Background: Inadvertent medication administration errors and secondary contamination during pediatric pharmaceutical preparation represent critical global patient safety threats. Direct bedside observation provides an authentic clinical audit of actual nursing practice compared with self-reported survey methods. Objective: To investigate pediatric nurses' real-world clinical adherence to basic infection prevention protocols and safe medication storage and handling regulations across public referral hospitals. Methods: A multicenter cross-sectional observational audit was conducted across pediatric departments in four governmental hospitals: Shandi Teaching Hospital, Al-Mak Nimr Teaching Hospital, Hosh Bannaga Hospital, and Al-Misktab Hospital. A total-coverage sample of 130 frontline bedside pediatric nurses was directly observed during routine medication rounds using an expert-validated clinical checklist comprising 11 basic infection control items and 3 medication storage parameters. Bivariate associations between nursing characteristics and clinical adherence were evaluated using Chi-square tests with statistical significance defined at p ≤ 0.05. Results: Direct clinical audits identified widespread compliance gaps across frontline pediatric units. Procedural hand hygiene was correctly performed in only 50.0% of encounters before and after drug handling, and in 53.8% upon direct patient contact. Strict aseptic injection preparation technique was observed in 46.2% of participants. Serious vulnerabilities were noted in parenteral device handling: only 40.0% segregated multi-dose vials within centralized clean medication stations, and dedicated single-patient insulin pen usage was restricted to 40.0%. Compliant pharmaceutical storage aligned with manufacturer temperature and light recommendations was observed in 46.2% of nurses. Bivariate analysis revealed that bachelor's degree qualification and extended clinical experience were significantly associated with higher clinical compliance (p < 0.05). Conclusion: Routine nursing compliance with basic infection control and safe medication handling remains critically compromised in public pediatric inpatient settings. Hospital administrations must establish centralized aseptic preparation stations, institute strict patient-specific device labeling policies, and sustain regular observational audits.