NUR 203/NUR203 Exam 4|Pediatric Nursing
HESI Speciality Benchmark
2026-2028 Testing Cycle | Newly Released
50 Questions With Answers & Expert Rationales
Guaranteed Pass | Graded A+ | Fortis College
Neurological Alterations, Pediatric Oncology, Hematology/Immunology &
Orthopedic/Musculoskeletal Disorders
Q1: A 4-year-old child is having a generalized tonic-clonic seizure in the pediatric unit. Which
action by the nurse is most appropriate?
A. Insert a padded tongue blade between the teeth to prevent airway obstruction
B. Restrain the child's arms and legs to prevent injury from flailing
C. Place the child supine with the head elevated on two pillows
D. Turn the child to the side and clear the immediate area of hard objects
Correct Answer: D
Rationale: Correct because turning the child to the side during an active seizure allows gravity
to drain oral secretions and prevents aspiration of vomitus or saliva, while clearing hard objects
from the environment minimizes trauma risk. Inserting objects into the mouth can fracture teeth,
cause oral lacerations, or obstruct the airway, and physical restraint may cause musculoskeletal
injury without shortening the seizure. The nurse must also loosen tight clothing, note the exact
onset time, and observe seizure characteristics for accurate post-event documentation.
Q2: A 3-year-old is admitted with a newly diagnosed intra-abdominal mass. The provider
suspects Wilms tumor. Which nursing intervention is the priority?
A. Gently palpate the abdomen to determine the size and mobility of the mass
B. Place a "DO NOT PALPATE ABDOMEN" warning sign at the bedside
C. Massage the abdomen to promote bowel elimination and reduce distension
D. Apply a warm pack to the abdomen to increase blood flow to the area
,Correct Answer: B
Rationale: Correct because palpation of a Wilms tumor can rupture the delicate tumor capsule
and seed malignant cells throughout the peritoneal cavity, transforming a localized resectable
tumor into a disseminated malignancy requiring more aggressive therapy. A clearly visible
warning sign alerts all healthcare personnel, including ancillary staff and float nurses, to avoid
abdominal manipulation. The nurse must also prepare the child and family for diagnostic
imaging and eventual nephrectomy while maintaining strict adherence to the no-palpation safety
rule.
Q3: A 5-year-old with acute lymphoblastic leukemia has an absolute neutrophil count of
400/mm³. Which precaution should the nurse implement?
A. Institute protective isolation and enforce strict hand hygiene
B. Allow fresh flowers to remain at the bedside for emotional support
C. Encourage a diet including raw fruits and vegetables for nutrition
D. Discontinue chemotherapy until the neutrophil count recovers
Correct Answer: A
Rationale: Correct because an absolute neutrophil count below 500/mm³ indicates severe
neutropenia with extreme risk for life-threatening infections, necessitating protective isolation
and rigorous hand hygiene to minimize exposure to environmental pathogens. Fresh flowers and
plants harbor Aspergillus and other fungi, while raw produce may contain bacteria that
overwhelm the child's compromised defenses. Chemotherapy is not discontinued for
neutropenia; instead, the nurse monitors for fever, which may be the only sign of infection and
requires immediate blood cultures and empiric antibiotics.
Q4: A nurse is assessing a 6-month-old infant for signs of increased intracranial pressure. Which
findings are consistent with this condition in an infant? Select all that apply.
A. Bulging anterior fontanel
B. Persistent headache worse in the morning
C. High-pitched, shrill cry
D. Sunsetting eyes
E. Separated cranial sutures
Correct Answer: A, C, D, E
Rationale: Correct because infants with increased intracranial pressure demonstrate bulging
fontanels, high-pitched cries, sunsetting eyes with visible sclera above the iris, and separated
cranial sutures as the skull bones expand to accommodate rising pressure. Persistent headaches
worse in the morning are characteristic of increased ICP in older children who can verbalize
, pain, not in preverbal infants. The nurse must measure head circumference serially, assess
fontanel tension, and report any change in level of consciousness immediately, as this is the
earliest indicator of neurological deterioration.
Q5: A 10-year-old returns from surgery with a long-leg cast for a tibial fracture. Two hours
postoperatively, the child reports severe pain unrelieved by morphine and describes numbness in
the toes. Which condition should the nurse suspect?
A. Normal postoperative pain responsive to elevation
B. Expected paresthesia from the regional anesthetic block
C. Compartment syndrome
D. Superficial cellulitis from cast application
Correct Answer: C
Rationale: Correct because pain out of proportion to injury that is unrelieved by opioid
analgesics, combined with paresthesia, represents the earliest signs of compartment syndrome
caused by elevated pressure within a closed fascial compartment compromising neurovascular
function. Cellulitis would present with warmth and erythema rather than ischemic pain, and
regional anesthesia should not produce progressive numbness hours after surgery. The nurse
must elevate the cast no higher than heart level, perform neurovascular checks frequently, and
prepare for emergent fasciotomy if compartment pressures exceed 30 mmHg.
Q6: A child receiving vincristine via peripheral IV complains of burning and stinging at the
insertion site, and the nurse notes redness and swelling. Which action is the priority?
A. Stop the infusion immediately and do not flush the line
B. Slow the infusion rate and apply a warm compress
C. Flush the line with normal saline to dilute the vesicant
D. Remove the catheter and apply firm pressure to the site
Correct Answer: A
Rationale: Correct because vincristine is a vesicant chemotherapy agent that causes severe tissue
necrosis upon extravasation, and stopping the infusion immediately prevents additional drug
from infiltrating surrounding tissue. Flushing the line would force more vesicant into the
subcutaneous space, and removing the catheter without aspirating residual drug may spill
additional medication. The nurse should leave the needle in place initially, attempt to aspirate the
residual drug, notify the provider, administer the appropriate antidote per protocol, and document
the estimated amount of drug extravasated and the site appearance.
HESI Speciality Benchmark
2026-2028 Testing Cycle | Newly Released
50 Questions With Answers & Expert Rationales
Guaranteed Pass | Graded A+ | Fortis College
Neurological Alterations, Pediatric Oncology, Hematology/Immunology &
Orthopedic/Musculoskeletal Disorders
Q1: A 4-year-old child is having a generalized tonic-clonic seizure in the pediatric unit. Which
action by the nurse is most appropriate?
A. Insert a padded tongue blade between the teeth to prevent airway obstruction
B. Restrain the child's arms and legs to prevent injury from flailing
C. Place the child supine with the head elevated on two pillows
D. Turn the child to the side and clear the immediate area of hard objects
Correct Answer: D
Rationale: Correct because turning the child to the side during an active seizure allows gravity
to drain oral secretions and prevents aspiration of vomitus or saliva, while clearing hard objects
from the environment minimizes trauma risk. Inserting objects into the mouth can fracture teeth,
cause oral lacerations, or obstruct the airway, and physical restraint may cause musculoskeletal
injury without shortening the seizure. The nurse must also loosen tight clothing, note the exact
onset time, and observe seizure characteristics for accurate post-event documentation.
Q2: A 3-year-old is admitted with a newly diagnosed intra-abdominal mass. The provider
suspects Wilms tumor. Which nursing intervention is the priority?
A. Gently palpate the abdomen to determine the size and mobility of the mass
B. Place a "DO NOT PALPATE ABDOMEN" warning sign at the bedside
C. Massage the abdomen to promote bowel elimination and reduce distension
D. Apply a warm pack to the abdomen to increase blood flow to the area
,Correct Answer: B
Rationale: Correct because palpation of a Wilms tumor can rupture the delicate tumor capsule
and seed malignant cells throughout the peritoneal cavity, transforming a localized resectable
tumor into a disseminated malignancy requiring more aggressive therapy. A clearly visible
warning sign alerts all healthcare personnel, including ancillary staff and float nurses, to avoid
abdominal manipulation. The nurse must also prepare the child and family for diagnostic
imaging and eventual nephrectomy while maintaining strict adherence to the no-palpation safety
rule.
Q3: A 5-year-old with acute lymphoblastic leukemia has an absolute neutrophil count of
400/mm³. Which precaution should the nurse implement?
A. Institute protective isolation and enforce strict hand hygiene
B. Allow fresh flowers to remain at the bedside for emotional support
C. Encourage a diet including raw fruits and vegetables for nutrition
D. Discontinue chemotherapy until the neutrophil count recovers
Correct Answer: A
Rationale: Correct because an absolute neutrophil count below 500/mm³ indicates severe
neutropenia with extreme risk for life-threatening infections, necessitating protective isolation
and rigorous hand hygiene to minimize exposure to environmental pathogens. Fresh flowers and
plants harbor Aspergillus and other fungi, while raw produce may contain bacteria that
overwhelm the child's compromised defenses. Chemotherapy is not discontinued for
neutropenia; instead, the nurse monitors for fever, which may be the only sign of infection and
requires immediate blood cultures and empiric antibiotics.
Q4: A nurse is assessing a 6-month-old infant for signs of increased intracranial pressure. Which
findings are consistent with this condition in an infant? Select all that apply.
A. Bulging anterior fontanel
B. Persistent headache worse in the morning
C. High-pitched, shrill cry
D. Sunsetting eyes
E. Separated cranial sutures
Correct Answer: A, C, D, E
Rationale: Correct because infants with increased intracranial pressure demonstrate bulging
fontanels, high-pitched cries, sunsetting eyes with visible sclera above the iris, and separated
cranial sutures as the skull bones expand to accommodate rising pressure. Persistent headaches
worse in the morning are characteristic of increased ICP in older children who can verbalize
, pain, not in preverbal infants. The nurse must measure head circumference serially, assess
fontanel tension, and report any change in level of consciousness immediately, as this is the
earliest indicator of neurological deterioration.
Q5: A 10-year-old returns from surgery with a long-leg cast for a tibial fracture. Two hours
postoperatively, the child reports severe pain unrelieved by morphine and describes numbness in
the toes. Which condition should the nurse suspect?
A. Normal postoperative pain responsive to elevation
B. Expected paresthesia from the regional anesthetic block
C. Compartment syndrome
D. Superficial cellulitis from cast application
Correct Answer: C
Rationale: Correct because pain out of proportion to injury that is unrelieved by opioid
analgesics, combined with paresthesia, represents the earliest signs of compartment syndrome
caused by elevated pressure within a closed fascial compartment compromising neurovascular
function. Cellulitis would present with warmth and erythema rather than ischemic pain, and
regional anesthesia should not produce progressive numbness hours after surgery. The nurse
must elevate the cast no higher than heart level, perform neurovascular checks frequently, and
prepare for emergent fasciotomy if compartment pressures exceed 30 mmHg.
Q6: A child receiving vincristine via peripheral IV complains of burning and stinging at the
insertion site, and the nurse notes redness and swelling. Which action is the priority?
A. Stop the infusion immediately and do not flush the line
B. Slow the infusion rate and apply a warm compress
C. Flush the line with normal saline to dilute the vesicant
D. Remove the catheter and apply firm pressure to the site
Correct Answer: A
Rationale: Correct because vincristine is a vesicant chemotherapy agent that causes severe tissue
necrosis upon extravasation, and stopping the infusion immediately prevents additional drug
from infiltrating surrounding tissue. Flushing the line would force more vesicant into the
subcutaneous space, and removing the catheter without aspirating residual drug may spill
additional medication. The nurse should leave the needle in place initially, attempt to aspirate the
residual drug, notify the provider, administer the appropriate antidote per protocol, and document
the estimated amount of drug extravasated and the site appearance.
