NUR 203/NUR203 Exam 4 V3 | Pediatric
Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a school-age child experiencing a tonic-clonic seizure. What is the
priority nursing intervention during the seizure?
A. Insert a padded tongue blade into the child’s mouth.
B. Administer oral diazepam immediately.
C. Restrain the child’s limbs to prevent injury.
D. Place the child in a side-lying position.
Correct Answer: D
Expert Explanation: The priority action is to maintain a patent airway and prevent
aspiration by placing the child in a side-lying position. Restraining the child or inserting
objects into the mouth can cause injury or airway obstruction. The nurse should also clear
the area of hazards and time the seizure duration.
2. A 10-year-old child is being evaluated for scoliosis. Which assessment finding is most
characteristic of this condition?
A. Lordosis of the cervical spine.
B. Increased curvature of the thoracic spine (hunchback).
C. Pain in the lower back upon exertion.
,D. Asymmetry of the shoulders or hips.
Correct Answer: D
Expert Explanation: Scoliosis is characterized by a lateral curvature of the spine which
often results in uneven shoulder height or hip asymmetry. Screening is typically performed
using the Adam’s Forward Bend Test to observe for a rib hump. Pain is not a common early
symptom of idiopathic scoliosis in children.
3. A nurse is providing discharge instructions to the parents of a child with a new lower-leg
fiberglass cast. Which instruction should be included?
A. Use a hairdryer on a hot setting to soothe itching.
B. Allow the child to walk on the cast immediately.
C. Insert a small ruler under the cast to scratch itchy skin.
D. Perform neurovascular checks every 4 hours for the first 24 hours.
Correct Answer: D
Expert Explanation: Frequent neurovascular checks are essential to monitor for
compartment syndrome or impaired circulation. Parents should check for color,
temperature, movement, and sensation in the toes. Heat should never be used as it can
cause burns under the cast, and nothing should be inserted into the cast.
4. An infant is diagnosed with developmental dysplasia of the hip (DDH) and is prescribed a
Pavlik harness. How should the nurse instruct the parents?
A. Apply the harness over a thin shirt and socks.
, B. Adjust the straps every day to ensure a tight fit.
C. Remove the harness only for diaper changes.
D. Keep the infant’s legs in an adducted position.
Correct Answer: A
Expert Explanation: The harness should be worn over a thin shirt and socks to prevent
skin breakdown from the straps. It is generally worn 23 to 24 hours a day and should not
be adjusted by the parents; only the provider should make adjustments. The harness
maintains the hips in abduction and flexion.
5. Which clinical manifestation should a nurse expect to find in an infant with increased
intracranial pressure (ICP)?
A. Sunken anterior fontanel.
B. Increased appetite and weight gain.
C. High-pitched, shrill cry.
D. Bradycardia and bradypnea.
Correct Answer: C
Expert Explanation: A high-pitched, shrill cry is a classic sign of increased ICP in an infant.
Other signs include bulging fontanels, irritability, and ‘sunsetting’ eyes where the sclera is
visible above the iris. Sunken fontanels are more indicative of dehydration rather than
increased pressure.
Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a school-age child experiencing a tonic-clonic seizure. What is the
priority nursing intervention during the seizure?
A. Insert a padded tongue blade into the child’s mouth.
B. Administer oral diazepam immediately.
C. Restrain the child’s limbs to prevent injury.
D. Place the child in a side-lying position.
Correct Answer: D
Expert Explanation: The priority action is to maintain a patent airway and prevent
aspiration by placing the child in a side-lying position. Restraining the child or inserting
objects into the mouth can cause injury or airway obstruction. The nurse should also clear
the area of hazards and time the seizure duration.
2. A 10-year-old child is being evaluated for scoliosis. Which assessment finding is most
characteristic of this condition?
A. Lordosis of the cervical spine.
B. Increased curvature of the thoracic spine (hunchback).
C. Pain in the lower back upon exertion.
,D. Asymmetry of the shoulders or hips.
Correct Answer: D
Expert Explanation: Scoliosis is characterized by a lateral curvature of the spine which
often results in uneven shoulder height or hip asymmetry. Screening is typically performed
using the Adam’s Forward Bend Test to observe for a rib hump. Pain is not a common early
symptom of idiopathic scoliosis in children.
3. A nurse is providing discharge instructions to the parents of a child with a new lower-leg
fiberglass cast. Which instruction should be included?
A. Use a hairdryer on a hot setting to soothe itching.
B. Allow the child to walk on the cast immediately.
C. Insert a small ruler under the cast to scratch itchy skin.
D. Perform neurovascular checks every 4 hours for the first 24 hours.
Correct Answer: D
Expert Explanation: Frequent neurovascular checks are essential to monitor for
compartment syndrome or impaired circulation. Parents should check for color,
temperature, movement, and sensation in the toes. Heat should never be used as it can
cause burns under the cast, and nothing should be inserted into the cast.
4. An infant is diagnosed with developmental dysplasia of the hip (DDH) and is prescribed a
Pavlik harness. How should the nurse instruct the parents?
A. Apply the harness over a thin shirt and socks.
, B. Adjust the straps every day to ensure a tight fit.
C. Remove the harness only for diaper changes.
D. Keep the infant’s legs in an adducted position.
Correct Answer: A
Expert Explanation: The harness should be worn over a thin shirt and socks to prevent
skin breakdown from the straps. It is generally worn 23 to 24 hours a day and should not
be adjusted by the parents; only the provider should make adjustments. The harness
maintains the hips in abduction and flexion.
5. Which clinical manifestation should a nurse expect to find in an infant with increased
intracranial pressure (ICP)?
A. Sunken anterior fontanel.
B. Increased appetite and weight gain.
C. High-pitched, shrill cry.
D. Bradycardia and bradypnea.
Correct Answer: C
Expert Explanation: A high-pitched, shrill cry is a classic sign of increased ICP in an infant.
Other signs include bulging fontanels, irritability, and ‘sunsetting’ eyes where the sclera is
visible above the iris. Sunken fontanels are more indicative of dehydration rather than
increased pressure.
