NCLEX Pediatric Nursing: Growth and Development 1 — Questions and Answers

Question 1: A nurse is assessing a 2-year-old child. Which developmental milestone would the nurse expect to find?

Speaking in complete 5–6 word sentences
Walking up stairs with alternating feet
Using 50+ words and combining 2-word phrases (Correct answer)
Drawing a circle and copying simple shapes

Correct answer: Using 50+ words and combining 2-word phrases

At 2 years, children typically have a vocabulary of 50+ words and combine 2-word phrases ('more milk,' 'daddy go'). Walking with alternating feet on stairs develops around age 3. Sentences develop by age 3–4.

Key developmental milestones at 24 months (2 years): Language: 50+ word vocabulary, 2-word phrases (telegraphic speech), 50% intelligible to strangers; Motor: runs well, kicks a ball, throws overhand, climbs furniture, walks up/down stairs with both feet on each step (not alternating — that's age 3); Cognitive: beginning symbolic/pretend play, parallel play (not cooperative), object permanence fully established; Social: egocentric, parallel play, beginning independence, may have tantrums (autonomy vs. shame — Erikson). Denver II developmental screening categorizes abilities by age. Referral is needed if a child has fewer than 50 words or no 2-word phrases by 24 months.

Question 2: A parent asks when their infant should receive the first dose of the hepatitis B vaccine. The nurse should respond:

At 2 months of age at the first well-baby visit
Within 24 hours of birth (Correct answer)
At 6 months when the immune system matures
Only if the mother tests positive for hepatitis B

Correct answer: Within 24 hours of birth

The CDC recommends the first dose of hepatitis B vaccine within 24 hours of birth for all newborns. This is especially important if the mother's hepatitis B status is unknown or positive.

Hepatitis B vaccine schedule per CDC ACIP: (1) Dose 1: within 24 hours of birth; (2) Dose 2: 1–2 months; (3) Dose 3: 6–18 months. If the mother is HBsAg-positive: newborn should receive hepatitis B vaccine AND hepatitis B immune globulin (HBIG) within 12 hours of birth. If mother's status is unknown: administer the first dose within 12 hours and test the mother ASAP. Maternal HBsAg-positive status is associated with a 90% risk of chronic infection in the newborn if not treated. All newborns receive Hep B regardless of mother's status. Other birth-dose interventions: vitamin K IM, erythromycin eye ointment (ophthalmia neonatorum prophylaxis).

Question 3: A nurse is caring for a child with epiglottitis. Which intervention should the nurse avoid?

Administering humidified oxygen
Placing the child in a position of comfort (usually upright/sitting)
Examining the throat with a tongue depressor to visualize the epiglottis (Correct answer)
Preparing for possible emergency airway management

Correct answer: Examining the throat with a tongue depressor to visualize the epiglottis

Direct inspection of the throat with a tongue depressor can cause laryngospasm and complete airway obstruction in epiglottitis. This is absolutely contraindicated and can be fatal.

Epiglottitis is a life-threatening bacterial infection (most commonly Haemophilus influenzae type b — now rare due to Hib vaccine) causing edema of the epiglottis and supraglottic structures. Classic presentation: sudden onset high fever, severe sore throat, drooling, dysphagia, stridor, 'tripod' position (leaning forward, hands on knees to maximize airway). CRITICAL RULE: Never use a tongue depressor or attempt to visualize the oropharynx — sudden stimulation can trigger complete laryngospasm and respiratory arrest. Management: (1) Keep child calm in comfortable position; (2) Do NOT lay flat; (3) Provide humidified O2 without disturbing the child; (4) Prepare for emergency intubation or tracheostomy; (5) IV antibiotics in controlled setting (usually OR with anesthesia present). Lateral neck X-ray ('thumbprint sign') confirms diagnosis without direct visualization.

Question 4: A nurse is caring for a child with croup (laryngotracheobronchitis). The child has a 'barky' cough and inspiratory stridor at rest. Which treatment is most appropriate?

Initiate immediate IV antibiotics for bacterial infection
Administer nebulized racemic epinephrine and oral/IM dexamethasone (Correct answer)
Perform a throat culture to identify the pathogen
Perform immediate intubation to secure the airway

Correct answer: Administer nebulized racemic epinephrine and oral/IM dexamethasone

Moderate-to-severe croup with stridor at rest is treated with nebulized racemic epinephrine (reduces edema) and dexamethasone (corticosteroid reduces inflammation). Croup is viral and does not require antibiotics.

Croup (laryngotracheobronchitis) is the most common cause of acute stridor in children, primarily caused by parainfluenza virus (ages 6 months–3 years). Classic: 'barky seal-like' cough, inspiratory stridor, hoarse voice, low-grade fever, worse at night. Severity determines treatment: Mild (barky cough, no stridor at rest): cool mist air, oral dexamethasone; Moderate (stridor at rest, mild retractions): dexamethasone + nebulized epinephrine; Severe (severe stridor, significant retractions, altered mental status): nebulized epinephrine, IM/IV dexamethasone, hospitalization, airway standby. Steeple sign on X-ray (subglottic narrowing). Observation for rebound edema after epinephrine (2–3 hours). Antibiotics not indicated (viral etiology).

Question 5: The nurse is performing a developmental assessment on a 4-month-old infant. Which finding would be cause for concern?

Does not yet pull to stand
No social smile in response to caregiver (Correct answer)
Cannot walk with support
Cannot hold a rattle

Correct answer: No social smile in response to caregiver

Social smiling (responsive smile to a caregiver's face) normally develops by 6–8 weeks. Absence of a social smile by 4 months is a developmental red flag requiring further evaluation.

Developmental red flags at 4 months: No social smile (should appear by 6–8 weeks); doesn't follow objects with eyes (tracking); doesn't respond to sounds; no cooing/vocalization; doesn't bring hands to face; poor head control (should have full head control by 4 months). Expected at 4 months: head steady when upright, follows objects 180°, laughs, coos, social smile well established, brings hands to midline, enjoys visual stimulation. Red flags trigger referral for developmental evaluation (early intervention). Pulling to stand is an expected milestone at 9–12 months. Walking with support: 9–12 months. Holding a rattle: 3–4 months — absence by 4 months would also be concerning.

Question 6: A nurse is educating parents about preventing sudden infant death syndrome (SIDS). Which recommendation is most important?

Place the infant in the prone (tummy) position for sleep
Place the infant in a supine (back) position on a firm mattress in their own sleep space (Correct answer)
Co-sleep with the infant to monitor their breathing
Use a soft mattress and bumper pads for the crib

Correct answer: Place the infant in a supine (back) position on a firm mattress in their own sleep space

The 'Back to Sleep' (now Safe Sleep) campaign recommendation: always place infants on their backs on a firm, flat surface. This is the single most effective SIDS prevention measure, reducing SIDS by 50%.

Safe Sleep ABCs: Alone, on their Back, in their Crib (or firm sleep surface). AAP Safe Infant Sleep recommendations: (1) Supine (back) for every sleep until age 1; (2) Firm, flat sleep surface (crib, bassinet, play yard — no soft mattresses, inclined sleepers); (3) Own sleep space — no bed-sharing (although room-sharing without bed-sharing for 6 months is recommended); (4) Remove soft objects, loose bedding, bumper pads from sleep area; (5) Avoid overheating; (6) Breastfeed if possible (reduces SIDS risk ~50%); (7) Use pacifier at sleep after breastfeeding established; (8) Avoid smoke exposure; (9) Ensure up-to-date vaccinations. 'Back to Sleep' campaign since 1994 has reduced SIDS deaths by 50%.

Question 7: A school-age child (8 years old) is admitted for an appendectomy. According to Erikson's theory of psychosocial development, which stage is this child in?

Trust vs. Mistrust
Initiative vs. Guilt
Industry vs. Inferiority (Correct answer)
Identity vs. Role Confusion

Correct answer: Industry vs. Inferiority

School-age children (6–12 years) are in Erikson's Industry vs. Inferiority stage, where the central task is developing competence and skills. Hospitalization can threaten this by disrupting school and peer activities.

Erikson's Psychosocial Development Stages: (1) Trust vs. Mistrust: birth–18 months — develop trust through consistent caregiving; (2) Autonomy vs. Shame/Doubt: 18 months–3 years — develop self-control, independence; (3) Initiative vs. Guilt: 3–6 years — develop purpose, initiate activities; (4) Industry vs. Inferiority: 6–12 years — develop competence through school, peers, skills; (5) Identity vs. Role Confusion: 12–18 years — develop sense of identity; (6) Intimacy vs. Isolation: young adult; (7) Generativity vs. Stagnation: middle adult; (8) Integrity vs. Despair: older adult. Nursing implication: during hospitalization of school-agers, include educational activities, allow schoolwork continuation, involve child in care decisions, maintain peer connections.

Question 8: A nurse is assessing a 6-month-old infant for dehydration. Which clinical sign is the most reliable indicator of dehydration in infants?

Dry lips and mouth
Skin turgor — tenting when pinched and slow return (>2 seconds) (Correct answer)
Absence of tears when crying
Sunken anterior fontanel

Correct answer: Skin turgor — tenting when pinched and slow return (>2 seconds)

Skin turgor (skin tenting) is the most reliable physical sign of dehydration in infants and young children. Normal skin returns immediately; tenting (>2 second return) indicates significant fluid deficit.

Dehydration assessment in infants and children: Mild (3–5% body weight loss): increased thirst, slightly dry mucous membranes, concentrated urine; Moderate (6–9%): significant decrease in urine output, sunken fontanel, tachycardia, dry mucous membranes, reduced skin turgor; Severe (>10%): shock, mottled skin, severe tachycardia, hypotension, sunken eyes. Skin turgor is assessed by pinching skin on abdomen or thigh and observing recoil — tenting or slow return (>2 seconds) indicates ≥5% dehydration. Capillary refill >2 seconds also indicates moderate dehydration. Sunken fontanel and absence of tears are less reliable indicators. Weight measurement (before and after) is the gold standard for quantifying fluid loss.

Question 9: A child with sickle cell disease presents to the emergency department with severe bone pain, fever, and swelling in the hands and feet. What condition does this most likely represent?

Splenic sequestration crisis
Vaso-occlusive (pain) crisis (Correct answer)
Aplastic crisis due to parvovirus B19
Hyperhemolytic crisis

Correct answer: Vaso-occlusive (pain) crisis

Vaso-occlusive (pain) crisis is the most common sickle cell complication, caused by sickling of RBCs in small vessels. Dactylitis (swelling of hands/feet) is a classic early presentation in young children.

Sickle cell vaso-occlusive crisis (VOC/pain crisis) is caused by sickling of erythrocytes, which obstruct microvascular blood flow, causing ischemia and infarction of bone, soft tissue, and organs. Dactylitis (hand-foot syndrome) — swelling and pain of the hands and feet — is often the first manifestation in children <5 years. Common VOC triggers: hypoxia, infection, dehydration, cold exposure, stress. Management: (1) IV/oral hydration (3000 mL/m²/day); (2) Adequate analgesia (NSAIDs, opioids per pain scale); (3) Oxygen if hypoxic; (4) Treat underlying infection if present; (5) Incentive spirometry (prevents acute chest syndrome); (6) Monitor CBC, reticulocytes. Acute chest syndrome (fever, chest pain, infiltrate, hypoxia) is the leading cause of mortality.

Question 10: A nurse is educating parents of a child diagnosed with type 1 diabetes about sick day management. Which instruction is most important?

Hold insulin if the child is not eating to prevent hypoglycemia
Continue insulin, check blood glucose every 1–2 hours, and check urine/blood ketones (Correct answer)
Give only half the usual insulin dose during illness
Only administer insulin if blood glucose exceeds 400 mg/dL

Correct answer: Continue insulin, check blood glucose every 1–2 hours, and check urine/blood ketones

Illness triggers stress hormones that raise blood glucose and ketone production. Insulin should NEVER be withheld during illness — the child needs insulin plus additional monitoring for hypoglycemia and DKA prevention.

Sick day rules for pediatric type 1 diabetes: (1) NEVER stop insulin — illness causes stress hormone release (cortisol, glucagon, epinephrine) that raises blood glucose even without eating; (2) Check blood glucose every 1–2 hours; (3) Check urine or blood ketones when blood glucose >240 mg/dL; (4) Stay hydrated (prevent DKA) — small, frequent sips; (5) May need additional correction doses of rapid-acting insulin; (6) Seek medical attention for: blood glucose >400 mg/dL, moderate-large ketones, inability to keep fluids down, altered mental status, vomiting — signs of developing DKA; (7) Contact provider early in the illness. DKA (pH < 7.3, bicarbonate < 15, ketones positive) requires emergency treatment.

Question 11: An adolescent patient refuses a painful dressing change. According to Piaget's cognitive development theory, which stage is the adolescent in?

Sensorimotor
Preoperational
Concrete Operational
Formal Operational (Correct answer)

Correct answer: Formal Operational

Adolescents (12+ years) are in the Formal Operational stage (Piaget), characterized by abstract thinking, logical reasoning, and the ability to consider hypothetical situations — relevant to understanding medical consequences.

Piaget's Stages of Cognitive Development: (1) Sensorimotor: birth–2 years — learning through senses/motor; object permanence develops; (2) Preoperational: 2–7 years — symbolic/magical thinking, egocentric, animistic; (3) Concrete Operational: 7–11 years — logical thinking about concrete objects, conservation, classification, reversibility; (4) Formal Operational: 12+ years — abstract reasoning, hypothetical/deductive thinking, considering multiple possibilities. Nursing application for adolescent refusal: appeal to abstract reasoning — explain specific long-term consequences ('infection can lead to sepsis'), involve the adolescent in decision-making (autonomy important at this stage — Erikson's Identity stage), use negotiation ('what would make this easier?'). Peer influence is significant; privacy is important.

Question 12: A nurse is caring for a child with bacterial meningitis. Which assessment finding requires immediate intervention?

Temperature of 38.5°C (101.3°F)
Petechial rash spreading rapidly with purpura (Correct answer)
Mild headache and photophobia
Kernig's sign present

Correct answer: Petechial rash spreading rapidly with purpura

A rapidly spreading petechial/purpuric rash in bacterial meningitis indicates meningococcemia — disseminated meningococcal infection with septicemia and potential DIC. This is immediately life-threatening.

Neisseria meningitidis (meningococcal meningitis) can progress to fulminant meningococcemia — bacterial septicemia with rapid DIC, causing the classic petechial/purpuric rash (non-blanching). Petechiae indicate microhemorrhages from small vessel destruction and coagulopathy. Progression from petechiae to purpura (large areas of skin hemorrhage) to 'purpura fulminans' indicates severe septic shock and DIC — mortality can be >50% if untreated. EMERGENCY actions: immediate IV/IO access, blood cultures (don't delay treatment for cultures), IV antibiotics (ceftriaxone) immediately, vasopressors for septic shock, FFP/platelets for DIC, ICU admission. Other assessment findings (fever, headache, photophobia, Kernig's/Brudzinski's signs) are serious but less immediately urgent than the spreading purpuric rash.

Question 13: A 3-year-old child is admitted for a urinary tract infection (UTI). Which urine specimen collection method is most appropriate for this age group?

Midstream clean-catch urine from the toilet
Catheter specimen (urethral catheterization) or suprapubic aspiration for accurate culture (Correct answer)
Urine bag specimen attached to the perineum
First morning void collected at home

Correct answer: Catheter specimen (urethral catheterization) or suprapubic aspiration for accurate culture

In children who are not toilet-trained or whose bag specimen results are questionable, catheterization or suprapubic aspiration provides the most accurate, non-contaminated specimen for culture.

UTI in young children is a significant concern as it can cause permanent renal scarring if not promptly and correctly treated. Specimen collection methods in children: (1) Urine bag (perineal bag): non-invasive but highly susceptible to contamination from perineal flora; sensitivity ~85% but specificity ~79% — positive results require confirmation; (2) Catheterized specimen: more invasive but reliable for accurate culture; standard for non-toilet-trained children or when culture is needed for treatment decisions; (3) Suprapubic aspiration: gold standard, sterile; used when catheterization fails or in neonates; (4) Midstream clean catch: appropriate for toilet-trained children. AAP guidelines recommend catheterization or suprapubic aspiration for diagnosis in children <2 years and those who are not toilet-trained.

Question 14: Which assessment finding in a newborn at 24 hours of life requires the nurse to immediately notify the provider?

Cephalhematoma from vacuum extraction
Jaundice (yellow discoloration) visible at 24 hours of life (Correct answer)
Milia on the nose and cheeks
Epstein pearls on the hard palate

Correct answer: Jaundice (yellow discoloration) visible at 24 hours of life

Jaundice appearing within the first 24 hours of life is pathologic (not physiologic) and requires immediate evaluation. It suggests hemolytic disease (ABO or Rh incompatibility) requiring urgent bilirubin measurement.

Neonatal jaundice classification by timing: (1) Pathologic (<24 hours): must evaluate — causes include hemolytic disease (ABO/Rh incompatibility), G6PD deficiency, sepsis, congenital infection; serum bilirubin rises >5 mg/dL/day; (2) Physiologic (24 hours–14 days): benign, peaks at days 3–5 in term infants; (3) Prolonged (>14 days): investigate for breastmilk jaundice, hypothyroidism, cholestasis. Immediate actions for <24-hour jaundice: serum bilirubin (fractionated), blood type and Coombs test (direct antiglobulin test), CBC with differential, reticulocyte count. If serum bilirubin exceeds phototherapy threshold: start intensive phototherapy immediately. Prepare for possible exchange transfusion. Milia and Epstein pearls are normal neonatal findings.

Question 15: A nurse is assessing a toddler's pain using the FACES Pain Rating Scale. The child points to the second face with a slight frown. How should the nurse interpret this?

No pain — the child is showing they are comfortable
Mild pain — the second face represents a pain level of 2/10 (Correct answer)
The assessment is invalid for children under 3 years
Moderate pain requiring immediate opioid intervention

Correct answer: Mild pain — the second face represents a pain level of 2/10

In the Wong-Baker FACES Pain Scale (0–10), the second face (slight frown) represents mild discomfort (score 2/10). This indicates mild pain that may be managed with non-pharmacological methods first.

The Wong-Baker FACES Pain Rating Scale is validated for children ≥3 years. It shows 6 faces from happy/smiling (0=no pain) to crying (10=worst pain): Face 0: Happy smile — no pain; Face 2: Slight frown — slight pain; Face 4: Larger frown — some pain; Face 6: Bigger frown — even more pain; Face 8: Big frown, teary — lots of pain; Face 10: Crying heavily — worst possible pain. Pointing to face 2 indicates mild pain (score 2/10). Management: Non-pharmacological interventions (distraction, repositioning, comfort measures) are appropriate first. Acetaminophen or ibuprofen may be used for sustained mild pain. The scale is valid from age 3 and is useful when language is limited. Below age 3, FLACC (Face, Legs, Activity, Cry, Consolability) is preferred.

Question 16: A nurse is teaching parents of a child with febrile seizures. Which statement indicates the parents need further teaching?

I should position my child on their side during the seizure to prevent aspiration
I should give aspirin to quickly reduce the fever and stop the seizure (Correct answer)
I should note the time and duration of the seizure
I should call 911 if the seizure lasts longer than 5 minutes

Correct answer: I should give aspirin to quickly reduce the fever and stop the seizure

Aspirin is contraindicated in children under 18 years due to the risk of Reye's syndrome. Fever reducers (acetaminophen or ibuprofen) may be used but do not reliably prevent febrile seizures.

Febrile seizures are the most common seizure disorder in children (6 months–6 years), associated with rapid temperature elevation. Simple febrile seizures: generalized, <15 minutes, no recurrence within 24 hours — benign prognosis, no prophylactic anticonvulsants needed. Teaching points for parents: (1) Remain calm; (2) Position child laterally to prevent aspiration; (3) Do not restrain or place anything in the mouth; (4) Time the seizure; (5) Call 911 if >5 minutes (status epilepticus) or if child doesn't return to baseline; (6) Use acetaminophen or ibuprofen for fever — NEVER aspirin (Reye's syndrome risk: acute liver failure + encephalopathy associated with viral illness + aspirin in children <18); (7) Febrile seizures do not cause brain damage in most children; recurrence risk is 30–40%.

Question 17: A nurse is administering a medication to a 10-kg pediatric patient with an ordered dose of 15 mg/kg. The medication is available as 250 mg/5 mL. What volume should the nurse administer?

2.5 mL
3 mL (Correct answer)
4 mL
6 mL

Correct answer: 3 mL

Step 1: Calculate dose = 15 mg/kg × 10 kg = 150 mg. Step 2: Calculate volume = 150 mg ÷ 250 mg/5 mL = 150 × 5/250 = 750/250 = 3 mL.

Pediatric dosing calculation: Step 1 — Total dose = dose per kg × weight = 15 mg/kg × 10 kg = 150 mg. Step 2 — Convert to volume: Available concentration = 250 mg/5 mL = 50 mg/mL. Volume needed = 150 mg ÷ 50 mg/mL = 3 mL. Double-check: 3 mL × 50 mg/mL = 150 mg ✓. Pediatric medication safety: always calculate using weight in kg (verify weight with scale); use mg/kg dosing; verify calculation with a second nurse for high-alert medications; be aware of maximum doses regardless of weight; use an infusion pump for all IV medications; document in the MAR. Common errors: using pounds instead of kg (1 lb = 0.45 kg), incorrect unit conversion, decimal point errors.

Question 18: A nurse is assessing a 15-year-old for scoliosis using the Adam's forward bend test. Which finding indicates scoliosis?

Symmetric rib cage and flat back on forward bending
Asymmetric elevation of one side of the rib cage (rib hump) on forward bending (Correct answer)
Exaggerated lumbar lordosis when standing upright
Kyphosis of the thoracic spine when standing

Correct answer: Asymmetric elevation of one side of the rib cage (rib hump) on forward bending

The Adam's forward bend test reveals scoliosis as a rib hump (prominence on one side) when the patient bends forward at the waist. This is caused by vertebral rotation characteristic of idiopathic scoliosis.

Idiopathic scoliosis is the most common spinal deformity in adolescents, affecting girls predominantly (5:1 ratio) and presenting during the pubertal growth spurt. Adam's forward bend test: patient bends forward at the waist, arms hanging freely. A positive test shows asymmetric rib elevation (rib hump) on one side, caused by vertebral rotation accompanying the lateral curve. Screening is recommended for girls at 10 and 12 years, boys at 13–14 years. Diagnosis confirmed by X-ray (Cobb angle): <10° = normal; 10–25° = mild (observe); 25–45° = moderate (bracing); >45° = surgical consideration (spinal fusion). Bracing (Boston or Milwaukee brace) is used for growing children with moderate curves to prevent progression.

Question 19: A 2-year-old child is brought to the ED with suspected non-accidental trauma (child abuse). Which fracture pattern is most concerning for abuse?

Greenstick fracture of the forearm from a fall
Posterior rib fractures or metaphyseal 'corner' fractures in different stages of healing (Correct answer)
Clavicle fracture from birth trauma documented in medical record
Toddler's spiral fracture of the tibia from a fall while learning to walk

Correct answer: Posterior rib fractures or metaphyseal 'corner' fractures in different stages of healing

Posterior rib fractures and classic metaphyseal lesions (corner/bucket-handle fractures) in various stages of healing are highly specific for non-accidental trauma as they require high-force shaking or gripping mechanisms inconsistent with typical accidents.

Fractures highly specific for child abuse: (1) Posterior rib fractures — occur from forceful squeezing/shaking, not from falls; (2) Classic metaphyseal lesions (CML/corner fractures) — 'chip' fractures at the ends of long bones caused by yanking/twisting forces; (3) Fractures of different ages (multiple fractures in varying healing stages — indicates repeated trauma); (4) Spiral fractures in non-ambulatory children; (5) Skull fractures crossing suture lines. The nurse is a mandated reporter — suspected abuse must be reported to child protective services (CPS) regardless of parental explanation. Documentation: objective description of injuries and discrepancies between history and injury pattern. Children deserve the benefit of the doubt — safety is paramount.

Question 20: A nurse is educating parents about car seat safety for their 1-year-old, 20-lb child. Which recommendation is most current?

The child can now use a forward-facing car seat since they are 1 year old
Keep the child rear-facing until they reach the maximum height/weight limit of the rear-facing seat, regardless of age (Correct answer)
Switch to a booster seat when the child turns 1 year
Children are safe to ride without a car seat on short trips at this age

Correct answer: Keep the child rear-facing until they reach the maximum height/weight limit of the rear-facing seat, regardless of age

Current AAP guidelines (updated 2018) recommend keeping children rear-facing until they exceed the seat's height/weight limit — not a specific age. Rear-facing provides the best protection for young children's underdeveloped necks and spines.

AAP Updated Car Seat Guidelines (2018): (1) Rear-facing: as long as possible, until the child exceeds the rear-facing weight/height LIMIT of the seat (many seats allow rear-facing to 40–50 lbs); (2) Forward-facing with harness: when rear-facing limit is exceeded, use forward-facing with 5-point harness until harness limit; (3) Belt-positioning booster seat: when forward-facing harness limit is exceeded, until the vehicle seat belt fits properly (usually 4 ft 9 in tall, ages 8–12); (4) Seat belt: when booster is no longer needed. Rear-facing better protects the head, neck, and spine in frontal collisions (which are most common and most severe) because the entire back is supported. Never install in front seat with active airbag.

Question 21: A nurse is assessing an infant for pyloric stenosis. Which clinical finding is most characteristic?

Bilious (green) vomiting after every feeding
Projectile non-bilious vomiting, palpable olive-shaped mass in right upper quadrant, and visible peristaltic waves (Correct answer)
Bloody mucus in stool with currant-jelly appearance
Abdominal distension with high-pitched bowel sounds

Correct answer: Projectile non-bilious vomiting, palpable olive-shaped mass in right upper quadrant, and visible peristaltic waves

Pyloric stenosis classically presents with projectile non-bilious vomiting (pyloric obstruction is above the ampulla of Vater), palpable olive-shaped mass in RUQ, and visible left-to-right gastric peristaltic waves in 2–8 week-old infants.

Hypertrophic pyloric stenosis occurs in 2–8 week-old infants (peak onset 3–6 weeks), more common in firstborn males (5:1 male predominance). Pathophysiology: hypertrophy of pyloric smooth muscle causes progressive gastric outlet obstruction. Classic presentation: (1) Projectile non-bilious vomiting (obstruction proximal to bile duct entry — no bile = not bilious); (2) Olive-shaped pyloric mass palpable in RUQ after feeding; (3) Visible gastric peristaltic waves left to right on abdomen; (4) Hungry, dehydrated infant; (5) Metabolic alkalosis (loss of HCl from vomiting). Diagnosis: ultrasound (pyloric wall >3mm, channel >15mm). Treatment: surgical pyloromyotomy (Ramstedt procedure). Intussusception presents with currant-jelly stools and colicky pain. Bilious vomiting suggests obstruction distal to the bile duct.

Question 22: An infant is at the 4-month well-child visit. Which vaccine is NOT recommended at this visit according to the standard immunization schedule?

DTaP (diphtheria, tetanus, acellular pertussis)
MMR (measles, mumps, rubella) (Correct answer)
IPV (inactivated poliovirus)
Hib (Haemophilus influenzae type b)

Correct answer: MMR (measles, mumps, rubella)

MMR is not given until 12–15 months of age (and again at 4–6 years). At 4 months, the scheduled vaccines include DTaP, IPV, Hib, PCV13, and rotavirus.

CDC immunization schedule by age — 4 months: DTaP (2nd dose), IPV (2nd dose), Hib (2nd dose), PCV13 (pneumococcal, 2nd dose), RV (rotavirus, 2nd dose). Not at 4 months: MMR (scheduled at 12–15 months, 2nd dose at 4–6 years); Varicella (12–15 months); Hepatitis A (12–23 months); Meningococcal (11–12 years). MMR is delayed until 12–15 months because maternal antibodies (from placental transfer and breastfeeding) can neutralize the vaccine virus and prevent adequate immune response. Infants born to mothers with low antibody levels (immigrants, etc.) may be vaccinated earlier in specific circumstances. All vaccines at 4 months are given IM or orally (rotavirus).

Question 23: A nurse caring for a child with leukemia notes a temperature of 38.5°C (101.3°F) and an ANC (absolute neutrophil count) of 380 cells/mm³. What is the priority nursing action?

Administer acetaminophen and reassess in 4 hours
Notify the provider immediately — this represents febrile neutropenia requiring emergency evaluation and antibiotics (Correct answer)
Obtain a throat culture before starting any treatment
Place the child on reverse isolation and monitor for 24 hours

Correct answer: Notify the provider immediately — this represents febrile neutropenia requiring emergency evaluation and antibiotics

Febrile neutropenia (fever + ANC <500 cells/mm³) in an immunocompromised child is a medical emergency. Bacterial sepsis can be rapid and fatal without immediate IV antibiotics (broad-spectrum) within 1 hour of presentation.

Febrile neutropenia is defined as temperature ≥38.0°C AND ANC <500 cells/mm³ (or <1000 with expected decline). This is an oncologic emergency with mortality from sepsis if not treated immediately. ANC = WBC × (% neutrophils + % bands). Normal ANC: ≥1500. Severe neutropenia: <500. Emergency management: (1) STAT blood cultures from peripheral vein AND all central lines; (2) Urinalysis and urine culture; (3) Chest X-ray; (4) IV broad-spectrum antibiotics within 1 HOUR (piperacillin-tazobactam or cefepime ± vancomycin); (5) Initiate protective isolation; (6) Assess for source of infection. Do NOT delay antibiotics for culture results. Waiting, or merely observing, can result in septic shock and death within hours. Reverse (protective) isolation alone is insufficient.

Question 24: A nurse is assessing a child for signs of increased intracranial pressure (ICP). Which finding is most specific for elevated ICP in a pediatric patient?

Low-grade fever and mild headache
Bulging fontanel (in infants), papilledema, Cushing's triad (bradycardia, hypertension, irregular breathing) (Correct answer)
Peripheral edema and dyspnea
Diffuse muscle weakness and absent deep tendon reflexes

Correct answer: Bulging fontanel (in infants), papilledema, Cushing's triad (bradycardia, hypertension, irregular breathing)

In infants, a bulging fontanel indicates elevated ICP. In all ages, papilledema and Cushing's triad (bradycardia + hypertension + irregular respirations) are specific signs of severe increased ICP.

Increased intracranial pressure (ICP) manifestations in children: Early: headache (worse in AM, with position change), irritability, behavioral changes, vomiting (especially projectile without nausea), papilledema (optic disc swelling on fundoscopic exam — may take days to develop), blurred vision, diplopia, Macewen's 'cracked pot' sign (hollow sound on skull percussion). Infants: bulging anterior fontanel (when upright and calm), abnormally increasing head circumference. Late/severe: Cushing's triad — bradycardia, hypertension (widened pulse pressure), irregular (Cheyne-Stokes) respirations = sign of impending herniation — neurosurgical emergency; unequal/unreactive pupils (CN III compression); posturing (decorticate/decerebrate). Management: HOB 30°, minimize stimulation, osmotic therapy (mannitol), hyperventilation, emergency neurosurgery if needed.

NCLEX Pediatric Nursing: Growth and Development 1

A nurse is assessing a 2-year-old child.
Which developmental milestone would the nurse expect to find?

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