ESTUDYR
NUR 254 EXAM 4 | NURSING 254 MATERNAL EXAM 4 EXAM
QUESTIONS & ANSWERS, EXPLAINED SOLUTIONS
A child with leukemia has a WBC count <1,000/mm³. Which intervention should the nurse include in
the plan of care?
A) Encourage participation in group activities
B) Restrict all visitors
C) Administer prescribed influenza vaccination
D) Provide high-fiber diet
Rationale: Children with neutropenia are at high risk for infection; annual flu vaccine helps prevent a
potentially serious viral illness.
During a staff teaching session on osteosarcoma, which statement indicates a need for further
instruction?
A) “It often occurs in the metaphyses of long bones.”
B) “Pain may initially mimic growing pains.”
C) “In the early stage symptoms are typically attributed to normal growing pains.”
D) “Limb salvage may be possible with chemotherapy and surgery.”
Rationale: Early osteosarcoma pain is often attributed to trauma, not benign growing pains; assuming it
is “normal” delays diagnosis.
When caring for a child suspected of having a Wilms’ tumor, the nurse should avoid which action?
A) Checking vital signs every hour
B) Being gentle during play
C) Palpating the abdomen for tumor mass
D) Inspecting for abdominal swelling
Rationale: Palpation can rupture the tumor capsule and spread malignant cells. Abdominal examination
should be visual and auscultatory only.
A 5-year-old with SCD on IV morphine is found unarousable with respirations of 10. The nurse’s first
action is to:
A) Call the physician for more morphine
B) Increase the IV fluid rate
C) Administer naloxone
D) Elevate the head of the bed
Rationale: Bradypnea and unresponsiveness suggest opioid overdose; reversing morphine with
naloxone is the priority.
In vaso-occlusive sickle cell crisis, expected prescriptions include:
A) IV antibiotics and isolation
, ESTUDYR
B) Aggressive hydration and pain management
C) Hyperbaric oxygen therapy
D) Fluid restriction and diuretics
Rationale: Hydration reduces sickling; analgesia alleviates severe pain from vaso-occlusion.
Teaching parents of a child with hemophilia about a future knee injury, the nurse advises:
A) Apply heat first
B) Perform passive ROM
C) Use ice packs and compression wraps
D) Elevate and ambulate immediately
Rationale: RICE (rest, ice, compression, elevation) helps control bleeding and swelling.
To prevent iron-deficiency anemia in exclusively formula-fed infants, the nurse should recommend:
A) Cow’s milk from birth
B) Iron-fortified formula for the first 6 months
C) Delayed introduction of solids until 12 months
D) Only breast milk until 9 months
Rationale: Iron-fortified formula provides necessary iron stores during rapid growth; cow’s milk before
12 months increases risk of anemia.
A child with severe iron-deficiency anemia is most likely to exhibit:
A) Jaundice
B) Hypertension
C) Pallor
D) Hyperactivity
Rationale: Reduced hemoglobin causes pale skin and mucous membranes.
A 4-year-old is 36 hours post-op after nephrectomy for Wilms’ tumor. Which finding requires
immediate follow-up?
A) Urine output 2 mL/kg/hr
B) Pain score 3/10
C) Incision site pink at edges
D) Mild abdominal distension
Rationale: Pink (erythema) at wound edges suggests infection or dehiscence; red flags post-op.
Discharge teaching for parents after neuroblastoma resection is effective when they say:
A) “We’ll avoid all physical activity.”
B) “We’ll never have another surgery.”
C) “We will provide pain relief using medication and rest.”
D) “We’ll keep sharp pain secret.”
NUR 254 EXAM 4 | NURSING 254 MATERNAL EXAM 4 EXAM
QUESTIONS & ANSWERS, EXPLAINED SOLUTIONS
A child with leukemia has a WBC count <1,000/mm³. Which intervention should the nurse include in
the plan of care?
A) Encourage participation in group activities
B) Restrict all visitors
C) Administer prescribed influenza vaccination
D) Provide high-fiber diet
Rationale: Children with neutropenia are at high risk for infection; annual flu vaccine helps prevent a
potentially serious viral illness.
During a staff teaching session on osteosarcoma, which statement indicates a need for further
instruction?
A) “It often occurs in the metaphyses of long bones.”
B) “Pain may initially mimic growing pains.”
C) “In the early stage symptoms are typically attributed to normal growing pains.”
D) “Limb salvage may be possible with chemotherapy and surgery.”
Rationale: Early osteosarcoma pain is often attributed to trauma, not benign growing pains; assuming it
is “normal” delays diagnosis.
When caring for a child suspected of having a Wilms’ tumor, the nurse should avoid which action?
A) Checking vital signs every hour
B) Being gentle during play
C) Palpating the abdomen for tumor mass
D) Inspecting for abdominal swelling
Rationale: Palpation can rupture the tumor capsule and spread malignant cells. Abdominal examination
should be visual and auscultatory only.
A 5-year-old with SCD on IV morphine is found unarousable with respirations of 10. The nurse’s first
action is to:
A) Call the physician for more morphine
B) Increase the IV fluid rate
C) Administer naloxone
D) Elevate the head of the bed
Rationale: Bradypnea and unresponsiveness suggest opioid overdose; reversing morphine with
naloxone is the priority.
In vaso-occlusive sickle cell crisis, expected prescriptions include:
A) IV antibiotics and isolation
, ESTUDYR
B) Aggressive hydration and pain management
C) Hyperbaric oxygen therapy
D) Fluid restriction and diuretics
Rationale: Hydration reduces sickling; analgesia alleviates severe pain from vaso-occlusion.
Teaching parents of a child with hemophilia about a future knee injury, the nurse advises:
A) Apply heat first
B) Perform passive ROM
C) Use ice packs and compression wraps
D) Elevate and ambulate immediately
Rationale: RICE (rest, ice, compression, elevation) helps control bleeding and swelling.
To prevent iron-deficiency anemia in exclusively formula-fed infants, the nurse should recommend:
A) Cow’s milk from birth
B) Iron-fortified formula for the first 6 months
C) Delayed introduction of solids until 12 months
D) Only breast milk until 9 months
Rationale: Iron-fortified formula provides necessary iron stores during rapid growth; cow’s milk before
12 months increases risk of anemia.
A child with severe iron-deficiency anemia is most likely to exhibit:
A) Jaundice
B) Hypertension
C) Pallor
D) Hyperactivity
Rationale: Reduced hemoglobin causes pale skin and mucous membranes.
A 4-year-old is 36 hours post-op after nephrectomy for Wilms’ tumor. Which finding requires
immediate follow-up?
A) Urine output 2 mL/kg/hr
B) Pain score 3/10
C) Incision site pink at edges
D) Mild abdominal distension
Rationale: Pink (erythema) at wound edges suggests infection or dehiscence; red flags post-op.
Discharge teaching for parents after neuroblastoma resection is effective when they say:
A) “We’ll avoid all physical activity.”
B) “We’ll never have another surgery.”
C) “We will provide pain relief using medication and rest.”
D) “We’ll keep sharp pain secret.”
