NURS 5130 Exam 1 V3 | NURS 5130
Comprehensive Assessment – Pediatric
Assessment Lab | Actual Q&A with
Rationale (NURS5130 Exam 1) | The
University of Texas at Arlington
1. When performing a physical examination on a 15-month-old toddler, which approach is
most appropriate to ensure cooperation?
A. Perform intrusive procedures, such as examining the ears and throat, last.
B. Perform the head-to-toe examination in a strict linear order.
C. Separate the child from the parent to prevent distractions.
D. Ask the child for permission before starting any part of the exam.
Answer: A
Rationale: Toddlers are often fearful of invasive or intrusive procedures that involve their
face or body orifices. By performing the examination of the ears and throat last, the nurse
builds rapport and minimizes the risk of the child becoming upset early in the process. This
approach is a standard pediatric assessment technique taught at UTA to ensure the most
accurate data collection.
2. A nurse is assessing a 4-month-old infant. Which fontanelle should the nurse expect to find
closed?
A. Anterior fontanelle
,B. Mastoid fontanelle
C. Sphenoid fontanelle
D. Posterior fontanelle
Answer: D
Rationale: The posterior fontanelle is typically much smaller than the anterior fontanelle
and closes by 2 to 3 months of age. In contrast, the anterior fontanelle remains open until
approximately 12 to 18 months of age to allow for brain growth. Accurate assessment of
fontanelles is critical for evaluating hydration status and intracranial pressure in infants.
3. The nurse is using the FLACC scale to assess pain in a non-verbal 2-year-old child. What
does the ‘C’ in FLACC represent?
A. Color
B. Cry
C. Comfort
D. Consolability
Answer: B
Rationale: The FLACC scale is a behavioral pain assessment tool used for children who
cannot verbally communicate their pain level. It evaluates five categories: Face, Legs,
Activity, Cry, and Consolability. Each category is scored from 0 to 2, providing a total score
that helps determine the intensity of the child’s pain.
, 4. During a pediatric assessment, the nurse notes that an infant’s weight has doubled since
birth. At what age does this typically occur?
A. 6 months
B. 2 months
C. 9 months
D. 12 months
Answer: A
Rationale: It is a general rule of pediatric growth that an infant’s birth weight doubles by
the age of 5 to 6 months. By 12 months of age, the birth weight is expected to have tripled.
Monitoring these milestones is essential for assessing nutritional status and overall
development in the clinical setting.
5. According to Erikson’s stages of psychosocial development, a preschooler (ages 3 to 6) is in
which stage?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Industry vs. Inferiority
D. Initiative vs. Guilt
Answer: D
Comprehensive Assessment – Pediatric
Assessment Lab | Actual Q&A with
Rationale (NURS5130 Exam 1) | The
University of Texas at Arlington
1. When performing a physical examination on a 15-month-old toddler, which approach is
most appropriate to ensure cooperation?
A. Perform intrusive procedures, such as examining the ears and throat, last.
B. Perform the head-to-toe examination in a strict linear order.
C. Separate the child from the parent to prevent distractions.
D. Ask the child for permission before starting any part of the exam.
Answer: A
Rationale: Toddlers are often fearful of invasive or intrusive procedures that involve their
face or body orifices. By performing the examination of the ears and throat last, the nurse
builds rapport and minimizes the risk of the child becoming upset early in the process. This
approach is a standard pediatric assessment technique taught at UTA to ensure the most
accurate data collection.
2. A nurse is assessing a 4-month-old infant. Which fontanelle should the nurse expect to find
closed?
A. Anterior fontanelle
,B. Mastoid fontanelle
C. Sphenoid fontanelle
D. Posterior fontanelle
Answer: D
Rationale: The posterior fontanelle is typically much smaller than the anterior fontanelle
and closes by 2 to 3 months of age. In contrast, the anterior fontanelle remains open until
approximately 12 to 18 months of age to allow for brain growth. Accurate assessment of
fontanelles is critical for evaluating hydration status and intracranial pressure in infants.
3. The nurse is using the FLACC scale to assess pain in a non-verbal 2-year-old child. What
does the ‘C’ in FLACC represent?
A. Color
B. Cry
C. Comfort
D. Consolability
Answer: B
Rationale: The FLACC scale is a behavioral pain assessment tool used for children who
cannot verbally communicate their pain level. It evaluates five categories: Face, Legs,
Activity, Cry, and Consolability. Each category is scored from 0 to 2, providing a total score
that helps determine the intensity of the child’s pain.
, 4. During a pediatric assessment, the nurse notes that an infant’s weight has doubled since
birth. At what age does this typically occur?
A. 6 months
B. 2 months
C. 9 months
D. 12 months
Answer: A
Rationale: It is a general rule of pediatric growth that an infant’s birth weight doubles by
the age of 5 to 6 months. By 12 months of age, the birth weight is expected to have tripled.
Monitoring these milestones is essential for assessing nutritional status and overall
development in the clinical setting.
5. According to Erikson’s stages of psychosocial development, a preschooler (ages 3 to 6) is in
which stage?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Industry vs. Inferiority
D. Initiative vs. Guilt
Answer: D
