NUR 203/NUR203 Exam 3 V1 | Pediatric
Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for an infant who has just undergone a ventriculoperitoneal (VP) shunt
placement for hydrocephalus. Which assessment finding should the nurse prioritize as a
potential sign of increased intracranial pressure (ICP)?
A. High-pitched, shrill cry
B. Decreased head circumference
C. Increased appetite and weight gain
D. Normal pupillary response to light
Correct Answer: A
Expert Explanation: A high-pitched, shrill cry is a classic sign of neurological distress and
increased ICP in infants. Other signs include bulging fontanels, irritability, and sunsetting
eyes. The nurse must monitor these changes closely as they may indicate shunt malfunction
or infection.
2. A school-age child is admitted with a diagnosis of bacterial meningitis. Which of the
following isolation precautions must the nurse implement?
A. Standard precautions only
B. Droplet precautions
,C. Airborne precautions
D. Contact precautions
Correct Answer: B
Expert Explanation: Bacterial meningitis is transmitted through large-particle droplets
from the respiratory tract. Droplet precautions should be maintained for at least 24 hours
after the initiation of effective antibiotic therapy. This involves wearing a mask when
within three feet of the patient and ensuring the child is in a private room.
3. A nurse is teaching the parents of a child newly diagnosed with Type 1 Diabetes Mellitus
about exercise. Which instruction should be included?
A. Avoid exercise if blood glucose is above 150 mg/dL.
B. Administer extra insulin before starting a physical activity.
C. Exercise only in the morning when insulin levels are lowest.
D. Provide a complex carbohydrate snack prior to exercise.
Correct Answer: D
Expert Explanation: Physical activity increases glucose uptake by muscles, which can lead
to hypoglycemia in children with Type 1 Diabetes. Providing a carbohydrate snack before
exercise helps maintain stable blood glucose levels during exertion. The nurse should also
emphasize monitoring blood glucose before, during, and after strenuous activities.
, 4. Which of the following is a characteristic clinical manifestation of Duchenne Muscular
Dystrophy (DMD) in a preschool-aged child?
A. Hypertonicity of the lower extremities
B. High arching of the feet (pes cavus)
C. Gower’s sign when rising from the floor
D. Early achievement of motor milestones
Correct Answer: C
Expert Explanation: Gower’s sign involves the use of the hands to ‘walk up’ the legs to
reach a standing position, indicating pelvic girdle weakness. This is a hallmark sign of
Duchenne Muscular Dystrophy as muscle fibers are replaced by fat and connective tissue.
Affected children usually exhibit progressive muscle weakness and delayed motor
development.
5. A nurse is caring for an adolescent following a spinal fusion for scoliosis. Which nursing
action is essential for preventing complications in the immediate postoperative period?
A. Use the log-rolling technique to change the patient’s position.
B. Encourage the patient to sit in a chair for 2 hours twice daily.
C. Maintain the patient in a prone position to reduce pressure.
D. Restrict fluid intake to prevent spinal cord edema.
Correct Answer: A
Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for an infant who has just undergone a ventriculoperitoneal (VP) shunt
placement for hydrocephalus. Which assessment finding should the nurse prioritize as a
potential sign of increased intracranial pressure (ICP)?
A. High-pitched, shrill cry
B. Decreased head circumference
C. Increased appetite and weight gain
D. Normal pupillary response to light
Correct Answer: A
Expert Explanation: A high-pitched, shrill cry is a classic sign of neurological distress and
increased ICP in infants. Other signs include bulging fontanels, irritability, and sunsetting
eyes. The nurse must monitor these changes closely as they may indicate shunt malfunction
or infection.
2. A school-age child is admitted with a diagnosis of bacterial meningitis. Which of the
following isolation precautions must the nurse implement?
A. Standard precautions only
B. Droplet precautions
,C. Airborne precautions
D. Contact precautions
Correct Answer: B
Expert Explanation: Bacterial meningitis is transmitted through large-particle droplets
from the respiratory tract. Droplet precautions should be maintained for at least 24 hours
after the initiation of effective antibiotic therapy. This involves wearing a mask when
within three feet of the patient and ensuring the child is in a private room.
3. A nurse is teaching the parents of a child newly diagnosed with Type 1 Diabetes Mellitus
about exercise. Which instruction should be included?
A. Avoid exercise if blood glucose is above 150 mg/dL.
B. Administer extra insulin before starting a physical activity.
C. Exercise only in the morning when insulin levels are lowest.
D. Provide a complex carbohydrate snack prior to exercise.
Correct Answer: D
Expert Explanation: Physical activity increases glucose uptake by muscles, which can lead
to hypoglycemia in children with Type 1 Diabetes. Providing a carbohydrate snack before
exercise helps maintain stable blood glucose levels during exertion. The nurse should also
emphasize monitoring blood glucose before, during, and after strenuous activities.
, 4. Which of the following is a characteristic clinical manifestation of Duchenne Muscular
Dystrophy (DMD) in a preschool-aged child?
A. Hypertonicity of the lower extremities
B. High arching of the feet (pes cavus)
C. Gower’s sign when rising from the floor
D. Early achievement of motor milestones
Correct Answer: C
Expert Explanation: Gower’s sign involves the use of the hands to ‘walk up’ the legs to
reach a standing position, indicating pelvic girdle weakness. This is a hallmark sign of
Duchenne Muscular Dystrophy as muscle fibers are replaced by fat and connective tissue.
Affected children usually exhibit progressive muscle weakness and delayed motor
development.
5. A nurse is caring for an adolescent following a spinal fusion for scoliosis. Which nursing
action is essential for preventing complications in the immediate postoperative period?
A. Use the log-rolling technique to change the patient’s position.
B. Encourage the patient to sit in a chair for 2 hours twice daily.
C. Maintain the patient in a prone position to reduce pressure.
D. Restrict fluid intake to prevent spinal cord edema.
Correct Answer: A
