NUR106 | NUR106 Pediatric Nursing Exam 3
Version 2 Questions with Correct Answers and
Expert Explanation for Each Question
1. A nurse is caring for a 4-year-old child experiencing a generalized tonic-clonic
seizure. Which of the following actions should the nurse prioritize first?
A. Insert a padded tongue blade into the child’s mouth
B. Turn the child onto their side
C. Restrain the child’s limbs to prevent injury
D. Administer oral diazepam immediately
Correct Answer: B
Expert Explanation: Turning the child to a side-lying position is the priority to
maintain a patent airway and prevent aspiration. The nurse must never place
objects in the mouth as this can cause injury or airway blockage. Restraining the
child during a seizure can lead to fractures or further physical trauma.
Documentation of the seizure’s start time and characteristics should occur
simultaneously or immediately after safety is secured. Once the seizure subsides,
the nurse should assess the child’s respiratory status and provide suction if
necessary.
,2. A nurse is assessing an infant for signs of increased intracranial pressure (ICP).
Which of the following findings is a late sign of this condition?
A. Bulging anterior fontanelle
B. Bradycardia
C. High-pitched cry
D. Irritability
Correct Answer: B
Expert Explanation: Bradycardia is considered a late sign of increased intracranial
pressure and is part of Cushing’s triad. Early signs in infants include irritability, a
high-pitched cry, and a bulging fontanelle. As ICP continues to rise, systemic changes
like decreased heart rate and altered respiratory patterns occur. The nurse must
monitor for these changes to prevent permanent neurological damage or herniation.
Recognizing late signs requires immediate medical intervention and notification of
the surgical team.
3. A nurse is providing discharge teaching to the parents of a child with a new
diagnosis of absence seizures. Which description should the nurse use to help the
parents recognize this type of seizure?
A. A sudden, brief loss of consciousness with staring
B. Sudden loss of muscle tone causing the child to fall
,C. Brief, sudden muscle contractions of the face
D. Repetitive jerking movements of all four extremities
Correct Answer: A
Expert Explanation: Absence seizures are characterized by a brief loss of
consciousness often mistaken for daydreaming or inattentiveness. These seizures
typically last only a few seconds and the child recovers immediately without a
postictal state. Parents may notice the child stops speaking or moving mid-action
and stares blankly into space. Unlike tonic-clonic seizures, there is no falling or
convulsive movement associated with this condition. Understanding these subtle
signs is essential for monitoring the effectiveness of anticonvulsant therapy.
4. Which of the following is the most appropriate nursing intervention for a child with
spastic cerebral palsy (CP)?
A. Implement range-of-motion exercises to prevent contractures
B. Encourage total bed rest to prevent muscle fatigue
C. Provide a high-protein, low-calorie diet
D. Limit social interaction to reduce environmental stimuli
Correct Answer: A
, Expert Explanation: Spastic cerebral palsy is characterized by hypertonicity and
permanent muscle shortening which leads to contractures. Range-of-motion
exercises are vital to maintain joint flexibility and functional mobility for these
children. The goal of management is to promote independence and maximize the
child’s physical capabilities. Nurses should work closely with physical therapists to
implement an individualized exercise plan. Promoting activity rather than bed rest
helps prevent secondary complications like skin breakdown or respiratory issues.
5. A school nurse is evaluating a child who may have Autism Spectrum Disorder (ASD).
Which behavior is most characteristic of this diagnosis?
A. Extreme physical aggression toward peers
B. Consistently high levels of physical activity
C. Difficulty making eye contact and delayed speech
D. Frequent episodes of sadness and withdrawal
Correct Answer: C
Expert Explanation: Autism Spectrum Disorder is primarily characterized by
impairments in social communication and social interaction. Lack of eye contact and
delays in language development are hallmark signs observed during early
childhood. Children with ASD may also exhibit repetitive behaviors or restricted
interests that interfere with daily functioning. Early screening is essential for
Version 2 Questions with Correct Answers and
Expert Explanation for Each Question
1. A nurse is caring for a 4-year-old child experiencing a generalized tonic-clonic
seizure. Which of the following actions should the nurse prioritize first?
A. Insert a padded tongue blade into the child’s mouth
B. Turn the child onto their side
C. Restrain the child’s limbs to prevent injury
D. Administer oral diazepam immediately
Correct Answer: B
Expert Explanation: Turning the child to a side-lying position is the priority to
maintain a patent airway and prevent aspiration. The nurse must never place
objects in the mouth as this can cause injury or airway blockage. Restraining the
child during a seizure can lead to fractures or further physical trauma.
Documentation of the seizure’s start time and characteristics should occur
simultaneously or immediately after safety is secured. Once the seizure subsides,
the nurse should assess the child’s respiratory status and provide suction if
necessary.
,2. A nurse is assessing an infant for signs of increased intracranial pressure (ICP).
Which of the following findings is a late sign of this condition?
A. Bulging anterior fontanelle
B. Bradycardia
C. High-pitched cry
D. Irritability
Correct Answer: B
Expert Explanation: Bradycardia is considered a late sign of increased intracranial
pressure and is part of Cushing’s triad. Early signs in infants include irritability, a
high-pitched cry, and a bulging fontanelle. As ICP continues to rise, systemic changes
like decreased heart rate and altered respiratory patterns occur. The nurse must
monitor for these changes to prevent permanent neurological damage or herniation.
Recognizing late signs requires immediate medical intervention and notification of
the surgical team.
3. A nurse is providing discharge teaching to the parents of a child with a new
diagnosis of absence seizures. Which description should the nurse use to help the
parents recognize this type of seizure?
A. A sudden, brief loss of consciousness with staring
B. Sudden loss of muscle tone causing the child to fall
,C. Brief, sudden muscle contractions of the face
D. Repetitive jerking movements of all four extremities
Correct Answer: A
Expert Explanation: Absence seizures are characterized by a brief loss of
consciousness often mistaken for daydreaming or inattentiveness. These seizures
typically last only a few seconds and the child recovers immediately without a
postictal state. Parents may notice the child stops speaking or moving mid-action
and stares blankly into space. Unlike tonic-clonic seizures, there is no falling or
convulsive movement associated with this condition. Understanding these subtle
signs is essential for monitoring the effectiveness of anticonvulsant therapy.
4. Which of the following is the most appropriate nursing intervention for a child with
spastic cerebral palsy (CP)?
A. Implement range-of-motion exercises to prevent contractures
B. Encourage total bed rest to prevent muscle fatigue
C. Provide a high-protein, low-calorie diet
D. Limit social interaction to reduce environmental stimuli
Correct Answer: A
, Expert Explanation: Spastic cerebral palsy is characterized by hypertonicity and
permanent muscle shortening which leads to contractures. Range-of-motion
exercises are vital to maintain joint flexibility and functional mobility for these
children. The goal of management is to promote independence and maximize the
child’s physical capabilities. Nurses should work closely with physical therapists to
implement an individualized exercise plan. Promoting activity rather than bed rest
helps prevent secondary complications like skin breakdown or respiratory issues.
5. A school nurse is evaluating a child who may have Autism Spectrum Disorder (ASD).
Which behavior is most characteristic of this diagnosis?
A. Extreme physical aggression toward peers
B. Consistently high levels of physical activity
C. Difficulty making eye contact and delayed speech
D. Frequent episodes of sadness and withdrawal
Correct Answer: C
Expert Explanation: Autism Spectrum Disorder is primarily characterized by
impairments in social communication and social interaction. Lack of eye contact and
delays in language development are hallmark signs observed during early
childhood. Children with ASD may also exhibit repetitive behaviors or restricted
interests that interfere with daily functioning. Early screening is essential for
