,NUR254/NUR 254 Exam 4 | Maternal & Pediatric
1. A 6-year-old child with sickle cell disease is admitted with a vaso-occlusive crisis. Which nursing
intervention is the highest priority for this child?
A) Administering prophylactic antibiotics
B) Providing aggressive intravenous hydration
C) Restricting oral fluids to prevent fluid overload
D) Applying cold compresses to painful joints
Correct Answer: Providing aggressive intravenous hydration
Rationale: In a vaso-occlusive crisis, sickled cells block blood vessels, causing severe pain and tissue
ischemia. Aggressive intravenous hydration decreases blood viscosity and helps restore blood flow.
Pain control with opioids is also critical. Prophylactic antibiotics are important for infection prevention
but not the immediate priority during an acute crisis. Cold compresses can cause vasoconstriction and
worsen the crisis.
2. The nurse is caring for a child with leukemia who has a white blood cell count of 800 mm³. Which
action should the nurse include in the child's plan of care?
A) Administering a live influenza vaccination
B) Placing the child in a room with another immunocompromised child
C) Using sterile technique for all invasive procedures
D) Encouraging the child to play in the hospital playroom
Correct Answer: Using sterile technique for all invasive procedures
Rationale: A WBC count below 1,000 mm³ indicates severe neutropenia, placing the child at high risk
for life-threatening infections. Sterile technique for all procedures is essential to prevent pathogen
introduction. Live vaccines are contraindicated in severely immunocompromised children. The child
should be isolated from other children, especially those who may be ill.
3. The nurse is assessing a 4-year-old child who presents with a fever, a "strawberry tongue," and
bilateral conjunctival injection without exudate. Which condition should the nurse suspect?
,A) Scarlet fever
B) Kawasaki disease
C) Measles
D) Stevens-Johnson syndrome
Correct Answer: Kawasaki disease
Rationale: Kawasaki disease is an acute vasculitis of childhood characterized by fever lasting at least 5
days, bilateral conjunctival injection, erythematous cracked lips, and a strawberry tongue. Scarlet
fever also causes a strawberry tongue but typically presents with a sandpaper-like rash and exudative
pharyngitis. Measles presents with Koplik spots and a maculopapular rash.
4. The nurse is teaching the parents of a child with a new diagnosis of type 1 diabetes. Which
statement by the parents indicates a correct understanding of managing hypoglycemia?
A) We will give our child a glucagon injection for mild shakiness
B) We will treat hypoglycemia with 15 grams of fast-acting carbohydrates
C) We will withhold insulin for 24 hours after a hypoglycemic episode
D) We will encourage our child to drink regular soda and eat a candy bar
Correct Answer: We will treat hypoglycemia with 15 grams of fast-acting carbohydrates
Rationale: The standard treatment for mild to moderate hypoglycemia is the "Rule of 15": administer
15 grams of fast-acting carbohydrates (e.g., glucose tablets, 4 oz of juice), recheck blood glucose in 15
minutes, and repeat if needed. Glucagon is reserved for severe hypoglycemia with unconsciousness or
inability to swallow.
5. The nurse is caring for a child with asthma who is experiencing an acute exacerbation. The child's
oxygen saturation is 88% on room air. Which medication should the nurse administer first?
A) Inhaled corticosteroids
B) Oral prednisone
C) Albuterol via nebulizer
D) Montelukast
, Correct Answer: Albuterol via nebulizer
Rationale: In an acute asthma exacerbation, the priority is to rapidly reverse bronchospasm.
Albuterol, a short-acting beta-agonist, is the first-line rescue medication. Inhaled corticosteroids and
montelukast are controller medications used for long-term management, not acute relief. Oral
prednisone may be given for severe exacerbations but is not the first medication administered.
6. The nurse is assessing a 2-month-old infant who presents with a fever, poor feeding, and a bulging
fontanel. Which action should the nurse take first?
A) Administer acetaminophen for the fever
B) Obtain a urine culture
C) Prepare the infant for a lumbar puncture
D) Notify the healthcare provider immediately
Correct Answer: Notify the healthcare provider immediately
Rationale: A bulging fontanel in a febrile infant is a concerning sign that may indicate meningitis or
increased intracranial pressure. This requires immediate notification of the healthcare provider for
prompt evaluation and possible lumbar puncture. While acetaminophen may be given, it does not
address the underlying cause.
7. The nurse is providing education to a postpartum client who is Rh-negative and has just given birth
to an Rh-positive infant. Which statement by the client indicates understanding of the need for Rh
immune globulin?
A) This medication will prevent my baby from developing jaundice
B) This medication will prevent me from developing antibodies against future Rh-positive babies
C) This medication will treat my baby's anemia
D) This medication will prevent me from getting an infection
Correct Answer: This medication will prevent me from developing antibodies against future Rh-
positive babies
1. A 6-year-old child with sickle cell disease is admitted with a vaso-occlusive crisis. Which nursing
intervention is the highest priority for this child?
A) Administering prophylactic antibiotics
B) Providing aggressive intravenous hydration
C) Restricting oral fluids to prevent fluid overload
D) Applying cold compresses to painful joints
Correct Answer: Providing aggressive intravenous hydration
Rationale: In a vaso-occlusive crisis, sickled cells block blood vessels, causing severe pain and tissue
ischemia. Aggressive intravenous hydration decreases blood viscosity and helps restore blood flow.
Pain control with opioids is also critical. Prophylactic antibiotics are important for infection prevention
but not the immediate priority during an acute crisis. Cold compresses can cause vasoconstriction and
worsen the crisis.
2. The nurse is caring for a child with leukemia who has a white blood cell count of 800 mm³. Which
action should the nurse include in the child's plan of care?
A) Administering a live influenza vaccination
B) Placing the child in a room with another immunocompromised child
C) Using sterile technique for all invasive procedures
D) Encouraging the child to play in the hospital playroom
Correct Answer: Using sterile technique for all invasive procedures
Rationale: A WBC count below 1,000 mm³ indicates severe neutropenia, placing the child at high risk
for life-threatening infections. Sterile technique for all procedures is essential to prevent pathogen
introduction. Live vaccines are contraindicated in severely immunocompromised children. The child
should be isolated from other children, especially those who may be ill.
3. The nurse is assessing a 4-year-old child who presents with a fever, a "strawberry tongue," and
bilateral conjunctival injection without exudate. Which condition should the nurse suspect?
,A) Scarlet fever
B) Kawasaki disease
C) Measles
D) Stevens-Johnson syndrome
Correct Answer: Kawasaki disease
Rationale: Kawasaki disease is an acute vasculitis of childhood characterized by fever lasting at least 5
days, bilateral conjunctival injection, erythematous cracked lips, and a strawberry tongue. Scarlet
fever also causes a strawberry tongue but typically presents with a sandpaper-like rash and exudative
pharyngitis. Measles presents with Koplik spots and a maculopapular rash.
4. The nurse is teaching the parents of a child with a new diagnosis of type 1 diabetes. Which
statement by the parents indicates a correct understanding of managing hypoglycemia?
A) We will give our child a glucagon injection for mild shakiness
B) We will treat hypoglycemia with 15 grams of fast-acting carbohydrates
C) We will withhold insulin for 24 hours after a hypoglycemic episode
D) We will encourage our child to drink regular soda and eat a candy bar
Correct Answer: We will treat hypoglycemia with 15 grams of fast-acting carbohydrates
Rationale: The standard treatment for mild to moderate hypoglycemia is the "Rule of 15": administer
15 grams of fast-acting carbohydrates (e.g., glucose tablets, 4 oz of juice), recheck blood glucose in 15
minutes, and repeat if needed. Glucagon is reserved for severe hypoglycemia with unconsciousness or
inability to swallow.
5. The nurse is caring for a child with asthma who is experiencing an acute exacerbation. The child's
oxygen saturation is 88% on room air. Which medication should the nurse administer first?
A) Inhaled corticosteroids
B) Oral prednisone
C) Albuterol via nebulizer
D) Montelukast
, Correct Answer: Albuterol via nebulizer
Rationale: In an acute asthma exacerbation, the priority is to rapidly reverse bronchospasm.
Albuterol, a short-acting beta-agonist, is the first-line rescue medication. Inhaled corticosteroids and
montelukast are controller medications used for long-term management, not acute relief. Oral
prednisone may be given for severe exacerbations but is not the first medication administered.
6. The nurse is assessing a 2-month-old infant who presents with a fever, poor feeding, and a bulging
fontanel. Which action should the nurse take first?
A) Administer acetaminophen for the fever
B) Obtain a urine culture
C) Prepare the infant for a lumbar puncture
D) Notify the healthcare provider immediately
Correct Answer: Notify the healthcare provider immediately
Rationale: A bulging fontanel in a febrile infant is a concerning sign that may indicate meningitis or
increased intracranial pressure. This requires immediate notification of the healthcare provider for
prompt evaluation and possible lumbar puncture. While acetaminophen may be given, it does not
address the underlying cause.
7. The nurse is providing education to a postpartum client who is Rh-negative and has just given birth
to an Rh-positive infant. Which statement by the client indicates understanding of the need for Rh
immune globulin?
A) This medication will prevent my baby from developing jaundice
B) This medication will prevent me from developing antibodies against future Rh-positive babies
C) This medication will treat my baby's anemia
D) This medication will prevent me from getting an infection
Correct Answer: This medication will prevent me from developing antibodies against future Rh-
positive babies
