NUR 203/NUR203 Exam 4 V1 | Pediatric
Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a 10-year-old child with Type 1 Diabetes Mellitus who is experiencing
shakiness, pallor, and irritability. Which of the following is the priority nursing action?
A. Administer 15 grams of simple carbohydrates.
B. Check the urine for the presence of ketones.
C. Administer the scheduled dose of regular insulin.
D. Provide a high-protein snack like peanut butter.
Correct Answer: A
Expert Explanation: The child is demonstrating classic clinical manifestations of
hypoglycemia, which requires immediate intervention. The nurse should first provide 15
grams of a fast-acting carbohydrate to raise the blood glucose level effectively. Following
this, the nurse should re-assess the child’s glucose level in 15 minutes to determine if
additional treatment is needed.
2. When providing discharge teaching for a child who just received a ventriculoperitoneal (VP)
shunt for hydrocephalus, which sign of shunt malfunction should the nurse emphasize?
A. Increased irritability and projectile vomiting.
B. Occasional mild headache after activity.
,C. Increased appetite and thirst.
D. Sleepiness followed by an energetic state.
Correct Answer: A
Expert Explanation: Increased irritability and projectile vomiting are hallmark signs of
increased intracranial pressure, which often indicates a shunt obstruction or malfunction.
Parents must be educated to recognize these neurological changes immediately to prevent
further brain injury. Prompt medical evaluation is required if any signs of shunt failure or
infection are observed in the home setting.
3. A nurse is caring for an adolescent diagnosed with idiopathic scoliosis who is prescribed a
Boston brace. Which statement by the patient indicates understanding of the treatment?
A. “I should wear the brace for about 12 hours a day.”
B. “The brace will help straighten my spine permanently.”
C. “I will wear my brace for 23 hours every day.”
D. “I should apply lotion under the brace to prevent skin breakdown.”
Correct Answer: C
Expert Explanation: To be effective in slowing the progression of the spinal curvature, the
brace must be worn for approximately 23 hours a day. The patient should only remove the
brace for hygiene purposes such as showering or for specific prescribed exercises. It is also
important to wear a thin cotton t-shirt under the brace to protect the skin and maintain
integrity.
,4. A nurse is assessing a child suspected of having bacterial meningitis. Which of the following
findings should the nurse expect?
A. Negative Brudzinski sign and low fever.
B. Increased appetite and decreased heart rate.
C. Lethargy, nuchal rigidity, and positive Kernig sign.
D. Bilateral weakness in the lower extremities.
Correct Answer: C
Expert Explanation: Bacterial meningitis in children typically presents with symptoms
such as nuchal rigidity, lethargy, and a positive Kernig or Brudzinski sign. These findings
reflect the irritation of the meninges caused by the bacterial infection. The nurse must also
monitor for high fever and potential seizure activity as part of the neurological assessment.
5. Which of the following instructions should a nurse include when teaching parents about
caring for a child in a Pavlik harness for developmental dysplasia of the hip (DDH)?
A. Adjust the harness straps every week as the baby grows.
B. Place the diaper over the harness straps to keep them clean.
C. Remove the harness for 4 hours each day for skin rest.
D. Apply the harness over a thin undershirt and socks.
Correct Answer: D
, Expert Explanation: The Pavlik harness should be worn over a thin undershirt and socks
to prevent the straps from irritating the infant’s skin. Parents are strictly instructed not to
adjust the harness themselves, as this should only be done by a healthcare professional.
Maintaining the skin’s integrity is a primary nursing goal during the duration of this
treatment.
6. A 6-year-old child is admitted with a diagnosis of Duchenne Muscular Dystrophy (DMD).
The nurse observes the child using their hands to ‘walk up’ their legs to stand. How should
the nurse document this?
A. Gower’s sign
B. Trendelenburg gait
C. Babinski reflex
D. Ortolani maneuver
Correct Answer: A
Expert Explanation: Gower’s sign is a classic clinical finding in children with Duchenne
Muscular Dystrophy, resulting from weakness in the pelvic girdle muscles. The child must
use their arms and hands to push themselves into an upright position because their leg
muscles are insufficient. This finding is critical for the initial assessment and monitoring of
disease progression in pediatric patients.
Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a 10-year-old child with Type 1 Diabetes Mellitus who is experiencing
shakiness, pallor, and irritability. Which of the following is the priority nursing action?
A. Administer 15 grams of simple carbohydrates.
B. Check the urine for the presence of ketones.
C. Administer the scheduled dose of regular insulin.
D. Provide a high-protein snack like peanut butter.
Correct Answer: A
Expert Explanation: The child is demonstrating classic clinical manifestations of
hypoglycemia, which requires immediate intervention. The nurse should first provide 15
grams of a fast-acting carbohydrate to raise the blood glucose level effectively. Following
this, the nurse should re-assess the child’s glucose level in 15 minutes to determine if
additional treatment is needed.
2. When providing discharge teaching for a child who just received a ventriculoperitoneal (VP)
shunt for hydrocephalus, which sign of shunt malfunction should the nurse emphasize?
A. Increased irritability and projectile vomiting.
B. Occasional mild headache after activity.
,C. Increased appetite and thirst.
D. Sleepiness followed by an energetic state.
Correct Answer: A
Expert Explanation: Increased irritability and projectile vomiting are hallmark signs of
increased intracranial pressure, which often indicates a shunt obstruction or malfunction.
Parents must be educated to recognize these neurological changes immediately to prevent
further brain injury. Prompt medical evaluation is required if any signs of shunt failure or
infection are observed in the home setting.
3. A nurse is caring for an adolescent diagnosed with idiopathic scoliosis who is prescribed a
Boston brace. Which statement by the patient indicates understanding of the treatment?
A. “I should wear the brace for about 12 hours a day.”
B. “The brace will help straighten my spine permanently.”
C. “I will wear my brace for 23 hours every day.”
D. “I should apply lotion under the brace to prevent skin breakdown.”
Correct Answer: C
Expert Explanation: To be effective in slowing the progression of the spinal curvature, the
brace must be worn for approximately 23 hours a day. The patient should only remove the
brace for hygiene purposes such as showering or for specific prescribed exercises. It is also
important to wear a thin cotton t-shirt under the brace to protect the skin and maintain
integrity.
,4. A nurse is assessing a child suspected of having bacterial meningitis. Which of the following
findings should the nurse expect?
A. Negative Brudzinski sign and low fever.
B. Increased appetite and decreased heart rate.
C. Lethargy, nuchal rigidity, and positive Kernig sign.
D. Bilateral weakness in the lower extremities.
Correct Answer: C
Expert Explanation: Bacterial meningitis in children typically presents with symptoms
such as nuchal rigidity, lethargy, and a positive Kernig or Brudzinski sign. These findings
reflect the irritation of the meninges caused by the bacterial infection. The nurse must also
monitor for high fever and potential seizure activity as part of the neurological assessment.
5. Which of the following instructions should a nurse include when teaching parents about
caring for a child in a Pavlik harness for developmental dysplasia of the hip (DDH)?
A. Adjust the harness straps every week as the baby grows.
B. Place the diaper over the harness straps to keep them clean.
C. Remove the harness for 4 hours each day for skin rest.
D. Apply the harness over a thin undershirt and socks.
Correct Answer: D
, Expert Explanation: The Pavlik harness should be worn over a thin undershirt and socks
to prevent the straps from irritating the infant’s skin. Parents are strictly instructed not to
adjust the harness themselves, as this should only be done by a healthcare professional.
Maintaining the skin’s integrity is a primary nursing goal during the duration of this
treatment.
6. A 6-year-old child is admitted with a diagnosis of Duchenne Muscular Dystrophy (DMD).
The nurse observes the child using their hands to ‘walk up’ their legs to stand. How should
the nurse document this?
A. Gower’s sign
B. Trendelenburg gait
C. Babinski reflex
D. Ortolani maneuver
Correct Answer: A
Expert Explanation: Gower’s sign is a classic clinical finding in children with Duchenne
Muscular Dystrophy, resulting from weakness in the pelvic girdle muscles. The child must
use their arms and hands to push themselves into an upright position because their leg
muscles are insufficient. This finding is critical for the initial assessment and monitoring of
disease progression in pediatric patients.
