NUR 203/NUR203 Exam 4|Pediatric Nursing
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 nurse is caring for a 5-year-old who sustained a closed head injury. The parents report the
child seems "more irritable than usual" and did not recognize them briefly this morning. Which
finding represents the earliest indicator of neurological deterioration?
A. Projectile vomiting
B. Widening pulse pressure
C. Increased irritability and confusion
D. Bradycardia with irregular respirations
Correct Answer: C
Rationale: Correct because a change in level of consciousness, manifested as increased
irritability, confusion, or failure to recognize familiar caregivers, is the absolute earliest and most
sensitive indicator of deteriorating neurological status or increasing intracranial pressure in a
pediatric patient. Projectile vomiting, widening pulse pressure, and bradycardia with irregular
respirations are late signs of increased intracranial pressure that occur after neurological status
has already declined. The nurse must report any alteration in LOC immediately because these
changes precede vital sign abnormalities and herniation.
Q2: A 3-year-old is admitted with a suspected intra-abdominal mass. The provider suspects
Wilms' tumor. Which nursing action is the priority upon admission?
A. Place a "Do Not Palpate Abdomen" warning sign at the bedside
B. Palpate the abdomen gently to establish a baseline measurement
C. Prepare the child for immediate bone marrow aspiration
D. Massage the abdomen to promote bowel function
,Correct Answer: A
Rationale: Correct because Wilms' tumor is an encapsulated malignant kidney tumor, and
palpation can rupture the delicate tumor capsule causing cancer cells to seed throughout the
peritoneal cavity. Placing a visible warning sign alerts all healthcare personnel, including
ancillary staff, to avoid abdominal palpation or manipulation. Bone marrow aspiration is not
indicated for Wilms' tumor, and abdominal massage is contraindicated because it risks capsular
rupture and metastatic spread.
Q3: A pediatric nurse is reviewing age-specific manifestations of increased intracranial pressure.
Which findings are associated with increased ICP in infants? Select all that apply.
A. Bulging anterior fontanel
B. Persistent morning headache
C. Sunsetting eyes
D. Separated cranial sutures
E. High-pitched, shrill cry
Correct Answer: A, C, D, E
Rationale: Correct because infants with open fontanels and cranial sutures manifest increased
ICP through bulging of the anterior fontanel, sunsetting eyes with visible sclera above the iris,
separated cranial sutures as the skull expands to accommodate pressure, and a high-pitched shrill
cry. Persistent morning headache is a classic sign of increased ICP in older children and
adolescents whose cranial sutures have fused and cannot expand. The nurse must recognize these
age-specific differences to ensure early detection and intervention before herniation occurs.
Q4: A child receiving chemotherapy has a platelet count of 15,000/mm³. Which intervention is
the nurse's priority?
A. Encourage active play and ambulation
B. Initiate platelet transfusion per protocol
C. Administer aspirin for fever prevention
D. Obtain a rectal temperature every 4 hours
Correct Answer: B
Rationale: Correct because a platelet count below 20,000/mm³ places the child at extreme risk
for spontaneous intracranial and internal bleeding, making platelet transfusion the priority
intervention. Aspirin is absolutely contraindicated because it impairs platelet function and
increases bleeding risk, and rectal temperatures are prohibited to prevent mucosal trauma. The
nurse must also implement bleeding precautions including soft toothbrushes, avoidance of
intramuscular injections, and application of prolonged pressure to venipuncture sites.
, Q5: Parents of an infant being treated with a Pavlik harness for developmental dysplasia of the
hip are receiving discharge instructions. Which statement by the parents indicates correct
understanding of home care?
A. "We will remove the harness for 3 hours each day so our baby can kick freely."
B. "We will tighten the straps ourselves if they feel too loose."
C. "We will place the diaper over the harness straps."
D. "We will check the skin under the straps 2 to 3 times daily for redness."
Correct Answer: D
Rationale: Correct because checking the skin under the Pavlik harness straps 2 to 3 times daily
is essential to detect early signs of skin breakdown or pressure injury. The harness must be worn
23 hours per day and should never be removed by parents without provider instruction, and only
trained personnel should adjust strap tightness to maintain proper hip positioning. The diaper is
always applied underneath the harness straps to prevent moisture irritation, not over them.
Q6: A child in the pediatric unit begins having a generalized tonic-clonic seizure. Which action
should the nurse take first?
A. Insert an oral airway to maintain the airway
B. Restrain the child's limbs to prevent injury
C. Turn the child onto their side
D. Place a padded tongue blade between the teeth
Correct Answer: C
Rationale: Correct because turning the child onto their side during an active seizure is the
priority action to maintain airway patency, facilitate drainage of oral secretions, and prevent
aspiration. Restraining limbs can cause musculoskeletal injury, and placing objects in the mouth
including tongue blades or fingers is contraindicated because it can fracture teeth, cause oral
trauma, or obstruct the airway. The nurse must also clear the immediate area of hazards, loosen
tight clothing, and note the exact time and characteristics of the seizure.
Q7: A provider orders diazepam 0.2 mg/kg IV for a child weighing 44 lbs who is in status
epilepticus. How many milligrams should the nurse administer? (Round to the nearest tenth.)
_______ mg
Correct Answer: 4
Rationale: Correct because the child's weight converts to 20 kg after dividing 44 pounds by 2.2,
and the dose is calculated as 0.2 mg/kg multiplied by 20 kg, yielding 4 mg total. Status
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 nurse is caring for a 5-year-old who sustained a closed head injury. The parents report the
child seems "more irritable than usual" and did not recognize them briefly this morning. Which
finding represents the earliest indicator of neurological deterioration?
A. Projectile vomiting
B. Widening pulse pressure
C. Increased irritability and confusion
D. Bradycardia with irregular respirations
Correct Answer: C
Rationale: Correct because a change in level of consciousness, manifested as increased
irritability, confusion, or failure to recognize familiar caregivers, is the absolute earliest and most
sensitive indicator of deteriorating neurological status or increasing intracranial pressure in a
pediatric patient. Projectile vomiting, widening pulse pressure, and bradycardia with irregular
respirations are late signs of increased intracranial pressure that occur after neurological status
has already declined. The nurse must report any alteration in LOC immediately because these
changes precede vital sign abnormalities and herniation.
Q2: A 3-year-old is admitted with a suspected intra-abdominal mass. The provider suspects
Wilms' tumor. Which nursing action is the priority upon admission?
A. Place a "Do Not Palpate Abdomen" warning sign at the bedside
B. Palpate the abdomen gently to establish a baseline measurement
C. Prepare the child for immediate bone marrow aspiration
D. Massage the abdomen to promote bowel function
,Correct Answer: A
Rationale: Correct because Wilms' tumor is an encapsulated malignant kidney tumor, and
palpation can rupture the delicate tumor capsule causing cancer cells to seed throughout the
peritoneal cavity. Placing a visible warning sign alerts all healthcare personnel, including
ancillary staff, to avoid abdominal palpation or manipulation. Bone marrow aspiration is not
indicated for Wilms' tumor, and abdominal massage is contraindicated because it risks capsular
rupture and metastatic spread.
Q3: A pediatric nurse is reviewing age-specific manifestations of increased intracranial pressure.
Which findings are associated with increased ICP in infants? Select all that apply.
A. Bulging anterior fontanel
B. Persistent morning headache
C. Sunsetting eyes
D. Separated cranial sutures
E. High-pitched, shrill cry
Correct Answer: A, C, D, E
Rationale: Correct because infants with open fontanels and cranial sutures manifest increased
ICP through bulging of the anterior fontanel, sunsetting eyes with visible sclera above the iris,
separated cranial sutures as the skull expands to accommodate pressure, and a high-pitched shrill
cry. Persistent morning headache is a classic sign of increased ICP in older children and
adolescents whose cranial sutures have fused and cannot expand. The nurse must recognize these
age-specific differences to ensure early detection and intervention before herniation occurs.
Q4: A child receiving chemotherapy has a platelet count of 15,000/mm³. Which intervention is
the nurse's priority?
A. Encourage active play and ambulation
B. Initiate platelet transfusion per protocol
C. Administer aspirin for fever prevention
D. Obtain a rectal temperature every 4 hours
Correct Answer: B
Rationale: Correct because a platelet count below 20,000/mm³ places the child at extreme risk
for spontaneous intracranial and internal bleeding, making platelet transfusion the priority
intervention. Aspirin is absolutely contraindicated because it impairs platelet function and
increases bleeding risk, and rectal temperatures are prohibited to prevent mucosal trauma. The
nurse must also implement bleeding precautions including soft toothbrushes, avoidance of
intramuscular injections, and application of prolonged pressure to venipuncture sites.
, Q5: Parents of an infant being treated with a Pavlik harness for developmental dysplasia of the
hip are receiving discharge instructions. Which statement by the parents indicates correct
understanding of home care?
A. "We will remove the harness for 3 hours each day so our baby can kick freely."
B. "We will tighten the straps ourselves if they feel too loose."
C. "We will place the diaper over the harness straps."
D. "We will check the skin under the straps 2 to 3 times daily for redness."
Correct Answer: D
Rationale: Correct because checking the skin under the Pavlik harness straps 2 to 3 times daily
is essential to detect early signs of skin breakdown or pressure injury. The harness must be worn
23 hours per day and should never be removed by parents without provider instruction, and only
trained personnel should adjust strap tightness to maintain proper hip positioning. The diaper is
always applied underneath the harness straps to prevent moisture irritation, not over them.
Q6: A child in the pediatric unit begins having a generalized tonic-clonic seizure. Which action
should the nurse take first?
A. Insert an oral airway to maintain the airway
B. Restrain the child's limbs to prevent injury
C. Turn the child onto their side
D. Place a padded tongue blade between the teeth
Correct Answer: C
Rationale: Correct because turning the child onto their side during an active seizure is the
priority action to maintain airway patency, facilitate drainage of oral secretions, and prevent
aspiration. Restraining limbs can cause musculoskeletal injury, and placing objects in the mouth
including tongue blades or fingers is contraindicated because it can fracture teeth, cause oral
trauma, or obstruct the airway. The nurse must also clear the immediate area of hazards, loosen
tight clothing, and note the exact time and characteristics of the seizure.
Q7: A provider orders diazepam 0.2 mg/kg IV for a child weighing 44 lbs who is in status
epilepticus. How many milligrams should the nurse administer? (Round to the nearest tenth.)
_______ mg
Correct Answer: 4
Rationale: Correct because the child's weight converts to 20 kg after dividing 44 pounds by 2.2,
and the dose is calculated as 0.2 mg/kg multiplied by 20 kg, yielding 4 mg total. Status
