NURS 230 Maternal Exam 4: NURS 230 Exam 4: NUR 230
Pediatric and Maternity Nursing Final Exam Study Guide:
150 Questions & Answers
Batch 1 (Questions 1–50)
Question 1
The nurse is presenting information about attention-deficit/hyperactivity disorder
(ADHD) at a school-parent association meeting. Which of the following clinical
manifestations should the nurse include in the presentation?
• a. Completes projects quickly.
• b. Prefers detailed tasks.
• c. Refrains from volunteering.
• d. Grabs items from others without thinking.
• Correct Answer: d
• Rationale: ADHD is characterized by developmentally inappropriate
degrees of inattention, hyperactivity, and impulsiveness. A key symptom of
impulsivity is acting on a whim or having difficulty waiting one's turn, such
as grabbing items from others without thinking.
Question 2
The nurse is caring for an infant who is having an active seizure. Which of the
following actions should the nurse perform when caring for the infant during a
seizure?
• a. Place the infant in the prone position inside the crib.
• b. Suction any secretions out of the infant's mouth.
• c. Swaddle the infant to keep them warm and safe.
• d. Remove any items out of the crib that can harm the infant.
• Correct Answer: d
• Rationale: During an active seizure, the nurse's absolute priority is safety.
This includes clearing the immediate environment and removing any objects
or hazardous items away from the child to prevent physical injury. Putting
objects, pacifiers, or suction tubing into the mouth is strictly contraindicated
during a seizure.
Question 3
,The nurse is screening infants for signs of cerebral palsy (CP). Which findings
from the box below should the nurse recognize as early signs of cerebral palsy?
1. Poor head control after 1 month.
2. Feeding difficulties.
3. Failure to smile by 2 months.
4. Persistent Moro reflex.
5. Rigid arms or legs.
a. 1, 2, 3, 5
b. 3, 4, 5
c. 1, 2, 5
d. 2, 4, 5
Correct Answer: a (or the combination of 1, 2, 3, 5 based on options)
Rationale: Early clinical manifestations of cerebral palsy include delayed
developmental milestones, such as poor head control after 3 months (or noted
abnormally early/late), rigid or stiff limbs, failure to smile by 3 months (or 2
months on the exam), persistent primitive reflexes (such as the Moro or startle
reflex), and feeding difficulties (e.g., tongue thrusting, choking, or swallowing
issues).
Question 4
The nurse is admitting a toddler who is being hospitalized following a near-
drowning accident/submersion injury. The toddler is spontaneously breathing but
is unconscious. Which of the following actions should the nurse perform first?
• a. Administer oxygen via face mask.
• b. Implement seizure precautions.
• c. Notify spiritual advisor of parents' choice.
• d. Obtain arterial blood gases (ABGs).
• Correct Answer: a
• Rationale: Submersion injuries cause hypoxia due to lack of oxygen. The
primary and immediate priority in managing a near-drowning victim is to
restore oxygen delivery to the brain and tissues to prevent irreversible
cerebral damage.
,Question 5
The nurse is assessing a 6-year-old child for manifestations of autism spectrum
disorder (ASD). Which of the following manifestations should the nurse expect to
observe in this child?
• a. Continuous eye contact.
• b. Increased imitation of others.
• c. Interest in various activities.
• d. Verbal development delay.
Correct Answer: d
Rationale: Key diagnostic features of autism spectrum disorder (ASD)
include impairments in social communication and social interaction,
alongside highly restricted, repetitive behaviors. Children with ASD display
abnormal or absent eye contact and exhibit delayed verbal and language
development.
Question 6
The nurse is caring for a child who has increased intracranial pressure (ICP) and is
in stable condition. Which of the following interventions should the nurse
implement to decrease ICP in the child?
• a. Increase the number of visitors inside the child's room.
• b. Administer hypotonic intravenous (IV) fluids.
• c. Keep the child positioned midline on the bed.
• d. Administer opioids for pain control.
Correct Answer: c
Rationale: To facilitate venous drainage and lower ICP, the child's head
should be elevated 15 to 30 degrees and maintained in a midline position
to prevent jugular venous obstruction. Hypotonic fluids must be avoided
because they pull water into brain cells, worsening cerebral edema and
increasing swelling.
Question 7
, The nurse is caring for a child who had a ventricular shunt placement 24 hours ago.
The child is sitting up in bed crying and has vomited a small amount on the bed
linens. Which of the following actions should the nurse take first?
• a. Perform a neurologic assessment.
• b. Obtain a complete metabolic panel (CMP) specimen.
• c. Comfort the child while the linens are changed.
• d. Inspect the incision site for infection.
Correct Answer: a
Rationale: Crying and vomiting after a ventriculoperitoneal (VP) shunt
placement are prime indicators of increased ICP, which suggests a shunt
malfunction. When a patient with a VP shunt experiences nausea and
vomiting, the nurse must first assess the child's Level of Consciousness
(LOC).
Question 8
The nurse is caring for a child who is hospitalized for 24-hour observation
following a head injury. Which of the following actions by the nurse is the
priority?
• a. Assess for neck stiffness.
• b. Lower the television sound.
• c. Checking pupil reaction every 4 hours.
• d. Restrict visitation to 1 person at a time.
Correct Answer: c
Rationale: Following a head injury, frequent neurological assessments (such
as checking pupil size, reactivity, and level of consciousness) are vital to
monitor for worsening conditions, such as epidural or subdural hematomas.
Neuro checks must be performed routinely (even if it requires waking the
child) to identify early signs of brain herniation or swelling.
Question 9
The nurse is assessing a child who is in a coma and notes decorticate posturing.
Which of the following findings should the nurse expect the child to demonstrate?
Pediatric and Maternity Nursing Final Exam Study Guide:
150 Questions & Answers
Batch 1 (Questions 1–50)
Question 1
The nurse is presenting information about attention-deficit/hyperactivity disorder
(ADHD) at a school-parent association meeting. Which of the following clinical
manifestations should the nurse include in the presentation?
• a. Completes projects quickly.
• b. Prefers detailed tasks.
• c. Refrains from volunteering.
• d. Grabs items from others without thinking.
• Correct Answer: d
• Rationale: ADHD is characterized by developmentally inappropriate
degrees of inattention, hyperactivity, and impulsiveness. A key symptom of
impulsivity is acting on a whim or having difficulty waiting one's turn, such
as grabbing items from others without thinking.
Question 2
The nurse is caring for an infant who is having an active seizure. Which of the
following actions should the nurse perform when caring for the infant during a
seizure?
• a. Place the infant in the prone position inside the crib.
• b. Suction any secretions out of the infant's mouth.
• c. Swaddle the infant to keep them warm and safe.
• d. Remove any items out of the crib that can harm the infant.
• Correct Answer: d
• Rationale: During an active seizure, the nurse's absolute priority is safety.
This includes clearing the immediate environment and removing any objects
or hazardous items away from the child to prevent physical injury. Putting
objects, pacifiers, or suction tubing into the mouth is strictly contraindicated
during a seizure.
Question 3
,The nurse is screening infants for signs of cerebral palsy (CP). Which findings
from the box below should the nurse recognize as early signs of cerebral palsy?
1. Poor head control after 1 month.
2. Feeding difficulties.
3. Failure to smile by 2 months.
4. Persistent Moro reflex.
5. Rigid arms or legs.
a. 1, 2, 3, 5
b. 3, 4, 5
c. 1, 2, 5
d. 2, 4, 5
Correct Answer: a (or the combination of 1, 2, 3, 5 based on options)
Rationale: Early clinical manifestations of cerebral palsy include delayed
developmental milestones, such as poor head control after 3 months (or noted
abnormally early/late), rigid or stiff limbs, failure to smile by 3 months (or 2
months on the exam), persistent primitive reflexes (such as the Moro or startle
reflex), and feeding difficulties (e.g., tongue thrusting, choking, or swallowing
issues).
Question 4
The nurse is admitting a toddler who is being hospitalized following a near-
drowning accident/submersion injury. The toddler is spontaneously breathing but
is unconscious. Which of the following actions should the nurse perform first?
• a. Administer oxygen via face mask.
• b. Implement seizure precautions.
• c. Notify spiritual advisor of parents' choice.
• d. Obtain arterial blood gases (ABGs).
• Correct Answer: a
• Rationale: Submersion injuries cause hypoxia due to lack of oxygen. The
primary and immediate priority in managing a near-drowning victim is to
restore oxygen delivery to the brain and tissues to prevent irreversible
cerebral damage.
,Question 5
The nurse is assessing a 6-year-old child for manifestations of autism spectrum
disorder (ASD). Which of the following manifestations should the nurse expect to
observe in this child?
• a. Continuous eye contact.
• b. Increased imitation of others.
• c. Interest in various activities.
• d. Verbal development delay.
Correct Answer: d
Rationale: Key diagnostic features of autism spectrum disorder (ASD)
include impairments in social communication and social interaction,
alongside highly restricted, repetitive behaviors. Children with ASD display
abnormal or absent eye contact and exhibit delayed verbal and language
development.
Question 6
The nurse is caring for a child who has increased intracranial pressure (ICP) and is
in stable condition. Which of the following interventions should the nurse
implement to decrease ICP in the child?
• a. Increase the number of visitors inside the child's room.
• b. Administer hypotonic intravenous (IV) fluids.
• c. Keep the child positioned midline on the bed.
• d. Administer opioids for pain control.
Correct Answer: c
Rationale: To facilitate venous drainage and lower ICP, the child's head
should be elevated 15 to 30 degrees and maintained in a midline position
to prevent jugular venous obstruction. Hypotonic fluids must be avoided
because they pull water into brain cells, worsening cerebral edema and
increasing swelling.
Question 7
, The nurse is caring for a child who had a ventricular shunt placement 24 hours ago.
The child is sitting up in bed crying and has vomited a small amount on the bed
linens. Which of the following actions should the nurse take first?
• a. Perform a neurologic assessment.
• b. Obtain a complete metabolic panel (CMP) specimen.
• c. Comfort the child while the linens are changed.
• d. Inspect the incision site for infection.
Correct Answer: a
Rationale: Crying and vomiting after a ventriculoperitoneal (VP) shunt
placement are prime indicators of increased ICP, which suggests a shunt
malfunction. When a patient with a VP shunt experiences nausea and
vomiting, the nurse must first assess the child's Level of Consciousness
(LOC).
Question 8
The nurse is caring for a child who is hospitalized for 24-hour observation
following a head injury. Which of the following actions by the nurse is the
priority?
• a. Assess for neck stiffness.
• b. Lower the television sound.
• c. Checking pupil reaction every 4 hours.
• d. Restrict visitation to 1 person at a time.
Correct Answer: c
Rationale: Following a head injury, frequent neurological assessments (such
as checking pupil size, reactivity, and level of consciousness) are vital to
monitor for worsening conditions, such as epidural or subdural hematomas.
Neuro checks must be performed routinely (even if it requires waking the
child) to identify early signs of brain herniation or swelling.
Question 9
The nurse is assessing a child who is in a coma and notes decorticate posturing.
Which of the following findings should the nurse expect the child to demonstrate?
