PEDS EXAM #3 Questions and Answers
(Latest Update 2024)
Which of the following phrases describes a characteristic of most neonatal
seizures?
A. Generalized seizure
B. Tonic-clonic seizure
C. Well-organized seizure
D. Subtle and barely discernible seizure - Correct Answer ✅ D. Subtle and
barely discernible seizure
Signs of seizures in newborns are subtle. They include symptoms such as lip
smacking, tongue thrusting, eye rolling, and arching of the back.
The newborn's central nervous system is not sufficiently developed to
maintain a generalized seizure.
The newborn's central nervous system is not sufficiently developed to
maintain a tonic-clonic (generalized) seizure.
The newborn's central nervous system is not sufficiently developed to
maintain a well-organized seizure.
What is a clinical manifestation of increased intracranial pressure (ICP) in
infants?
A. Shrill, high-pitched cry
B. Photophobia
C. Pulsating anterior fontanel
D. Vomiting and diarrhea - Correct Answer ✅ A. Shrill, high-pitched cry
A shrill, high-pitched cry is a common clinical manifestation of increased ICP
in infants. The characteristic cry occurs secondary to the pressure being
placed on the meningeal nerves, causing pain.
Photophobia is not indicative of increased ICP in infants.
A pulsating anterior fontanel is normal in infants. The infant with increased
ICP would be seen with a bulging anterior fontanel.
Vomiting is one of the signs of increased ICP in children, but when present
with diarrhea, it is more indicative of a gastrointestinal disturbance.
,PEDS EXAM #3 Questions and Answers
(Latest Update 2024)
The nurse is doing a neurologic assessment on a child whose level of
consciousness has been variable since sustaining a cervical neck injury 12
hours ago. What is the priority assessment for this child?
A. Reactivity of pupils
B. Doll's head maneuver
C. Oculovestibular response
D. Funduscopic examination to identify papilledema - Correct Answer ✅ A.
Reactivity of pupils
Pupil reactivity is an important indication of neurologic health. The pupils
should be assessed for no reaction, unilateral reaction, and rate of reactivity.
The doll's head maneuver should not be performed if there is a cervical spine
injury.
Assessing for an oculovestibular response is a painful test that should not be
done for a child who is having variable levels of consciousness.
Papilledema does not develop for 24 to 48 hours in the course of
unconsciousness.
The nurse is performing a neurologic assessment of a 2-month-old infant
after a car accident. Moro, tonic neck, and withdrawal reflexes are present.
The nurse should recognize that these reflexes suggest
A. neurologic health
B. severe brain damage
C. decorticate posturing
D. decerebrate posturing - Correct Answer ✅ A. neurologic health
The Moro, tonic neck, and withdrawal reflexes are usually present in infants
under 3 to 4 months of age. Therefore, the presence of these reflexes
indicates neurologic health.
The presence of the Moro, tonic neck, and withdrawal reflexes does not
indicate severe brain damage.
,PEDS EXAM #3 Questions and Answers
(Latest Update 2024)
Decorticate posturing is indicative of severe dysfunction of the cerebral
cortex and is not related to the presence of the Moro, tonic neck, or
withdrawal reflexes.
Decerebrate posturing is indicative of dysfunction at the level of the
midbrain and is not related to the presence of the Moro, tonic neck, or
withdrawal reflexes.
The temperature of an unconscious adolescent is 105º F (40.5º C). The
priority nursing intervention is to
A. continue to monitor temperature.
B. initiate a pain assessment.
C. apply a hypothermia blanket.
D. administer aspirin stat. - Correct Answer ✅ C. apply a hypothermia
blanket.
Brain damage can occur at temperatures as high as 105º F (40.5º C). It is
extremely important to institute temperature-lowering interventions such as
hypothermia blankets and tepid water baths immediately.
The temperature needs to be monitored, but lowering the temperature is the
priority.
Pain assessments should be ongoing, but this is not the priority at this time.
Lowering the body temperature is the priority.
Aspirin should never be administered to a child, because of the risk of Reye
syndrome. Antipyretics, such as acetaminophen or ibuprofen, usually are not
effective with temperatures as high as 105º F (40. 5ºC).
The nurse is caring for a comatose child with multiple injuries. The nurse
should recognize that pain
A. cannot occur if the child is comatose.
B. may occur if the child regains consciousness.
C. requires astute nursing assessment and management.
, PEDS EXAM #3 Questions and Answers
(Latest Update 2024)
D. is best assessed by family members who are familiar with the child. -
Correct Answer ✅ C. requires astute nursing assessment and
management.
Because the child cannot communicate pain through one of the standard
pain rating scales, the nurse must focus on physiologic and behavioral
manifestations to accurately assess pain.
Pain can occur in the comatose child.
The child can be in pain while comatose.
The family can provide insight into the child's different responses, but the
nurse should be monitoring physiologic and behavioral manifestations.
What nursing intervention is used to prevent increased intracranial pressure
(ICP) in an unconscious child?
A. Suction the child frequently.
B. Provide environmental stimulation.
C. Turn the head side to side every hour.
D. Avoid activities that cause pain or crying. - Correct Answer ✅ Avoid
activities that cause pain or crying.
Nursing interventions should focus on assessment and interventions to
minimize pain. These activities can cause the ICP to increase.
Suctioning is a distressing procedure. In addition, the resultant decrease in
carbon dioxide can increase ICP.
Environmental stimulation should be minimized because it can increase ICP.
The child's head should not be turned side to side. If the jugular vein is
compressed, the ICP can rise.
The nurse is caring for a 2-year-old child who is unconscious but stable after
a car accident. The child's parents are staying at the bedside most of the
time. What is an appropriate nursing intervention?
A. Suggest that the parents go home until the child is alert enough to know
they are present.
(Latest Update 2024)
Which of the following phrases describes a characteristic of most neonatal
seizures?
A. Generalized seizure
B. Tonic-clonic seizure
C. Well-organized seizure
D. Subtle and barely discernible seizure - Correct Answer ✅ D. Subtle and
barely discernible seizure
Signs of seizures in newborns are subtle. They include symptoms such as lip
smacking, tongue thrusting, eye rolling, and arching of the back.
The newborn's central nervous system is not sufficiently developed to
maintain a generalized seizure.
The newborn's central nervous system is not sufficiently developed to
maintain a tonic-clonic (generalized) seizure.
The newborn's central nervous system is not sufficiently developed to
maintain a well-organized seizure.
What is a clinical manifestation of increased intracranial pressure (ICP) in
infants?
A. Shrill, high-pitched cry
B. Photophobia
C. Pulsating anterior fontanel
D. Vomiting and diarrhea - Correct Answer ✅ A. Shrill, high-pitched cry
A shrill, high-pitched cry is a common clinical manifestation of increased ICP
in infants. The characteristic cry occurs secondary to the pressure being
placed on the meningeal nerves, causing pain.
Photophobia is not indicative of increased ICP in infants.
A pulsating anterior fontanel is normal in infants. The infant with increased
ICP would be seen with a bulging anterior fontanel.
Vomiting is one of the signs of increased ICP in children, but when present
with diarrhea, it is more indicative of a gastrointestinal disturbance.
,PEDS EXAM #3 Questions and Answers
(Latest Update 2024)
The nurse is doing a neurologic assessment on a child whose level of
consciousness has been variable since sustaining a cervical neck injury 12
hours ago. What is the priority assessment for this child?
A. Reactivity of pupils
B. Doll's head maneuver
C. Oculovestibular response
D. Funduscopic examination to identify papilledema - Correct Answer ✅ A.
Reactivity of pupils
Pupil reactivity is an important indication of neurologic health. The pupils
should be assessed for no reaction, unilateral reaction, and rate of reactivity.
The doll's head maneuver should not be performed if there is a cervical spine
injury.
Assessing for an oculovestibular response is a painful test that should not be
done for a child who is having variable levels of consciousness.
Papilledema does not develop for 24 to 48 hours in the course of
unconsciousness.
The nurse is performing a neurologic assessment of a 2-month-old infant
after a car accident. Moro, tonic neck, and withdrawal reflexes are present.
The nurse should recognize that these reflexes suggest
A. neurologic health
B. severe brain damage
C. decorticate posturing
D. decerebrate posturing - Correct Answer ✅ A. neurologic health
The Moro, tonic neck, and withdrawal reflexes are usually present in infants
under 3 to 4 months of age. Therefore, the presence of these reflexes
indicates neurologic health.
The presence of the Moro, tonic neck, and withdrawal reflexes does not
indicate severe brain damage.
,PEDS EXAM #3 Questions and Answers
(Latest Update 2024)
Decorticate posturing is indicative of severe dysfunction of the cerebral
cortex and is not related to the presence of the Moro, tonic neck, or
withdrawal reflexes.
Decerebrate posturing is indicative of dysfunction at the level of the
midbrain and is not related to the presence of the Moro, tonic neck, or
withdrawal reflexes.
The temperature of an unconscious adolescent is 105º F (40.5º C). The
priority nursing intervention is to
A. continue to monitor temperature.
B. initiate a pain assessment.
C. apply a hypothermia blanket.
D. administer aspirin stat. - Correct Answer ✅ C. apply a hypothermia
blanket.
Brain damage can occur at temperatures as high as 105º F (40.5º C). It is
extremely important to institute temperature-lowering interventions such as
hypothermia blankets and tepid water baths immediately.
The temperature needs to be monitored, but lowering the temperature is the
priority.
Pain assessments should be ongoing, but this is not the priority at this time.
Lowering the body temperature is the priority.
Aspirin should never be administered to a child, because of the risk of Reye
syndrome. Antipyretics, such as acetaminophen or ibuprofen, usually are not
effective with temperatures as high as 105º F (40. 5ºC).
The nurse is caring for a comatose child with multiple injuries. The nurse
should recognize that pain
A. cannot occur if the child is comatose.
B. may occur if the child regains consciousness.
C. requires astute nursing assessment and management.
, PEDS EXAM #3 Questions and Answers
(Latest Update 2024)
D. is best assessed by family members who are familiar with the child. -
Correct Answer ✅ C. requires astute nursing assessment and
management.
Because the child cannot communicate pain through one of the standard
pain rating scales, the nurse must focus on physiologic and behavioral
manifestations to accurately assess pain.
Pain can occur in the comatose child.
The child can be in pain while comatose.
The family can provide insight into the child's different responses, but the
nurse should be monitoring physiologic and behavioral manifestations.
What nursing intervention is used to prevent increased intracranial pressure
(ICP) in an unconscious child?
A. Suction the child frequently.
B. Provide environmental stimulation.
C. Turn the head side to side every hour.
D. Avoid activities that cause pain or crying. - Correct Answer ✅ Avoid
activities that cause pain or crying.
Nursing interventions should focus on assessment and interventions to
minimize pain. These activities can cause the ICP to increase.
Suctioning is a distressing procedure. In addition, the resultant decrease in
carbon dioxide can increase ICP.
Environmental stimulation should be minimized because it can increase ICP.
The child's head should not be turned side to side. If the jugular vein is
compressed, the ICP can rise.
The nurse is caring for a 2-year-old child who is unconscious but stable after
a car accident. The child's parents are staying at the bedside most of the
time. What is an appropriate nursing intervention?
A. Suggest that the parents go home until the child is alert enough to know
they are present.
