immediately notify the charge nurse and contact Poison Control

Even asymptomatic acetaminophen overdose can cause delayed liver failure. Any ingestion in a child requires immediate notification and contact with Poison Control for guidance on N-acetylcysteine administration.

Acetaminophen toxicity follows four stages: Phase 1 (0–24h): nausea, vomiting, malaise (or asymptomatic); Phase 2 (24–72h): right upper quadrant pain, elevated LFTs; Phase 3 (72–96h): peak hepatotoxicity, jaundice, coagulopathy, possible liver failure; Phase 4 (>4 days): recovery or liver failure. The asymptomatic phase is deceptive — treatment with N-acetylcysteine (NAC) is most effective if given within 8–10 hours of ingestion. Syrup of ipecac is no longer recommended. The LPN must immediately notify the charge nurse, call Poison Control (1-800-222-1222), and prepare for NAC administration.

Question 12: A 5-year-old child is hospitalized and undergoing a painful procedure. Which distraction technique is most developmentally appropriate?

Explaining the full procedure in anatomical detail
Asking the child to count backward from 100
Providing a pinwheel or bubbles to blow during the procedure (Correct answer)
Leaving the child alone to self-soothe

Correct answer: Providing a pinwheel or bubbles to blow during the procedure

Blowing bubbles or a pinwheel provides developmentally appropriate distraction for a preschooler during painful procedures, promoting controlled breathing and reducing anxiety.

Developmentally appropriate pain management for preschoolers (2–6 years) includes: distraction with blowing bubbles, pinwheels, or singing songs (promotes controlled breathing, reduces anxiety, and provides sensory distraction); presence of a parent; topical anesthetic (EMLA cream); and validated pain scales (Wong-Baker FACES scale). Complex cognitive tasks (counting backward) are developmentally inappropriate for a 5-year-old in pain. Preschoolers think concretely and respond to sensory distraction. Therapeutic play, storytelling, and simple explanations using dolls are also effective. Leaving a child alone increases fear and pain perception.

Question 13: A 15-year-old adolescent with type 1 diabetes is being discharged. Which statement by the adolescent indicates a need for further teaching?

I need to check my blood sugar before and after playing sports
If I feel shaky during practice, I can eat glucose tablets or drink juice
I can skip my insulin on days when I'm not eating much to avoid low blood sugar (Correct answer)
I should wear my medical alert bracelet at all times

Correct answer: I can skip my insulin on days when I'm not eating much to avoid low blood sugar

Insulin must NEVER be skipped in type 1 diabetes because the pancreas produces no insulin. Skipping insulin causes diabetic ketoacidosis (DKA), not just low blood sugar.

Type 1 diabetes requires lifelong insulin therapy because the pancreas produces no endogenous insulin. During illness or reduced food intake, the body still needs basal insulin to prevent DKA (caused by fat breakdown, ketone production, and acidosis in the absence of insulin). Insulin dose may need adjustment (often reduced) but should never be skipped. The adolescent should 'sick day rules': check blood glucose every 4 hours, check ketones, stay hydrated, take basal insulin, and contact the provider. Options A, B, and D demonstrate correct understanding. The LPN should reinforce DKA symptoms (nausea, vomiting, abdominal pain, fruity breath).

Question 14: A newborn is born with a cleft lip and palate. Which nursing action is the priority in the neonatal period?

Prepare the infant for immediate surgical repair before discharge
Ensure adequate nutrition by using specialized cleft feeder and positioning (Correct answer)
Avoid all oral feeding until surgery to prevent aspiration
Apply topical antiseptic to the cleft to prevent infection

Correct answer: Ensure adequate nutrition by using specialized cleft feeder and positioning

Before surgical repair (done at 2–3 months for cleft lip), the priority is ensuring adequate nutrition using a specialized cleft palate feeder and upright positioning to reduce regurgitation and aspiration.

Cleft lip and palate prevent the infant from generating sufficient negative pressure for breastfeeding or standard bottle feeding. Nursing priorities in the neonatal period: (1) Establish effective feeding using specialized equipment (Haberman feeder, squeezable bottles, palatal obturators); (2) Position upright at 45–90 degrees during feeding; (3) Feed slowly with frequent burping; (4) Monitor weight gain; (5) Refer to cleft team (plastic surgeon, speech pathologist, orthodontist, social worker). Cleft lip repair occurs at 2–3 months; palate repair at 9–18 months. Oral feeding should be established — NPO is incorrect. Teach parents feeding techniques before discharge.

Question 15: An 8-year-old child is admitted with diabetic ketoacidosis (DKA). Which laboratory finding is most consistent with this diagnosis?

Blood glucose 320 mg/dL, pH 7.20, positive serum ketones, bicarbonate 10 mEq/L (Correct answer)
Blood glucose 320 mg/dL, pH 7.40, negative ketones, bicarbonate 24 mEq/L
Blood glucose 60 mg/dL, pH 7.30, positive ketones
Blood glucose 320 mg/dL, pH 7.35, sodium 125 mEq/L

Correct answer: Blood glucose 320 mg/dL, pH 7.20, positive serum ketones, bicarbonate 10 mEq/L

DKA is characterized by hyperglycemia (>250 mg/dL), metabolic acidosis (pH <7.30, bicarbonate <18 mEq/L), and positive serum or urine ketones.

Diabetic ketoacidosis (DKA) occurs in type 1 diabetes when insulin deficiency forces fat breakdown, producing ketone bodies (acidic). Diagnostic criteria: blood glucose >250 mg/dL, arterial pH <7.30 (or <7.25 for severe DKA), serum bicarbonate <18 mEq/L (or <10 for severe), and positive serum or urine ketones with a significant anion gap. Treatment: IV fluid resuscitation (normal saline), insulin infusion (after potassium verified adequate), potassium replacement (insulin drives K+ into cells), and continuous monitoring. The child will likely have hypokalemia during treatment as insulin is administered.

Question 16: The LPN is caring for a child who has been physically abused. After stabilizing the child medically, which action is the priority?

Confront the parents about the suspected abuse
Discuss the findings privately with the parents to give them a chance to explain
Document objective findings and report to the charge nurse for mandatory reporting (Correct answer)
Reassure the child everything is fine to prevent further trauma

Correct answer: Document objective findings and report to the charge nurse for mandatory reporting

All healthcare workers are mandated reporters. The LPN must objectively document physical findings and report suspected abuse through proper channels without confronting or investigating independently.

Healthcare providers are legally mandated reporters of suspected child abuse in all U.S. states. The LPN's responsibilities include: (1) Document objective findings (injuries, bruises in various healing stages, inconsistencies between history and injuries, inappropriate parental affect); (2) Do NOT confront parents or conduct an independent investigation — this can compromise the official investigation; (3) Report findings to the charge nurse, who will involve the social worker, provider, and child protective services (CPS); (4) Provide compassionate care to the child; (5) Maintain child safety — do NOT discharge to a potentially abusive environment.

Question 17: A 4-year-old is admitted with croup (laryngotracheobronchitis). The parents are anxious because the child has a harsh, seal-like barking cough. The LPN should explain that initial home management includes:

Placing the child in a hot shower's steam for 20 minutes
Taking the child outside into cool, humid night air or sitting in front of an open freezer (Correct answer)
Giving the child honey and warm tea to soothe the throat
Elevating the head of the bed 90 degrees and restricting fluids

Correct answer: Taking the child outside into cool, humid night air or sitting in front of an open freezer

Cool, moist air (night air or from a cool mist humidifier) reduces subglottic edema and quickly relieves the barking cough and stridor of croup.

Croup (laryngotracheobronchitis) is caused by parainfluenza virus causing subglottic airway edema. The characteristic barking cough and inspiratory stridor typically worsen at night. Home management: (1) Cool mist humidifier in the child's room; (2) Taking the child outside into cool night air; (3) Sitting in front of an open refrigerator or freezer breathing cool air. In the ED, racemic epinephrine nebulization treats moderate-severe croup (reduces edema), and dexamethasone reduces inflammation. Hospitalization criteria: stridor at rest, cyanosis, drooling, inability to swallow, significantly increased work of breathing. Steam therapy is no longer recommended and may worsen anxiety.

Question 18: A 14-year-old with anorexia nervosa is admitted for medical stabilization. The LPN recognizes the most immediate physiological danger as:

Vitamin deficiencies from inadequate diet
Cardiac arrhythmias from electrolyte disturbances (hypokalemia, hypomagnesemia) (Correct answer)
Excessive weight loss causing decreased mobility
Menstrual irregularities from low body fat

Correct answer: Cardiac arrhythmias from electrolyte disturbances (hypokalemia, hypomagnesemia)

In anorexia nervosa, electrolyte disturbances — especially hypokalemia from purging or severe restriction — are the most immediate life-threatening risk, causing potentially fatal cardiac arrhythmias.

Anorexia nervosa carries the highest mortality rate of any psychiatric disorder, primarily from cardiac complications. Starvation and purging behaviors cause severe electrolyte abnormalities including hypokalemia, hypomagnesemia, and hypophosphatemia, which destabilize cardiac membrane potentials and cause arrhythmias (QT prolongation, ventricular tachycardia, sudden cardiac death). The LPN must monitor: ECG, serum electrolytes, vital signs (bradycardia and orthostatic hypotension are common), and weight. Refeeding syndrome (phosphate drop when nutrition is restarted) is another immediate risk. Medical stabilization prioritizes cardiac monitoring and electrolyte correction.

Question 19: A 3-year-old child is in Bryant's traction for a fractured femur. The LPN should assess for which complication specific to this traction type?

Hyperextension of the hip joint
Impaired circulation to the buttocks and perineum (Correct answer)
Pressure ulcers only on the heels
Contracture of the knee joint

Correct answer: Impaired circulation to the buttocks and perineum

Bryant's traction suspends both legs vertically at 90 degrees, which can impair blood flow to the buttocks, perineum, and lower extremities, risking ischemia.

Bryant's traction is used for children under 2 years and/or under 35 lbs with femur fractures. Both lower extremities are suspended vertically at 90 degrees hip flexion with the buttocks slightly elevated off the bed. This position creates pressure and can impair circulation to the buttocks and perineum. Nursing assessments every 2 hours: neurovascular checks (color, warmth, capillary refill, pulses, sensation, movement in feet), skin integrity of buttocks and perineum, and ensure traction is continuous. Some experts no longer recommend Bryant's traction due to circulatory complications; Pavlik harness or surgical fixation may be preferred.

Question 20: A toddler is admitted with iron deficiency anemia. The LPN is teaching the parents about dietary iron sources. Which foods should be recommended?

Whole milk and dairy products as primary iron sources
Lean meats, fortified cereals, legumes, and dark leafy vegetables (Correct answer)
White bread, rice, and pasta for energy and iron
High-fiber foods to improve iron absorption

Correct answer: Lean meats, fortified cereals, legumes, and dark leafy vegetables

Heme iron (lean meats) and non-heme iron (fortified cereals, legumes, dark leafy vegetables) are the best dietary sources of iron for toddlers with iron deficiency anemia.

Iron deficiency anemia is the most common nutritional deficiency in toddlers, often caused by excessive cow's milk consumption (cow's milk is low in iron, interferes with iron absorption, and displaces iron-rich foods). Dietary iron sources: heme iron (more bioavailable) — lean red meat, dark poultry, fish; non-heme iron — iron-fortified cereals (the most practical source for toddlers), legumes (lentils, beans), dark leafy greens (spinach, kale), tofu. Vitamin C enhances non-heme iron absorption. Limit cow's milk to 16–24 oz/day. Avoid giving milk with iron-rich meals as calcium inhibits iron absorption.

Question 21: A 10-year-old child with leukemia is receiving chemotherapy and develops a temperature of 38.5°C (101.3°F). The absolute neutrophil count (ANC) is 300 cells/mm³. The LPN should:

Give acetaminophen and monitor for improvement over 24 hours
Perform a full physical exam and contact the family
Immediately notify the charge nurse — this is a neutropenic fever emergency (Correct answer)
Apply a cool cloth to the forehead and restrict visitors

Correct answer: Immediately notify the charge nurse — this is a neutropenic fever emergency

An ANC <500 cells/mm³ with fever constitutes a neutropenic fever — a medical emergency with high mortality from infection. Immediate broad-spectrum IV antibiotics are required.

Febrile neutropenia is defined as a single temperature ≥38.3°C (101°F) or ≥38.0°C for >1 hour with an ANC <500 cells/mm³. In cancer patients on chemotherapy, this is a life-threatening emergency because the immune system cannot fight infection. The standard of care requires: blood cultures from central and peripheral lines before starting antibiotics; broad-spectrum IV antibiotics within 1 hour; hospitalization; vital sign monitoring every 15–30 minutes. Mortality rises dramatically with each hour of delay. Acetaminophen can be given but does not replace emergent antibiotic therapy. The LPN must escalate immediately.

Question 22: A child with Down syndrome (Trisomy 21) is admitted for cardiac surgery. The LPN knows that Down syndrome is most commonly associated with which cardiac defect?

Transposition of the great arteries
Atrioventricular septal defect (AVSD/endocardial cushion defect) (Correct answer)
Hypoplastic left heart syndrome
Coarctation of the aorta

Correct answer: Atrioventricular septal defect (AVSD/endocardial cushion defect)

Atrioventricular septal defect (AVSD), also called endocardial cushion defect, is the most common congenital heart disease in children with Down syndrome, occurring in approximately 40–50% of cases.

Approximately 40–50% of children with Down syndrome (Trisomy 21) have congenital heart defects, with atrioventricular septal defect (AVSD) being the most common. AVSD involves a defect at the center of the heart (primum ASD + inlet VSD + abnormal AV valves) allowing blood to mix between all four chambers. This causes pulmonary hypertension, congestive heart failure, and failure to thrive. Surgical repair is usually performed before 6 months of age. Other Down syndrome cardiac defects include VSD (second most common), PDA, and ASD. The LPN should monitor for signs of heart failure (tachycardia, poor feeding, sweating with feeds, respiratory distress).

Question 23: A 2-year-old child is accidentally ingested button batteries from a remote control. The parent calls the emergency department. The LPN should advise the parent to:

Give the child milk or water to help neutralize the battery's chemicals
Induce vomiting immediately to remove the battery
Bring the child to the emergency department immediately — this is a life-threatening emergency (Correct answer)
Monitor for symptoms and come in if the child develops abdominal pain

Correct answer: Bring the child to the emergency department immediately — this is a life-threatening emergency

Button battery ingestion can cause esophageal necrosis, perforation, and death within 2 hours if lodged in the esophagus. Immediate emergency evaluation is required regardless of symptoms.

Button (disc) battery ingestion is a pediatric emergency because batteries lodged in the esophagus generate an electrical current that produces hydroxide (alkali) at the negative pole, causing liquefactive necrosis within 2 hours. This can lead to esophageal perforation, aortoesophageal fistula, and death. Even asymptomatic children must be seen immediately — X-ray determines location. If in the esophagus, emergency endoscopic removal within 2 hours is required. If in the stomach with no symptoms in children >5 years, serial X-ray monitoring may be acceptable. Induce vomiting is never recommended as it risks esophageal damage. Honey (if >1 year old) may be given to coat and slow damage en route to the ED.

Question 24: The LPN is teaching parents about fever management in a 3-year-old. Which statement indicates correct understanding?

I should give both acetaminophen and ibuprofen at the same time for faster fever control
I will use age-appropriate doses of acetaminophen or ibuprofen and call the doctor if fever exceeds 39°C (102.2°F) for more than 2 days (Correct answer)
I should alternate acetaminophen and ibuprofen every 2 hours to keep the fever down
I need to bring my child to the ER for any fever above 37.5°C (99.5°F)

Correct answer: I will use age-appropriate doses of acetaminophen or ibuprofen and call the doctor if fever exceeds 39°C (102.2°F) for more than 2 days

The AAP recommends using a single antipyretic in weight-appropriate doses. A fever >39°C lasting >2 days in a child 3 months to 3 years warrants medical evaluation.

Fever management guidelines for children: (1) Use weight-based dosing of acetaminophen (15 mg/kg/dose q4–6h) or ibuprofen (10 mg/kg/dose q6–8h, not for infants <6 months); (2) Do not combine or alternate antipyretics routinely — alternating is not recommended by AAP as it risks dosing errors; (3) Fever is beneficial (immune response) — treat if causing discomfort; (4) Call the provider: any fever in infant <3 months, fever >38.9°C lasting >1–2 days in toddlers, or any fever with serious symptoms (stiff neck, rash, difficulty breathing, severe headache). Fever itself (below seizure threshold) is not dangerous in healthy children.

Question 25: An infant at 6 weeks of age is brought to the clinic with projectile vomiting after every feeding for 4 days. The infant appears hungry immediately after vomiting. The LPN suspects:

Gastroesophageal reflux disease (GERD)
Pyloric stenosis and reports findings to the provider urgently (Correct answer)
Normal infant spitting up
Milk protein allergy requiring formula change

Correct answer: Pyloric stenosis and reports findings to the provider urgently

Pyloric stenosis presents in infants 2–8 weeks old with projectile (forceful) non-bilious vomiting immediately after feeding, followed by intense hunger. An olive-shaped mass may be palpated.

Pyloric stenosis is hypertrophy of the pyloric muscle causing gastric outlet obstruction. Classic presentation: 3–6 week old infant (more common in first-born males) with projectile, non-bilious (no bile since obstruction is above the duodenum), forceful vomiting after feeding; the infant appears hungry immediately; signs of dehydration and metabolic alkalosis develop (hypokalemic, hypochloremic). A palpable olive-shaped mass in the right upper quadrant is pathognomonic. Diagnosis by ultrasound. Treatment is surgical pyloromyotomy after electrolyte correction. The LPN must report these findings urgently and prepare for hospital admission.

Question 26: A 7-year-old child with asthma is using a metered-dose inhaler (MDI) with a spacer. The LPN evaluates that the child is using the device correctly when the child:

Rapidly exhales after actuation to clear the medication from the lungs
Shakes the inhaler, actuates while inhaling slowly and deeply, and holds the breath for 10 seconds (Correct answer)
Holds the inhaler 2 inches from the mouth without a spacer
Takes rapid shallow breaths after pressing the canister to distribute the medication

Correct answer: Shakes the inhaler, actuates while inhaling slowly and deeply, and holds the breath for 10 seconds

Correct MDI technique requires shaking the inhaler, coordinating slow deep inhalation with actuation, and breath-holding for 10 seconds to maximize medication deposition in the airways.

Correct MDI with spacer technique: (1) Shake the inhaler 10–15 times; (2) Exhale fully; (3) Seal lips around the spacer mouthpiece; (4) Press the canister once; (5) Inhale SLOWLY and DEEPLY over 3–5 seconds; (6) Hold breath for 10 seconds to allow medication to settle; (7) Wait 1 minute between puffs; (8) Rinse mouth after corticosteroid inhalers. Common errors: shaking incorrectly, breathing too fast, not holding breath, and not using a spacer in young children. A spacer (valved holding chamber) slows the aerosol and reduces oropharyngeal deposition of inhaled corticosteroids, reducing candidiasis risk.

Question 27: A 4-year-old child is receiving chemotherapy and develops oral mucositis. The LPN teaches the parents to:

Use a firm toothbrush after each meal to remove debris from lesions
Rinse the mouth with a hydrogen peroxide mouthwash every 2 hours
Provide soft, non-acidic foods and rinse with normal saline or prescribed mouthwash (Correct answer)
Avoid all oral hygiene until lesions heal completely

Correct answer: Provide soft, non-acidic foods and rinse with normal saline or prescribed mouthwash

Oral mucositis from chemotherapy requires gentle care: soft foods, saline rinses to maintain moisture and reduce bacterial load, and prescribed analgesic mouthwash for pain.

Oral mucositis is a common side effect of chemotherapy (and radiation to the head/neck) causing painful inflammation and ulceration of the oral mucosa. Nursing management: (1) Use an ultra-soft toothbrush or foam swab; (2) Rinse with saline or sodium bicarbonate solution every 4–6 hours (avoids acidic commercial mouthwashes); (3) Provide soft, non-acidic, non-spicy foods at room temperature; (4) Administer prescribed oral analgesics or analgesic mouthwash ('magic mouthwash') before meals; (5) Monitor for signs of secondary infection (candidiasis — white patches); (6) Maintain oral hydration; (7) Avoid hydrogen peroxide rinses (delays mucosal healing by destroying granulation tissue).

Question 28: A child is diagnosed with celiac disease. The LPN should teach the family to eliminate which foods from the diet?

Dairy products, eggs, and citrus fruits
Wheat, barley, rye, and products containing gluten (Correct answer)
Red meat, processed foods, and all legumes
Corn, rice, and potatoes

Correct answer: Wheat, barley, rye, and products containing gluten

Celiac disease is an immune-mediated reaction to gluten — a protein found in wheat, barley, and rye — requiring lifelong elimination from the diet.

Celiac disease is an autoimmune disorder triggered by gluten ingestion in genetically predisposed individuals, causing small intestinal villous atrophy and malabsorption. Treatment: strict lifelong gluten-free diet. Gluten is found in: wheat (bread, pasta, cereals, flour, couscous, bulgur, spelt), barley (malt, beer, barley soups), rye, and anything processed in facilities shared with these grains (cross-contamination). Gluten-free grains: rice, corn, quinoa, oats (certified gluten-free), potato starch, tapioca. Label reading is critical. Hidden gluten sources: soy sauce, some medications, communion wafers. A registered dietitian referral is essential. Strict adherence prevents malnutrition, growth failure, and long-term complications (lymphoma, osteoporosis).

Question 29: A 4-month-old infant is brought to the emergency department and found to have multiple healing rib fractures in various stages of healing, retinal hemorrhages, and subdural hematoma. The parent reports the infant 'fell off the couch.' The LPN should recognize this presentation as:

Consistent with the parent's description of a minor fall
Highly suspicious for abusive head trauma (shaken baby syndrome) (Correct answer)
Typical findings of osteogenesis imperfecta
Normal findings in an active 4-month-old infant

Correct answer: Highly suspicious for abusive head trauma (shaken baby syndrome)

Multiple healing rib fractures, retinal hemorrhages, and subdural hematoma in an infant — inconsistent with the reported minor mechanism — are classic for non-accidental abusive head trauma.

Abusive head trauma (AHT/shaken baby syndrome) is the leading cause of fatal child abuse. Classic triad: subdural hematoma, retinal hemorrhages, and encephalopathy. Additional findings: multiple rib fractures (from squeezing) at different stages of healing (indicating repeated trauma), long bone metaphyseal fractures ('bucket handle' or 'corner' fractures). These findings are highly specific for non-accidental trauma and incompatible with a couch fall (which does not generate sufficient force). The LPN must: document objective findings, notify the charge nurse for mandatory reporting, not confront parents, ensure child safety, and initiate a full skeletal survey. A multidisciplinary child protective team investigates.

Question 30: A 10-year-old child with newly diagnosed type 1 diabetes has blood glucose of 450 mg/dL, Kussmaul respirations, and a fruity odor to the breath. The LPN recognizes these as signs of:

Hyperosmolar hyperglycemic state (HHS)
Diabetic ketoacidosis (DKA) in a pediatric patient (Correct answer)
Insulin reaction from excessive insulin administration
Normal variation in an uncontrolled diabetic child

Correct answer: Diabetic ketoacidosis (DKA) in a pediatric patient

Kussmaul respirations (deep, rapid breaths to blow off CO2 from acidosis) and fruity (acetone) breath are hallmarks of DKA caused by ketone body production in severe insulin deficiency.

Kussmaul respirations are deep, rapid, labored breaths representing the respiratory compensation for metabolic acidosis in DKA. The brain drives increased ventilation to blow off CO2, raising pH. Fruity or acetone odor on breath results from exhaled acetone (a volatile ketone). Other DKA signs: dehydration, polyuria, polydipsia, vomiting, abdominal pain, lethargy, altered mental status. Lab findings: glucose >250 mg/dL, pH <7.30, bicarbonate <18 mEq/L, positive ketones. HHS occurs primarily in type 2 diabetes with extreme hyperglycemia, minimal ketonemia, and severe dehydration without acidosis. Treatment priorities: fluid resuscitation (cautious in pediatrics due to cerebral edema risk), insulin infusion, electrolyte monitoring.

Question 31: A 2-year-old is admitted with a temperature of 40.2°C (104.4°F) and sudden onset tonic-clonic seizure lasting 2 minutes. After the seizure stops, the child is lethargic but arousable. The LPN understands this presentation is most consistent with:

Status epilepticus requiring emergency anticonvulsants
A simple febrile seizure with benign prognosis (Correct answer)
Bacterial meningitis requiring immediate lumbar puncture
Epilepsy requiring lifelong anticonvulsant therapy

Correct answer: A simple febrile seizure with benign prognosis

A febrile seizure is a tonic-clonic seizure lasting <15 minutes occurring with fever in a child aged 6 months to 5 years with no CNS cause. Most are simple and benign with no increased risk of epilepsy.

Febrile seizures are the most common seizure disorder of childhood, occurring in 2–5% of children aged 6 months to 5 years. Simple febrile seizures: generalized tonic-clonic, <15 minutes, occur once in 24-hour period, no focal features, no neurological abnormality — benign prognosis. Complex febrile seizures: focal features, duration >15 minutes, or recur within 24 hours — require further evaluation. Simple febrile seizures do NOT increase risk of epilepsy or brain damage. Post-ictal lethargy is expected and temporary. Management: lower fever (antipyretics), investigate the source of fever, parental education, recurrence prevention by controlling fever during future illnesses. Anticonvulsants are NOT indicated for simple febrile seizures.

Question 32: The LPN is teaching the parents of a child with hemophilia A about home management of a joint bleed (hemarthrosis). Which instruction is the correct initial treatment?

Apply heat and have the child exercise the joint to prevent stiffness
Administer factor VIII concentrate as prescribed and apply RICE (Rest, Ice, Compression, Elevation) (Correct answer)
Apply deep massage to the joint to break up the blood clot
Give aspirin for pain and take the child to the ER for X-rays

Correct answer: Administer factor VIII concentrate as prescribed and apply RICE (Rest, Ice, Compression, Elevation)

Hemarthrosis in hemophilia A is treated with factor VIII replacement (the missing clotting factor) and RICE to minimize bleeding, swelling, and joint damage.

Hemophilia A is a factor VIII deficiency causing abnormal bleeding. Hemarthrosis (bleeding into joints) is the most common manifestation, causing pain, swelling, warmth, and limited motion. Home treatment protocol: (1) Administer prescribed factor VIII concentrate (recombinant or plasma-derived) immediately — do not wait for symptoms to worsen; (2) Apply RICE: Rest the joint, Ice (wrapped, not direct — 15–20 minutes), Compression bandage, Elevate above heart level; (3) Avoid aspirin and NSAIDs (impair platelet function); (4) Use acetaminophen for pain; (5) Contact the hematology team if bleeding doesn't resolve. Early factor replacement reduces long-term joint damage (hemophilic arthropathy). Never massage bleeding joints.

Question 33: A 6-year-old child is admitted with suspected lead poisoning. A blood lead level of 45 mcg/dL is confirmed. The LPN should expect the provider to order:

IV fluids only — chelation therapy is not indicated at this level
Chelation therapy with oral succimer (DMSA) and removal from lead source (Correct answer)
High-dose vitamin C to bind and excrete the lead
Immediate gastric lavage to remove ingested lead

Correct answer: Chelation therapy with oral succimer (DMSA) and removal from lead source

Blood lead levels ≥45 mcg/dL indicate significant toxicity requiring chelation therapy with succimer (DMSA) in addition to removing the child from the lead source.

Lead poisoning management by blood lead level (BLL): <5 mcg/dL: no known safe level — primary prevention; 5–14 mcg/dL: identify and eliminate sources, retest in 3 months; 15–44 mcg/dL: case management, environmental investigation, nutritional counseling; ≥45 mcg/dL: chelation therapy with oral succimer (DMSA, dimercaptosuccinic acid) — oral chelator used for BLLs 25–44 mcg/dL in some protocols, or BLL ≥45 mcg/dL; BLL ≥70 mcg/dL: IV dimercaprol (BAL) + IV EDTA. Lead sources must be removed before chelation or re-exposure will re-elevate levels. Monitor CBC, renal function, and BLL during chelation. Lead causes irreversible neurodevelopmental damage.

Question 34: A 9-month-old infant is being discharged after treatment for bronchiolitis. The LPN provides discharge teaching. Which instruction is the MOST important for the parents?

Give cough syrup as needed when the infant has difficulty breathing at night
Administer a decongestant twice daily to reduce nasal congestion
Return immediately if the infant shows increased work of breathing, poor feeding, or worsening color (Correct answer)
Keep the infant indoors for 6 weeks to prevent re-infection

Correct answer: Return immediately if the infant shows increased work of breathing, poor feeding, or worsening color

Bronchiolitis can worsen suddenly in infants. Parents must know the warning signs of respiratory deterioration (retractions, grunting, cyanosis, poor feeding) requiring immediate emergency care.

Bronchiolitis (usually RSV) is the most common lower respiratory infection in infants. It is self-limiting (peaks day 3–5, resolves in 2 weeks) with supportive care only (nasal suction, fluids, humidified air). Cough/cold medications and decongestants are NOT recommended for infants <2 years (FDA black box warning). Discharge teaching must emphasize warning signs requiring emergency return: (1) Increased respiratory rate or effort (nasal flaring, retractions, grunting); (2) Decreased feeding (<50% normal intake); (3) Fewer wet diapers; (4) Apnea episodes; (5) Cyanosis or pallor; (6) Inconsolable irritability or unusual lethargy. Most infants recover at home, but approximately 1–3% require hospitalization for oxygen or IV fluids.

Question 35: A child undergoing bone marrow transplant has an ANC of 100 cells/mm³. The LPN implements neutropenic precautions, which include:

Placing the child in a regular room with droplet precautions only
Private room, HEPA filter if available, no fresh flowers/plants, meticulous hand hygiene, cooked foods only (Correct answer)
Restricting all family visits for 4 weeks
Administering live attenuated vaccines to boost immune function

Correct answer: Private room, HEPA filter if available, no fresh flowers/plants, meticulous hand hygiene, cooked foods only

Profound neutropenia requires protective environment: private room with HEPA filtration (if available), no fresh flowers/plants (mold/bacteria), strict hand hygiene, and avoiding raw/uncooked foods.

Profound neutropenia (ANC <500 cells/mm³, especially <100) after bone marrow transplant requires strict protective isolation. Evidence-based neutropenic precautions: (1) Private room; HEPA-filtered positive pressure room reduces fungal exposure; (2) No fresh flowers, plants, or standing water (harbor Aspergillus and other fungi); (3) Strict hand hygiene by all staff and visitors; (4) No raw fruits/vegetables (neutropenic diet — all foods cooked); (5) No fresh flowers; (6) N95 masks for construction dust exposure; (7) Mask for the patient when leaving the room; (8) Live vaccines absolutely contraindicated (can cause vaccine-strain infection in immunocompromised). Family visits are encouraged with appropriate precautions — isolation is protective, not punitive.

Question 36: A 2-year-old is brought to the clinic after swallowing a coin. The child is asymptomatic, eating and drinking normally, and has no drooling or respiratory distress. The LPN anticipates:

Emergency endoscopy to remove the coin before it causes damage
X-ray confirmation of location; if in stomach, watchful waiting for spontaneous passage (Correct answer)
Inducing vomiting at home to remove the coin
Immediate surgery to prevent intestinal perforation

Correct answer: X-ray confirmation of location; if in stomach, watchful waiting for spontaneous passage

A coin in the stomach of an asymptomatic child will typically pass spontaneously through the GI tract within 2–4 days. Coins in the esophagus require endoscopic removal.

Foreign body ingestion management depends on object type and location: (1) Esophagus: most foreign bodies lodged in the esophagus require endoscopic removal (risk of erosion, perforation, fistula) — signs include drooling, dysphagia, vomiting, respiratory symptoms; (2) Stomach/intestines: smooth objects like coins in asymptomatic children typically pass spontaneously in 2–4 days — stools should be checked; (3) Button batteries: always emergent wherever located (see previous); (4) Sharp objects (pins, bones): require monitoring or endoscopic removal. Asymptomatic coin ingestion confirmed by X-ray to be below the esophagus (in stomach) can be managed with watchful waiting and outpatient follow-up. Inducing vomiting risks aspiration.

LPN Pediatric Nursing Fundamentals 1

A 3-year-old child is admitted with suspected epiglottitis.
Which nursing action is the priority?

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