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Pediatrics · Pediatric Nursing Assessment Questions

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Showing all 15 practice questions with expert explanatory rationales.

Question 1 of 15

Case excerpt

During care in an acute-care unit at 13:35, a 2-year-old with vomiting has dry mucous membranes, no tears, and fewer wet diapers than usual.

How should the nurse respond to this finding?

A. Hair growth
B. Urine output and signs of hydration
C. Permanent tooth eruption
D. Daily shoe size
E. Pupil color

Expert Explanatory Rationale

Correct Answer: B. Urine output and signs of hydration

Urine output, mucous membranes, tears, capillary refill, and behavior help evaluate pediatric hydration.

Question 2 of 15

Case excerpt

During care in a rehabilitation unit at 15:50, a 6-month-old is admitted with bronchiolitis and has nasal congestion that interferes with feeding.

Which action best protects the patient?

A. Delay all fluids for 12 hours
B. Place the infant flat
C. Give an over-the-counter cough suppressant
D. Gently clear nasal secretions using the prescribed method
E. Offer a large bottle rapidly

Expert Explanatory Rationale

Correct Answer: D. Gently clear nasal secretions using the prescribed method

Infants are obligate nasal breathers; gentle nasal clearance before feeds can improve breathing and feeding.

Question 3 of 15

Case excerpt

During care in a specialty care unit at 18:15, a child with a fever has a generalized seizure lasting about one minute and is now drowsy.

Which nursing action is the priority?

A. Place a spoon in the mouth
B. Protect the child from injury and maintain a safe side-lying position
C. Attempt to force the jaw open
D. Offer oral medication during the seizure
E. Restrain the child's arms and legs

Expert Explanatory Rationale

Correct Answer: B. Protect the child from injury and maintain a safe side-lying position

During a seizure, protect from injury, position to support airway drainage, time the event, and do not place objects in the mouth.

Question 4 of 15

Case excerpt

During care in a medical unit at 21:05, a school-age child with type 1 diabetes is pale, shaky, and sweaty before lunch and is alert enough to swallow.

What is the safest response by the nurse?

A. Encourage exercise
B. Give a long-acting insulin dose
C. Administer the scheduled insulin immediately
D. Check blood glucose and give rapid-acting carbohydrate if hypoglycemia is confirmed or strongly suspected per protocol
E. Withhold all carbohydrate

Expert Explanatory Rationale

Correct Answer: D. Check blood glucose and give rapid-acting carbohydrate if hypoglycemia is confirmed or strongly suspected per protocol

Symptoms suggest hypoglycemia. Follow the child's emergency plan, check glucose when feasible, and treat promptly with fast-acting carbohydrate if safe to swallow.

Question 5 of 15

Case excerpt

During care in an outpatient clinic at 07:20, a 4-year-old is scheduled for an unfamiliar procedure and asks whether it will hurt.

Which intervention should the nurse implement first?

A. Give a simple, honest explanation using words the child understands
B. Promise that it will not hurt at all
C. Ignore the question
D. Provide a detailed technical explanation
E. Tell the child to behave or the procedure will be worse

Expert Explanatory Rationale

Correct Answer: A. Give a simple, honest explanation using words the child understands

Preschool children benefit from concrete, honest explanations and preparation close to the procedure.

Question 6 of 15

Case excerpt

During care in a community health setting at 09:45, a 3-month-old has a rectal temperature of 38.2°C (100.8°F).

How should the nurse respond to this finding?

A. Wait several days before reporting it
B. Give aspirin at home
C. Arrange prompt medical evaluation according to the young-infant fever protocol
D. Reassure the caregiver that fever is expected
E. Use an ice bath

Expert Explanatory Rationale

Correct Answer: C. Arrange prompt medical evaluation according to the young-infant fever protocol

Fever in a young infant requires prompt evaluation because serious infection may present with few other signs.

Question 7 of 15

Case excerpt

During care in an acute-care unit at 11:10, a child with asthma is using accessory muscles and can speak only a few words at a time.

Which action best protects the patient?

A. Initiate the prescribed rescue treatment and urgently escalate respiratory distress
B. Encourage the child to lie flat
C. Offer a large meal
D. Use a paper bag for breathing
E. Delay treatment until peak flow is recorded

Expert Explanatory Rationale

Correct Answer: A. Initiate the prescribed rescue treatment and urgently escalate respiratory distress

Severe work of breathing and limited speech signal a potentially severe exacerbation requiring immediate treatment and escalation.

Question 8 of 15

Case excerpt

During care in a rehabilitation unit at 13:35, a toddler is admitted with suspected epiglottitis, drooling, and a tripod position.

Which nursing action is the priority?

A. Summoning the appropriate airway team
B. Inspecting the throat with a tongue blade
C. Keeping emergency airway support available
D. Minimizing agitation
E. Allowing the child to remain in a position of comfort

Expert Explanatory Rationale

Correct Answer: B. Inspecting the throat with a tongue blade

Throat inspection can precipitate complete airway obstruction. Keep the child calm and prepare for expert airway management.

Question 9 of 15

Case excerpt

During care in a specialty care unit at 15:50, a child with acute diarrhea is prescribed oral rehydration solution.

Which nursing actions are appropriate? (Select all that apply)

A. Give a large volume all at once
B. Escalate promptly if the patient's condition worsens or remains outside the expected range
C. Replace it with undiluted juice
D. Document objective findings, actions taken, and the patient's response
E. Delay follow-up until the end of the shift even if the condition is worsening
F. Reassess the patient after the intervention and compare findings with the baseline
G. Offer small, frequent amounts and increase as tolerated

Expert Explanatory Rationale

Correct Answer: B. Escalate promptly if the patient's condition worsens or remains outside the expected range; D. Document objective findings, actions taken, and the patient's response; F. Reassess the patient after the intervention and compare findings with the baseline; G. Offer small, frequent amounts and increase as tolerated

Small frequent amounts of oral rehydration solution are often better tolerated and replace water and electrolytes appropriately. Reassessment, accurate documentation, and timely escalation support safe, coordinated care.

Question 10 of 15

Case excerpt

During care in a medical unit at 18:15, a 5-year-old is admitted with a suspected fracture and reports increasing pain despite immobilization.

Which nursing actions are appropriate? (Select all that apply)

A. Increasing pain with numbness or coolness distal to the injury
B. Escalate promptly if the patient's condition worsens or remains outside the expected range
C. Delay follow-up until the end of the shift even if the condition is worsening
D. Reassess the patient after the intervention and compare findings with the baseline
E. A request for a favorite toy
F. Mild anxiety about the cast
G. Document objective findings, actions taken, and the patient's response

Expert Explanatory Rationale

Correct Answer: A. Increasing pain with numbness or coolness distal to the injury; B. Escalate promptly if the patient's condition worsens or remains outside the expected range; D. Reassess the patient after the intervention and compare findings with the baseline; G. Document objective findings, actions taken, and the patient's response

Increasing pain, paresthesia, pallor, coolness, or impaired movement may indicate neurovascular compromise or compartment syndrome. Reassessment, accurate documentation, and timely escalation support safe, coordinated care.

Question 11 of 15

Case excerpt

During care in an outpatient clinic at 21:05, a caregiver asks how to reduce the risk of sudden unexpected infant death.

Which nursing actions are appropriate? (Select all that apply)

A. Delay follow-up until the end of the shift even if the condition is worsening
B. Place the infant supine on a firm, flat sleep surface without loose bedding
C. Use pillows to support the infant
D. Place the infant prone after every feeding
E. Escalate promptly if the patient's condition worsens or remains outside the expected range
F. Document objective findings, actions taken, and the patient's response
G. Reassess the patient after the intervention and compare findings with the baseline

Expert Explanatory Rationale

Correct Answer: B. Place the infant supine on a firm, flat sleep surface without loose bedding; E. Escalate promptly if the patient's condition worsens or remains outside the expected range; F. Document objective findings, actions taken, and the patient's response; G. Reassess the patient after the intervention and compare findings with the baseline

A supine position on a firm, flat, separate sleep surface without soft objects reduces sleep-related infant death risk. Reassessment, accurate documentation, and timely escalation support safe, coordinated care.

Question 12 of 15

Case excerpt

During care in a community health setting at 07:20, a child is prescribed an oral liquid medication. The caregiver plans to use a kitchen teaspoon.

Which nursing actions are appropriate? (Select all that apply)

A. Estimate the dose by bottle level
B. Measure the dose with an oral syringe or calibrated medication device
C. Delay follow-up until the end of the shift even if the condition is worsening
D. Use any household spoon
E. Escalate promptly if the patient's condition worsens or remains outside the expected range
F. Document objective findings, actions taken, and the patient's response
G. Reassess the patient after the intervention and compare findings with the baseline

Expert Explanatory Rationale

Correct Answer: B. Measure the dose with an oral syringe or calibrated medication device; E. Escalate promptly if the patient's condition worsens or remains outside the expected range; F. Document objective findings, actions taken, and the patient's response; G. Reassess the patient after the intervention and compare findings with the baseline

A calibrated oral syringe or medication cup provides more accurate dosing than household spoons. Reassessment, accurate documentation, and timely escalation support safe, coordinated care.

Question 13 of 15

Case excerpt

During care in an acute-care unit at 09:45, a child with a peanut allergy develops hives, wheezing, and lip swelling after eating a snack.

Which nursing actions are appropriate? (Select all that apply)

A. Inhaled saline
B. Reassess the patient after the intervention and compare findings with the baseline
C. Escalate promptly if the patient's condition worsens or remains outside the expected range
D. Document objective findings, actions taken, and the patient's response
E. Oral antihistamine as the only treatment
F. Delay follow-up until the end of the shift even if the condition is worsening
G. Intramuscular epinephrine

Expert Explanatory Rationale

Correct Answer: B. Reassess the patient after the intervention and compare findings with the baseline; C. Escalate promptly if the patient's condition worsens or remains outside the expected range; D. Document objective findings, actions taken, and the patient's response; G. Intramuscular epinephrine

Respiratory symptoms and swelling suggest anaphylaxis. Epinephrine is first-line; activate emergency response and support airway and circulation. Reassessment, accurate documentation, and timely escalation support safe, coordinated care.

Question 14 of 15

Case excerpt

A prescribed IV infusion contains 520 mL and must run evenly over 4 hours. The patient is receiving care related to pediatrics.

What rate should the nurse program in mL/hr? Enter the number only.

Expert Explanatory Rationale

Correct Answer: 130

Calculate volume divided by time: 520 mL ÷ 4 hr = 130 mL/hr. Verify the prescription, pump settings, and patient response.

Question 15 of 15

Case excerpt

The nurse is completing a safe nursing care sequence for a patient receiving pediatrics care.

Place the nursing actions in the safest order.

A. Verify the patient's identity, explain the planned care, and assess current status
B. Gather the required equipment and confirm that it is functioning
C. Perform the intervention using the prescribed procedure and appropriate safety measures
D. Reassess the patient and evaluate the response
E. Document the findings, intervention, and outcome

Expert Explanatory Rationale

Correct Answer: A. Verify the patient's identity, explain the planned care, and assess current status; B. Gather the required equipment and confirm that it is functioning; C. Perform the intervention using the prescribed procedure and appropriate safety measures; D. Reassess the patient and evaluate the response; E. Document the findings, intervention, and outcome

The nurse first verifies identity and assesses the patient, prepares equipment, performs the intervention safely, reassesses the response, and documents the care.

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