NUR 254 EXAM 4 | NURSING 254
MATERNAL EXAM 4 EXAM QUESTIONS &
ANSWERS, EXPLAINED SOLUTIONS| 2026
Sickle Cell Anemia - ANSWER Nursing Care Management: Observe for
presence of inflammation or possible infection
Sickle Cell Anemia - ANSWER Nursing Care Management: Carefully monitor
for signs of shock
Sickle Cell Anemia - ANSWER Psychosocial Needs: Coping mechanisms,
Support with genetic counseling, Financial needs, Caregiver role strain, Living
with chronic illness in the family
Thalassemia - ANSWER Inherited blood disorders of Hgb synthesis
Thalassemia - ANSWER Classified by the Hgb chain affected and the amount
of effect
Thalassemia - ANSWER Autosomal recessive with varying expressivity
Thalassemia - ANSWER Both parents must be carriers to have offspring with
disease
, Thalassemia - ANSWER Anemia results from defective synthesis of Hgb,
structurally impaired RBCs, and shortened life of RBCs
Thalassemia - ANSWER Chronic hypoxia: Headache, irritability, precordial
and bone pain, exercise intolerance, anorexia, epistaxis
Thalassemia - ANSWER Detected in infancy or toddlerhood: Pallor, FTT,
hepatosplenomegaly, severe anemia (Hgb <6)
. The nurse is developing a plan of care for a child diagnosed with attention-deficit
hyperactivity disorder (ADHD). Which of the following pieces of information
should the nurse include in the plan of care? - ANSWER Psychostimulant
medications and behavior modification.
The nurse preceptor is observing a newly hired nurse care for a child who has
Down syndrome. Which of the following manifestations, if documented by the
newly hired nurse, requires follow-up by the nurse preceptor? -
ANSWER Protruding tongue
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? -
ANSWER Complete a neurological assessment.
The nurse working in the emergency department (ED) is caring for a 2-month-old
child who presents with intraocular bleeding, bradycardia, and bulging fontanels,
but no trauma to the head, face, or neck. Health history and physical examination is
incongruent, and abuse is suspected. Which of the following actions should the
nurse perform? - ANSWER Notify child protective services (CPS)
, 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? - ANSWER Checking pupil reaction every 4 hours
The nurse is assessing a child in a coma and notes that the child has decorticate
posturing. Which of the following findings should the nurse expect the child to
demonstrate? - ANSWER Rigid flexion with elbows, wrists and fingers flexed,
and legs extended and rotated inward
The nurse is admitting a toddler who is being hospitalized following a near-
drowning accident/submersion injury. The child's mother states to the nurse, "This
is unnecessary. My child seems perfectly fine." What is an appropriate response for
the nurse to provide to the mother? - ANSWER "Complications can still occur
with your child."
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? - ANSWER Remove any items from the crib that can harm the infant
The nurse is caring for an infant with a myelomeningocele sac. Which of the
following interventions demonstrates appropriate care for the infant? -
ANSWER Use latex-free medical products
The school nurse is instructing a school-age child who has diabetes mellitus (type
1). The child participates in soccer practice 3 afternoons a week. Which of the
following statements by the child indicates a correct understanding of how to
prevent hypoglycemia during practice? - ANSWER "I will eat a small box of
raisins or a cup of juice before soccer practice."
, The nurse is preparing discharge instructions for a child who has precocious
puberty. Which of the following should the nurse include in the teaching? -
ANSWER Explain the importance for the child to have peers of the same age
The nurse is teaching a 10-year-old child and the parents about scoliosis and
treatment options. Which of the following should the nurse include when teaching
about scoliosis? - ANSWER Use of a brace will slow the progression of
scoliosis for most clients.
The nurse is caring for a 12-year-old child who has acute osteomyelitis in the right
foot. The child's parents ask the nurse if the child can go to the activity room.
Which of the following responses should the nurse reply to the parents? -
ANSWER "Let me get a wheelchair for your child to help keep the foot
supported
The nurse working in a community clinic is teaching the mother of an infant who
was recently diagnosed with congenital hypothyroidism. Which of the following
instructions should the nurse give the mother about the administration of
prescribed levothyroxine? - ANSWER "Give the medication one hour after a
feeding."
The nurse is preparing to teach a parent about how to care for a child who has
impetigo contagiosa. Which of the following should the nurse include in the
teaching plan? - ANSWER Apply bactericidal ointment to lesions
The nurse working in a clinic is instructing the parent of a child who has atopic
dermatitis (eczema) about the administration of a prescribed topical corticosteroid.
When instructing the parent about how to apply the cream, it is appropriate for the
MATERNAL EXAM 4 EXAM QUESTIONS &
ANSWERS, EXPLAINED SOLUTIONS| 2026
Sickle Cell Anemia - ANSWER Nursing Care Management: Observe for
presence of inflammation or possible infection
Sickle Cell Anemia - ANSWER Nursing Care Management: Carefully monitor
for signs of shock
Sickle Cell Anemia - ANSWER Psychosocial Needs: Coping mechanisms,
Support with genetic counseling, Financial needs, Caregiver role strain, Living
with chronic illness in the family
Thalassemia - ANSWER Inherited blood disorders of Hgb synthesis
Thalassemia - ANSWER Classified by the Hgb chain affected and the amount
of effect
Thalassemia - ANSWER Autosomal recessive with varying expressivity
Thalassemia - ANSWER Both parents must be carriers to have offspring with
disease
, Thalassemia - ANSWER Anemia results from defective synthesis of Hgb,
structurally impaired RBCs, and shortened life of RBCs
Thalassemia - ANSWER Chronic hypoxia: Headache, irritability, precordial
and bone pain, exercise intolerance, anorexia, epistaxis
Thalassemia - ANSWER Detected in infancy or toddlerhood: Pallor, FTT,
hepatosplenomegaly, severe anemia (Hgb <6)
. The nurse is developing a plan of care for a child diagnosed with attention-deficit
hyperactivity disorder (ADHD). Which of the following pieces of information
should the nurse include in the plan of care? - ANSWER Psychostimulant
medications and behavior modification.
The nurse preceptor is observing a newly hired nurse care for a child who has
Down syndrome. Which of the following manifestations, if documented by the
newly hired nurse, requires follow-up by the nurse preceptor? -
ANSWER Protruding tongue
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? -
ANSWER Complete a neurological assessment.
The nurse working in the emergency department (ED) is caring for a 2-month-old
child who presents with intraocular bleeding, bradycardia, and bulging fontanels,
but no trauma to the head, face, or neck. Health history and physical examination is
incongruent, and abuse is suspected. Which of the following actions should the
nurse perform? - ANSWER Notify child protective services (CPS)
, 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? - ANSWER Checking pupil reaction every 4 hours
The nurse is assessing a child in a coma and notes that the child has decorticate
posturing. Which of the following findings should the nurse expect the child to
demonstrate? - ANSWER Rigid flexion with elbows, wrists and fingers flexed,
and legs extended and rotated inward
The nurse is admitting a toddler who is being hospitalized following a near-
drowning accident/submersion injury. The child's mother states to the nurse, "This
is unnecessary. My child seems perfectly fine." What is an appropriate response for
the nurse to provide to the mother? - ANSWER "Complications can still occur
with your child."
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? - ANSWER Remove any items from the crib that can harm the infant
The nurse is caring for an infant with a myelomeningocele sac. Which of the
following interventions demonstrates appropriate care for the infant? -
ANSWER Use latex-free medical products
The school nurse is instructing a school-age child who has diabetes mellitus (type
1). The child participates in soccer practice 3 afternoons a week. Which of the
following statements by the child indicates a correct understanding of how to
prevent hypoglycemia during practice? - ANSWER "I will eat a small box of
raisins or a cup of juice before soccer practice."
, The nurse is preparing discharge instructions for a child who has precocious
puberty. Which of the following should the nurse include in the teaching? -
ANSWER Explain the importance for the child to have peers of the same age
The nurse is teaching a 10-year-old child and the parents about scoliosis and
treatment options. Which of the following should the nurse include when teaching
about scoliosis? - ANSWER Use of a brace will slow the progression of
scoliosis for most clients.
The nurse is caring for a 12-year-old child who has acute osteomyelitis in the right
foot. The child's parents ask the nurse if the child can go to the activity room.
Which of the following responses should the nurse reply to the parents? -
ANSWER "Let me get a wheelchair for your child to help keep the foot
supported
The nurse working in a community clinic is teaching the mother of an infant who
was recently diagnosed with congenital hypothyroidism. Which of the following
instructions should the nurse give the mother about the administration of
prescribed levothyroxine? - ANSWER "Give the medication one hour after a
feeding."
The nurse is preparing to teach a parent about how to care for a child who has
impetigo contagiosa. Which of the following should the nurse include in the
teaching plan? - ANSWER Apply bactericidal ointment to lesions
The nurse working in a clinic is instructing the parent of a child who has atopic
dermatitis (eczema) about the administration of a prescribed topical corticosteroid.
When instructing the parent about how to apply the cream, it is appropriate for the
