PEDS EXAM #3
Which of the following phrases describes a characteristic of most neonatal seizures?
A. Generalized seizure
B. Tonic-clonic seizure
C. Well-organized seizure
D. Subtle and barely discernible seizure - ANS D. Subtle and barely discernible seizure
Signs of seizures in newborns are subtle. They include symptoms such as lip smacking,
tongue thrusting, eye rolling, and arching of the back.
The newborn's central nervous system is not sufficiently developed to maintain a
generalized seizure.
The newborn's central nervous system is not sufficiently developed to maintain a
tonic-clonic (generalized) seizure.
The newborn's central nervous system is not sufficiently developed to maintain a
well-organized seizure.
What is a clinical manifestation of increased intracranial pressure (ICP) in infants?
A. Shrill, high-pitched cry
B. Photophobia
C. Pulsating anterior fontanel
D. Vomiting and diarrhea - ANS A. Shrill, high-pitched cry
A shrill, high-pitched cry is a common clinical manifestation of increased ICP in infants.
The characteristic cry occurs secondary to the pressure being placed on the meningeal
nerves, causing pain.
Photophobia is not indicative of increased ICP in infants.
A pulsating anterior fontanel is normal in infants. The infant with increased ICP would be
seen with a bulging anterior fontanel.
Vomiting is one of the signs of increased ICP in children, but when present with
diarrhea, it is more indicative of a gastrointestinal disturbance.
The nurse is doing a neurologic assessment on a child whose level of consciousness
has been variable since sustaining a cervical neck injury 12 hours ago. What is the
priority assessment for this child?
A. Reactivity of pupils
B. Doll's head maneuver
C. Oculovestibular response
D. Funduscopic examination to identify papilledema - ANS A. Reactivity of pupils
Pupil reactivity is an important indication of neurologic health. The pupils should be
assessed for no reaction, unilateral reaction, and rate of reactivity.
, The doll's head maneuver should not be performed if there is a cervical spine injury.
Assessing for an oculovestibular response is a painful test that should not be done for a
child who is having variable levels of consciousness.
Papilledema does not develop for 24 to 48 hours in the course of unconsciousness.
The nurse is performing a neurologic assessment of a 2-month-old infant after a car
accident. Moro, tonic neck, and withdrawal reflexes are present. The nurse should
recognize that these reflexes suggest
A. neurologic health
B. severe brain damage
C. decorticate posturing
D. decerebrate posturing - ANS A. neurologic health
The Moro, tonic neck, and withdrawal reflexes are usually present in infants under 3 to 4
months of age. Therefore, the presence of these reflexes indicates neurologic health.
The presence of the Moro, tonic neck, and withdrawal reflexes does not indicate severe
brain damage.
Decorticate posturing is indicative of severe dysfunction of the cerebral cortex and is not
related to the presence of the Moro, tonic neck, or withdrawal reflexes.
Decerebrate posturing is indicative of dysfunction at the level of the midbrain and is not
related to the presence of the Moro, tonic neck, or withdrawal reflexes.
The temperature of an unconscious adolescent is 105º F (40.5º C). The priority nursing
intervention is to
A. continue to monitor temperature.
B. initiate a pain assessment.
C. apply a hypothermia blanket.
D. administer aspirin stat. - ANS C. apply a hypothermia blanket.
Brain damage can occur at temperatures as high as 105º F (40.5º C). It is extremely
important to institute temperature-lowering interventions such as hypothermia blankets
and tepid water baths immediately.
The temperature needs to be monitored, but lowering the temperature is the priority.
Pain assessments should be ongoing, but this is not the priority at this time. Lowering
the body temperature is the priority.
Aspirin should never be administered to a child, because of the risk of Reye syndrome.
Antipyretics, such as acetaminophen or ibuprofen, usually are not effective with
temperatures as high as 105º F (40. 5ºC).
The nurse is caring for a comatose child with multiple injuries. The nurse should
recognize that pain
A. cannot occur if the child is comatose.
Which of the following phrases describes a characteristic of most neonatal seizures?
A. Generalized seizure
B. Tonic-clonic seizure
C. Well-organized seizure
D. Subtle and barely discernible seizure - ANS D. Subtle and barely discernible seizure
Signs of seizures in newborns are subtle. They include symptoms such as lip smacking,
tongue thrusting, eye rolling, and arching of the back.
The newborn's central nervous system is not sufficiently developed to maintain a
generalized seizure.
The newborn's central nervous system is not sufficiently developed to maintain a
tonic-clonic (generalized) seizure.
The newborn's central nervous system is not sufficiently developed to maintain a
well-organized seizure.
What is a clinical manifestation of increased intracranial pressure (ICP) in infants?
A. Shrill, high-pitched cry
B. Photophobia
C. Pulsating anterior fontanel
D. Vomiting and diarrhea - ANS A. Shrill, high-pitched cry
A shrill, high-pitched cry is a common clinical manifestation of increased ICP in infants.
The characteristic cry occurs secondary to the pressure being placed on the meningeal
nerves, causing pain.
Photophobia is not indicative of increased ICP in infants.
A pulsating anterior fontanel is normal in infants. The infant with increased ICP would be
seen with a bulging anterior fontanel.
Vomiting is one of the signs of increased ICP in children, but when present with
diarrhea, it is more indicative of a gastrointestinal disturbance.
The nurse is doing a neurologic assessment on a child whose level of consciousness
has been variable since sustaining a cervical neck injury 12 hours ago. What is the
priority assessment for this child?
A. Reactivity of pupils
B. Doll's head maneuver
C. Oculovestibular response
D. Funduscopic examination to identify papilledema - ANS A. Reactivity of pupils
Pupil reactivity is an important indication of neurologic health. The pupils should be
assessed for no reaction, unilateral reaction, and rate of reactivity.
, The doll's head maneuver should not be performed if there is a cervical spine injury.
Assessing for an oculovestibular response is a painful test that should not be done for a
child who is having variable levels of consciousness.
Papilledema does not develop for 24 to 48 hours in the course of unconsciousness.
The nurse is performing a neurologic assessment of a 2-month-old infant after a car
accident. Moro, tonic neck, and withdrawal reflexes are present. The nurse should
recognize that these reflexes suggest
A. neurologic health
B. severe brain damage
C. decorticate posturing
D. decerebrate posturing - ANS A. neurologic health
The Moro, tonic neck, and withdrawal reflexes are usually present in infants under 3 to 4
months of age. Therefore, the presence of these reflexes indicates neurologic health.
The presence of the Moro, tonic neck, and withdrawal reflexes does not indicate severe
brain damage.
Decorticate posturing is indicative of severe dysfunction of the cerebral cortex and is not
related to the presence of the Moro, tonic neck, or withdrawal reflexes.
Decerebrate posturing is indicative of dysfunction at the level of the midbrain and is not
related to the presence of the Moro, tonic neck, or withdrawal reflexes.
The temperature of an unconscious adolescent is 105º F (40.5º C). The priority nursing
intervention is to
A. continue to monitor temperature.
B. initiate a pain assessment.
C. apply a hypothermia blanket.
D. administer aspirin stat. - ANS C. apply a hypothermia blanket.
Brain damage can occur at temperatures as high as 105º F (40.5º C). It is extremely
important to institute temperature-lowering interventions such as hypothermia blankets
and tepid water baths immediately.
The temperature needs to be monitored, but lowering the temperature is the priority.
Pain assessments should be ongoing, but this is not the priority at this time. Lowering
the body temperature is the priority.
Aspirin should never be administered to a child, because of the risk of Reye syndrome.
Antipyretics, such as acetaminophen or ibuprofen, usually are not effective with
temperatures as high as 105º F (40. 5ºC).
The nurse is caring for a comatose child with multiple injuries. The nurse should
recognize that pain
A. cannot occur if the child is comatose.
