NUR 203/NUR203 Exam 4 V2 | Pediatric
Nursing Q&A with Rationale | Fortis
College
1. A pediatric nurse is caring for a 10-year-old child diagnosed with Type 1 Diabetes Mellitus.
The child is experiencing diaphoresis, shakiness, and pallor. Which action should the nurse
take first?
A. Administer 15 grams of rapid-acting carbohydrates.
B. Check the child’s blood glucose level.
C. Call the healthcare provider immediately.
D. Administer the scheduled dose of regular insulin.
Correct Answer: B
Expert Explanation: The clinical manifestations described are classic signs of
hypoglycemia. While the priority is to treat low blood sugar, the first nursing action is to
confirm the blood glucose level to ensure appropriate intervention. Administering insulin
(Option D) would be contraindicated and dangerous in a hypoglycemic state.
2. A child is admitted with a suspected diagnosis of bacterial meningitis. What is the priority
nursing intervention while awaiting the results of the lumbar puncture?
A. Maintain the child in a supine position.
B. Initiate droplet precautions.
,C. Administer broad-spectrum antibiotics.
D. Perform a neurological assessment every 4 hours.
Correct Answer: B
Expert Explanation: Bacterial meningitis is highly contagious and spread via respiratory
droplets. The nurse must prioritize infection control by initiating droplet precautions
immediately upon suspicion of the diagnosis. While antibiotics are essential, they are
usually administered after the culture is obtained, and safety via isolation comes first.
3. Which clinical finding should the nurse expect in a child diagnosed with a Vaso-occlusive
Sickle Cell Crisis?
A. Decreased white blood cell count.
B. Increased urinary output.
C. Extreme joint and bone pain.
D. Bradycardia and hypertension.
Correct Answer: C
Expert Explanation: Vaso-occlusive crisis is caused by the clumping of sickled red blood
cells in the microvasculature, leading to ischemia and severe pain. Pain is the hallmark
symptom of this condition and typically occurs in the joints, bones, and abdomen. Nursing
care focuses on hydration and aggressive pain management.
, 4. A 4-year-old is scheduled for a Wilms tumor resection. Which of the following is a critical
preoperative nursing consideration?
A. Place a sign over the bed saying ‘Do Not Palpate Abdomen’.
B. Perform deep abdominal palpation to check tumor size.
C. Auscultate bowel sounds every 2 hours.
D. Increase oral fluid intake to 3000 mL/day.
Correct Answer: A
Expert Explanation: Wilms tumor (nephroblastoma) is encapsulated, and palpation of the
abdomen can cause the capsule to rupture, leading to the seeding of cancer cells
throughout the peritoneal cavity. It is a critical safety intervention to prevent any physical
manipulation of the mass. The nurse must ensure all staff are aware of this restriction.
5. A child with hemophilia A has fallen and injured their knee. What is the nurse’s first action?
A. Apply a warm compress to the knee.
B. Perform passive range of motion exercises.
C. Administer aspirin for pain relief.
D. Administer the specific factor VIII concentrate.
Correct Answer: D
Expert Explanation: In hemophilia A, the primary concern is the lack of Factor VIII, which
prevents effective clotting. In the event of an injury, replacing the missing clotting factor is
Nursing Q&A with Rationale | Fortis
College
1. A pediatric nurse is caring for a 10-year-old child diagnosed with Type 1 Diabetes Mellitus.
The child is experiencing diaphoresis, shakiness, and pallor. Which action should the nurse
take first?
A. Administer 15 grams of rapid-acting carbohydrates.
B. Check the child’s blood glucose level.
C. Call the healthcare provider immediately.
D. Administer the scheduled dose of regular insulin.
Correct Answer: B
Expert Explanation: The clinical manifestations described are classic signs of
hypoglycemia. While the priority is to treat low blood sugar, the first nursing action is to
confirm the blood glucose level to ensure appropriate intervention. Administering insulin
(Option D) would be contraindicated and dangerous in a hypoglycemic state.
2. A child is admitted with a suspected diagnosis of bacterial meningitis. What is the priority
nursing intervention while awaiting the results of the lumbar puncture?
A. Maintain the child in a supine position.
B. Initiate droplet precautions.
,C. Administer broad-spectrum antibiotics.
D. Perform a neurological assessment every 4 hours.
Correct Answer: B
Expert Explanation: Bacterial meningitis is highly contagious and spread via respiratory
droplets. The nurse must prioritize infection control by initiating droplet precautions
immediately upon suspicion of the diagnosis. While antibiotics are essential, they are
usually administered after the culture is obtained, and safety via isolation comes first.
3. Which clinical finding should the nurse expect in a child diagnosed with a Vaso-occlusive
Sickle Cell Crisis?
A. Decreased white blood cell count.
B. Increased urinary output.
C. Extreme joint and bone pain.
D. Bradycardia and hypertension.
Correct Answer: C
Expert Explanation: Vaso-occlusive crisis is caused by the clumping of sickled red blood
cells in the microvasculature, leading to ischemia and severe pain. Pain is the hallmark
symptom of this condition and typically occurs in the joints, bones, and abdomen. Nursing
care focuses on hydration and aggressive pain management.
, 4. A 4-year-old is scheduled for a Wilms tumor resection. Which of the following is a critical
preoperative nursing consideration?
A. Place a sign over the bed saying ‘Do Not Palpate Abdomen’.
B. Perform deep abdominal palpation to check tumor size.
C. Auscultate bowel sounds every 2 hours.
D. Increase oral fluid intake to 3000 mL/day.
Correct Answer: A
Expert Explanation: Wilms tumor (nephroblastoma) is encapsulated, and palpation of the
abdomen can cause the capsule to rupture, leading to the seeding of cancer cells
throughout the peritoneal cavity. It is a critical safety intervention to prevent any physical
manipulation of the mass. The nurse must ensure all staff are aware of this restriction.
5. A child with hemophilia A has fallen and injured their knee. What is the nurse’s first action?
A. Apply a warm compress to the knee.
B. Perform passive range of motion exercises.
C. Administer aspirin for pain relief.
D. Administer the specific factor VIII concentrate.
Correct Answer: D
Expert Explanation: In hemophilia A, the primary concern is the lack of Factor VIII, which
prevents effective clotting. In the event of an injury, replacing the missing clotting factor is
