Exam 3: NUR203/ NUR 203 (2026/ 2027 Update)
Pediatric Nursing Review| Questions and Verified
Answers| 100% Correct| A Grade – Fortis
Question 1
The nurse is caring for a child who sustained a closed-head injury. Which assessment
finding requires immediate follow-up?
A. Drowsiness but arousable
B. Fixed and dilated pupils
C. Mild headache
D. Nausea and vomiting
Correct Answer: B) Fixed and dilated pupils
Rationale: Fixed and dilated pupils are a sign of increased intracranial pressure (IICP) and
possible brain herniation. This is a medical emergency requiring immediate intervention.
Drowsiness, mild headache, and nausea may be present in mild head injury but are not as
immediately concerning as fixed pupils.
Question 2
What is essential for the early detection of changes associated with increased
intracranial pressure (IICP) in a child?
A. Daily weight measurements
B. Baseline of child's behavior and level of development
C. Weekly head circumference measurements
D. Frequent blood pressure checks
Correct Answer: B) Baseline of child's behavior and level of development
Rationale: Understanding the child's baseline behavior and developmental level is
essential for early detection of changes associated with IICP. Subtle changes in behavior,
,level of consciousness, or developmental regression may be the earliest signs of increased
pressure.
Question 3
The nurse is assessing an infant who sustained a traumatic brain injury. Which
assessment findings require follow-up? (Select all that apply.)
A. Bradycardia
B. Bulging fontanel
C. Distended scalp veins
D. Normal heart rate
E. Flat fontanel
Correct Answers: A, B, C
Rationale: Signs of increased intracranial pressure in infants include bradycardia, a
bulging fontanel, and distended scalp veins. These findings indicate increased pressure
within the cranium and require immediate follow-up. A flat fontanel is a normal finding.
Question 4
The nurse assesses a child who has had a recent head injury. Which finding indicates a
progression of symptoms requiring immediate intervention?
A. Altered mental status
B. Mild confusion
C. Restlessness
D. Headache
Correct Answer: A) Altered mental status
Rationale: Altered mental status is a key indicator of worsening neurological status and
progression of symptoms following a head injury. Any change from the child's baseline
mental status requires immediate reassessment and intervention.
,Question 5
A child with a suspected spinal cord injury is being admitted to the emergency room.
What is the nurse's priority action?
A. Administer pain medication
B. Maintain/ensure immobilization
C. Obtain a stat MRI
D. Notify the family
Correct Answer: B) Maintain/ensure immobilization
Rationale: Spinal immobilization is the priority for a child with a suspected spinal cord
injury to prevent further damage to the spinal cord. Movement can cause or worsen
neurological injury. Other interventions should follow stabilization.
Question 6
What is a priority nursing assessment for a child who developed Guillain-Barré
syndrome following a viral infection?
A. Pain level
B. Respiratory effort
C. Bowel sounds
D. Skin integrity
Correct Answer: B) Respiratory effort
Rationale: Respiratory effort is the priority assessment for a child with Guillain-Barré
syndrome because the paralysis can ascend to involve the respiratory muscles, leading to
respiratory failure. Monitoring respiratory status is essential for early intervention.
Question 7
An 8-month-old infant should be expected to perform which fine motor skills?
A. Grasp rattle by handle & use crude pincer grasp
B. Hold bottle independently
C. Transfer objects from hand to hand
D. Use a mature pincer grasp
, Correct Answer: A) Grasp rattle by handle & use crude pincer grasp
Rationale: At 8 months of age, an infant should be able to grasp a rattle by the handle
and begin to use a crude pincer grasp (using thumb and forefinger). A mature pincer grasp
typically develops around 9-10 months.
Question 8
What is the most common cause of increased seizure activity in children?
A. Fever
B. Medication noncompliance
C. Sleep deprivation
D. Infection
Correct Answer: B) Medication noncompliance
Rationale: Medication noncompliance is the most common cause of increased seizure
activity in children with seizure disorders. Missing doses or abruptly stopping antiseizure
medications can lead to breakthrough seizures.
Question 9
A child with a ventriculoperitoneal (VP) shunt is being cared for post-operatively. What
should the nurse instruct the parents regarding pumping the shunt?
A. Pump the shunt daily to maintain function
B. The shunt should never be pumped because delicate valves can be damaged
C. Pump the shunt only when the child has a headache
D. Pump the shunt if the fontanel is bulging
Correct Answer: B) The shunt should never be pumped because delicate valves can
be damaged
Rationale: VP shunts have delicate valves that can be damaged by pumping. Pumping can
also change pressures within the ventricles, potentially causing harm. Parents should be
instructed to never pump the shunt.
Pediatric Nursing Review| Questions and Verified
Answers| 100% Correct| A Grade – Fortis
Question 1
The nurse is caring for a child who sustained a closed-head injury. Which assessment
finding requires immediate follow-up?
A. Drowsiness but arousable
B. Fixed and dilated pupils
C. Mild headache
D. Nausea and vomiting
Correct Answer: B) Fixed and dilated pupils
Rationale: Fixed and dilated pupils are a sign of increased intracranial pressure (IICP) and
possible brain herniation. This is a medical emergency requiring immediate intervention.
Drowsiness, mild headache, and nausea may be present in mild head injury but are not as
immediately concerning as fixed pupils.
Question 2
What is essential for the early detection of changes associated with increased
intracranial pressure (IICP) in a child?
A. Daily weight measurements
B. Baseline of child's behavior and level of development
C. Weekly head circumference measurements
D. Frequent blood pressure checks
Correct Answer: B) Baseline of child's behavior and level of development
Rationale: Understanding the child's baseline behavior and developmental level is
essential for early detection of changes associated with IICP. Subtle changes in behavior,
,level of consciousness, or developmental regression may be the earliest signs of increased
pressure.
Question 3
The nurse is assessing an infant who sustained a traumatic brain injury. Which
assessment findings require follow-up? (Select all that apply.)
A. Bradycardia
B. Bulging fontanel
C. Distended scalp veins
D. Normal heart rate
E. Flat fontanel
Correct Answers: A, B, C
Rationale: Signs of increased intracranial pressure in infants include bradycardia, a
bulging fontanel, and distended scalp veins. These findings indicate increased pressure
within the cranium and require immediate follow-up. A flat fontanel is a normal finding.
Question 4
The nurse assesses a child who has had a recent head injury. Which finding indicates a
progression of symptoms requiring immediate intervention?
A. Altered mental status
B. Mild confusion
C. Restlessness
D. Headache
Correct Answer: A) Altered mental status
Rationale: Altered mental status is a key indicator of worsening neurological status and
progression of symptoms following a head injury. Any change from the child's baseline
mental status requires immediate reassessment and intervention.
,Question 5
A child with a suspected spinal cord injury is being admitted to the emergency room.
What is the nurse's priority action?
A. Administer pain medication
B. Maintain/ensure immobilization
C. Obtain a stat MRI
D. Notify the family
Correct Answer: B) Maintain/ensure immobilization
Rationale: Spinal immobilization is the priority for a child with a suspected spinal cord
injury to prevent further damage to the spinal cord. Movement can cause or worsen
neurological injury. Other interventions should follow stabilization.
Question 6
What is a priority nursing assessment for a child who developed Guillain-Barré
syndrome following a viral infection?
A. Pain level
B. Respiratory effort
C. Bowel sounds
D. Skin integrity
Correct Answer: B) Respiratory effort
Rationale: Respiratory effort is the priority assessment for a child with Guillain-Barré
syndrome because the paralysis can ascend to involve the respiratory muscles, leading to
respiratory failure. Monitoring respiratory status is essential for early intervention.
Question 7
An 8-month-old infant should be expected to perform which fine motor skills?
A. Grasp rattle by handle & use crude pincer grasp
B. Hold bottle independently
C. Transfer objects from hand to hand
D. Use a mature pincer grasp
, Correct Answer: A) Grasp rattle by handle & use crude pincer grasp
Rationale: At 8 months of age, an infant should be able to grasp a rattle by the handle
and begin to use a crude pincer grasp (using thumb and forefinger). A mature pincer grasp
typically develops around 9-10 months.
Question 8
What is the most common cause of increased seizure activity in children?
A. Fever
B. Medication noncompliance
C. Sleep deprivation
D. Infection
Correct Answer: B) Medication noncompliance
Rationale: Medication noncompliance is the most common cause of increased seizure
activity in children with seizure disorders. Missing doses or abruptly stopping antiseizure
medications can lead to breakthrough seizures.
Question 9
A child with a ventriculoperitoneal (VP) shunt is being cared for post-operatively. What
should the nurse instruct the parents regarding pumping the shunt?
A. Pump the shunt daily to maintain function
B. The shunt should never be pumped because delicate valves can be damaged
C. Pump the shunt only when the child has a headache
D. Pump the shunt if the fontanel is bulging
Correct Answer: B) The shunt should never be pumped because delicate valves can
be damaged
Rationale: VP shunts have delicate valves that can be damaged by pumping. Pumping can
also change pressures within the ventricles, potentially causing harm. Parents should be
instructed to never pump the shunt.
