NUR 203/NUR203 Exam 4 V1 | Pediatric Nursing
Q&A with Rationale | Fortis College
1. A nurse is caring for a 10-year-old child with Type 1 Diabetes Mellitus who is experiencing
shakiness, diaphoresis, and a heart rate of 110 bpm. Which action should the nurse take first?
A. Administer the scheduled dose of NPH insulin
B. Obtain a blood glucose level immediately
C. Administer 15 grams of a simple carbohydrate
D. Provide a high-protein snack such as peanut butter
Correct Answer: C
Explanation: Shakiness and diaphoresis are classic signs of hypoglycemia in a diabetic
child. The priority intervention is to provide a rapid-acting carbohydrate to raise blood
sugar levels quickly. After the initial treatment, the nurse should follow up with a complex
carbohydrate and protein to maintain stability.
2. When assessing a child for Developmental Dysplasia of the Hip (DDH), which finding is
most indicative of this condition in an infant?
A. Presence of a positive Ortolani sign
B. Symmetrical gluteal folds
C. Equally distributed weight during standing
D. Negative Barlow test
,Correct Answer: A
Explanation: The Ortolani sign is a standard assessment tool used to detect the hip
popping back into the socket, which indicates instability. Asymmetrical gluteal folds are
also a common indicator of DDH. Early detection is critical for successful non-surgical
management using a Pavlik harness.
3. A school-aged child is admitted with a diagnosis of Acute Glomerulonephritis (AGN). Which
clinical manifestation should the nurse expect to observe?
A. Hypotension and massive proteinuria
B. Extreme lethargy and low blood pressure
C. Polyuria and weight loss
D. Periorbital edema and tea-colored urine
Correct Answer: D
Explanation: Acute Glomerulonephritis typically follows a streptococcal infection and
results in hematuria, leading to tea-colored urine. Periorbital edema is a result of fluid
retention due to decreased glomerular filtration. Hypertension is also a common finding,
requiring frequent blood pressure monitoring.
4. The nurse is providing discharge teaching to the parents of a child with a new diagnosis of
Growth Hormone (GH) deficiency. Which statement by the parent indicates a need for further
instruction?
A. I will give the injection subcutaneously every day.
, B. We will see immediate results in height within a week.
C. Treatment will continue until the growth plates close.
D. We should monitor for side effects like hip pain.
Correct Answer: B
Explanation: Growth hormone therapy requires consistent daily administration over a
long period before significant changes in height are visible. Parents must understand that
growth is a gradual process that continues until skeletal maturation occurs. Misaligned
expectations can lead to non-compliance with the treatment regimen.
5. Which nursing intervention is the priority for a child experiencing a generalized tonic-clonic
seizure?
A. Turn the child onto their side to maintain the airway
B. Restrain the child’s limbs to prevent injury
C. Insert a padded tongue blade into the mouth
D. Administer oral diazepam immediately
Correct Answer: A
Explanation: Maintaining a patent airway is the absolute priority during a seizure, and
turning the child to the side allows secretions to drain. Nothing should ever be placed in the
child’s mouth, and physical restraints can cause fractures or soft tissue damage. The nurse
should also clear the environment of sharp objects and time the seizure.
Q&A with Rationale | Fortis College
1. A nurse is caring for a 10-year-old child with Type 1 Diabetes Mellitus who is experiencing
shakiness, diaphoresis, and a heart rate of 110 bpm. Which action should the nurse take first?
A. Administer the scheduled dose of NPH insulin
B. Obtain a blood glucose level immediately
C. Administer 15 grams of a simple carbohydrate
D. Provide a high-protein snack such as peanut butter
Correct Answer: C
Explanation: Shakiness and diaphoresis are classic signs of hypoglycemia in a diabetic
child. The priority intervention is to provide a rapid-acting carbohydrate to raise blood
sugar levels quickly. After the initial treatment, the nurse should follow up with a complex
carbohydrate and protein to maintain stability.
2. When assessing a child for Developmental Dysplasia of the Hip (DDH), which finding is
most indicative of this condition in an infant?
A. Presence of a positive Ortolani sign
B. Symmetrical gluteal folds
C. Equally distributed weight during standing
D. Negative Barlow test
,Correct Answer: A
Explanation: The Ortolani sign is a standard assessment tool used to detect the hip
popping back into the socket, which indicates instability. Asymmetrical gluteal folds are
also a common indicator of DDH. Early detection is critical for successful non-surgical
management using a Pavlik harness.
3. A school-aged child is admitted with a diagnosis of Acute Glomerulonephritis (AGN). Which
clinical manifestation should the nurse expect to observe?
A. Hypotension and massive proteinuria
B. Extreme lethargy and low blood pressure
C. Polyuria and weight loss
D. Periorbital edema and tea-colored urine
Correct Answer: D
Explanation: Acute Glomerulonephritis typically follows a streptococcal infection and
results in hematuria, leading to tea-colored urine. Periorbital edema is a result of fluid
retention due to decreased glomerular filtration. Hypertension is also a common finding,
requiring frequent blood pressure monitoring.
4. The nurse is providing discharge teaching to the parents of a child with a new diagnosis of
Growth Hormone (GH) deficiency. Which statement by the parent indicates a need for further
instruction?
A. I will give the injection subcutaneously every day.
, B. We will see immediate results in height within a week.
C. Treatment will continue until the growth plates close.
D. We should monitor for side effects like hip pain.
Correct Answer: B
Explanation: Growth hormone therapy requires consistent daily administration over a
long period before significant changes in height are visible. Parents must understand that
growth is a gradual process that continues until skeletal maturation occurs. Misaligned
expectations can lead to non-compliance with the treatment regimen.
5. Which nursing intervention is the priority for a child experiencing a generalized tonic-clonic
seizure?
A. Turn the child onto their side to maintain the airway
B. Restrain the child’s limbs to prevent injury
C. Insert a padded tongue blade into the mouth
D. Administer oral diazepam immediately
Correct Answer: A
Explanation: Maintaining a patent airway is the absolute priority during a seizure, and
turning the child to the side allows secretions to drain. Nothing should ever be placed in the
child’s mouth, and physical restraints can cause fractures or soft tissue damage. The nurse
should also clear the environment of sharp objects and time the seizure.
