NURS 5130 Final Exam V3 | NURS 5130
Comprehensive Assessment – Pediatric
Assessment Lab | Actual Q&A with
Rationale (NURS5130 Final Exam) | The
University of Texas at Arlington
1. A nurse is assessing a 2-month-old infant during a well-child visit. Which developmental
milestone is considered age-appropriate for this infant?
A. Rolling from back to front
B. Coos and makes gurgling sounds
C. Reaching for a rattle
D. Sitting with support
Answer: B
Rationale: At 2 months of age, infants typically begin to coo and demonstrate social smiles.
Reaching for objects and rolling usually occur between 4 and 6 months. Nurses must
recognize these early vocalizations as critical markers of neurological and social
development.
2. During a physical examination of a 4-month-old, the nurse notes the posterior fontanelle is
closed. How should the nurse interpret this finding?
A. This is a sign of premature craniosynostosis
,B. This is a normal finding for this age
C. The infant is likely dehydrated
D. This indicates increased intracranial pressure
Answer: B
Rationale: The posterior fontanelle typically closes by 2 to 3 months of age. In contrast, the
anterior fontanelle remains open until approximately 12 to 18 months. Identifying normal
closure patterns helps the clinician differentiate between typical growth and pathological
cranial conditions.
3. When performing a physical assessment on a toddler, in which order should the nurse
perform the following actions?
A. Ears, throat, heart, lungs
B. Head to toe, starting with the eyes
C. Auscultate heart and lungs while quiet, then invasive procedures like ears
D. Blood pressure, temperature, heart rate
Answer: C
Rationale: To ensure accuracy and minimize distress, the nurse should assess the least
invasive systems first while the toddler is calm. Procedures that are perceived as intrusive,
such as examining the ears or throat, should be saved for the end of the exam. This
,approach fosters cooperation and allows for more reliable auscultation of heart and lung
sounds.
4. An adolescent male is evaluated for pubertal development. The nurse notes the
enlargement of the scrotum and testes, but no enlargement of the penis. Which Tanner stage
does this represent?
A. Stage 1
B. Stage 3
C. Stage 2
D. Stage 4
Answer: C
Rationale: Tanner Stage 2 in males is characterized by the initial enlargement of the
scrotum and testes, along with changes in scrotal skin texture. Penis enlargement typically
does not begin until Stage 3. Proper staging is essential for tracking normal physiological
maturation during the adolescent physical exam.
5. A 10-month-old infant is observed using the thumb and forefinger to pick up a small piece
of cereal. How should the nurse document this fine motor skill?
A. Palmar grasp
B. Neat pincer grasp
C. Raking motion
, D. Reflexive grasp
Answer: B
Rationale: The neat pincer grasp involves using the tips of the thumb and forefinger and is
a significant milestone around 9 to 10 months of age. Earlier infants use a raking motion or
a crude pincer grasp involving the pads of the fingers. This development indicates
advancing coordination and neurological maturity in the infant.
6. While assessing a 3-year-old child, the nurse notes a loud, harsh murmur heard best at the
left lower sternal border. The child is asymptomatic. What is the most likely cause?
A. Coarctation of the aorta
B. Ventricular septal defect (VSD)
C. Tetralogy of Fallot
D. Patent ductus arteriosus (PDA)
Answer: B
Rationale: A ventricular septal defect typically presents as a pansystolic or holosystolic
murmur heard most clearly at the left lower sternal border. While many VSDs are
asymptomatic if small, they represent a common congenital heart finding in pediatric
assessments. The nurse must distinguish this from other defects, such as a PDA which
features a continuous machinery-like murmur.
Comprehensive Assessment – Pediatric
Assessment Lab | Actual Q&A with
Rationale (NURS5130 Final Exam) | The
University of Texas at Arlington
1. A nurse is assessing a 2-month-old infant during a well-child visit. Which developmental
milestone is considered age-appropriate for this infant?
A. Rolling from back to front
B. Coos and makes gurgling sounds
C. Reaching for a rattle
D. Sitting with support
Answer: B
Rationale: At 2 months of age, infants typically begin to coo and demonstrate social smiles.
Reaching for objects and rolling usually occur between 4 and 6 months. Nurses must
recognize these early vocalizations as critical markers of neurological and social
development.
2. During a physical examination of a 4-month-old, the nurse notes the posterior fontanelle is
closed. How should the nurse interpret this finding?
A. This is a sign of premature craniosynostosis
,B. This is a normal finding for this age
C. The infant is likely dehydrated
D. This indicates increased intracranial pressure
Answer: B
Rationale: The posterior fontanelle typically closes by 2 to 3 months of age. In contrast, the
anterior fontanelle remains open until approximately 12 to 18 months. Identifying normal
closure patterns helps the clinician differentiate between typical growth and pathological
cranial conditions.
3. When performing a physical assessment on a toddler, in which order should the nurse
perform the following actions?
A. Ears, throat, heart, lungs
B. Head to toe, starting with the eyes
C. Auscultate heart and lungs while quiet, then invasive procedures like ears
D. Blood pressure, temperature, heart rate
Answer: C
Rationale: To ensure accuracy and minimize distress, the nurse should assess the least
invasive systems first while the toddler is calm. Procedures that are perceived as intrusive,
such as examining the ears or throat, should be saved for the end of the exam. This
,approach fosters cooperation and allows for more reliable auscultation of heart and lung
sounds.
4. An adolescent male is evaluated for pubertal development. The nurse notes the
enlargement of the scrotum and testes, but no enlargement of the penis. Which Tanner stage
does this represent?
A. Stage 1
B. Stage 3
C. Stage 2
D. Stage 4
Answer: C
Rationale: Tanner Stage 2 in males is characterized by the initial enlargement of the
scrotum and testes, along with changes in scrotal skin texture. Penis enlargement typically
does not begin until Stage 3. Proper staging is essential for tracking normal physiological
maturation during the adolescent physical exam.
5. A 10-month-old infant is observed using the thumb and forefinger to pick up a small piece
of cereal. How should the nurse document this fine motor skill?
A. Palmar grasp
B. Neat pincer grasp
C. Raking motion
, D. Reflexive grasp
Answer: B
Rationale: The neat pincer grasp involves using the tips of the thumb and forefinger and is
a significant milestone around 9 to 10 months of age. Earlier infants use a raking motion or
a crude pincer grasp involving the pads of the fingers. This development indicates
advancing coordination and neurological maturity in the infant.
6. While assessing a 3-year-old child, the nurse notes a loud, harsh murmur heard best at the
left lower sternal border. The child is asymptomatic. What is the most likely cause?
A. Coarctation of the aorta
B. Ventricular septal defect (VSD)
C. Tetralogy of Fallot
D. Patent ductus arteriosus (PDA)
Answer: B
Rationale: A ventricular septal defect typically presents as a pansystolic or holosystolic
murmur heard most clearly at the left lower sternal border. While many VSDs are
asymptomatic if small, they represent a common congenital heart finding in pediatric
assessments. The nurse must distinguish this from other defects, such as a PDA which
features a continuous machinery-like murmur.
