NURS 5130 Exam 4 V2 | NURS 5130
Comprehensive Assessment – Pediatric
Assessment Lab | Actual Q&A with
Rationale (NURS5130 Exam 4) | The
University of Texas at Arlington
1. Which developmental milestone is typically achieved by a 4-month-old infant during a
physical assessment?
A. Sitting up without support
B. Walking with assistance
C. Pincer grasp development
D. Rolling from back to side
Answer: D
Rationale: At 4 months, an infant typically begins to roll from their back to their side as
gross motor skills develop. Sitting without support is expected around 6 to 8 months. A
pincer grasp and walking occur much later in the first year of life.
2. When assessing a 2-year-old child’s ear with an otoscope, how should the nurse position
the pinna?
A. Up and back
B. Straight back
,C. Down and back
D. Down and forward
Answer: C
Rationale: For children under the age of 3, the nurse must pull the pinna down and back to
straighten the external ear canal. This anatomical adjustment is necessary because the
canal is shorter and straighter than in adults. Pulling up and back is the technique reserved
for children older than 3 and adults.
3. Which pain scale is most appropriate for a nurse to use when assessing a non-verbal 6-
month-old infant?
A. Wong-Baker FACES scale
B. Numerical Rating Scale (0-10)
C. Visual Analog Scale
D. FLACC Scale
Answer: D
Rationale: The FLACC scale assesses Face, Legs, Activity, Cry, and Consolability, making it
ideal for infants who cannot communicate pain. The Wong-Baker FACES scale is generally
used for children aged 3 and older who can point to a face. Numerical and Visual Analog
scales require cognitive levels not present in infancy.
, 4. The nurse notes a ‘strawberry tongue’ during a physical examination of a child. Which
condition should the nurse suspect?
A. Measles (Rubeola)
B. Oral Candidiasis
C. Diphtheria
D. Kawasaki Disease
Answer: D
Rationale: A strawberry tongue is a classic clinical manifestation of Kawasaki Disease,
which involves systemic vasculitis. It may also be seen in scarlet fever, but is a hallmark
sign in the diagnostic criteria for Kawasaki. Prompt recognition is critical to initiate IVIG
treatment and prevent coronary artery aneurysms.
5. What is the expected age for the closure of the anterior fontanelle in a healthy infant?
A. 2 to 3 months
B. 6 to 8 months
C. 24 to 30 months
D. 12 to 18 months
Answer: D
Rationale: The anterior fontanelle typically closes between 12 and 18 months of age.
Premature closure can indicate craniosynostosis, while delayed closure may suggest
Comprehensive Assessment – Pediatric
Assessment Lab | Actual Q&A with
Rationale (NURS5130 Exam 4) | The
University of Texas at Arlington
1. Which developmental milestone is typically achieved by a 4-month-old infant during a
physical assessment?
A. Sitting up without support
B. Walking with assistance
C. Pincer grasp development
D. Rolling from back to side
Answer: D
Rationale: At 4 months, an infant typically begins to roll from their back to their side as
gross motor skills develop. Sitting without support is expected around 6 to 8 months. A
pincer grasp and walking occur much later in the first year of life.
2. When assessing a 2-year-old child’s ear with an otoscope, how should the nurse position
the pinna?
A. Up and back
B. Straight back
,C. Down and back
D. Down and forward
Answer: C
Rationale: For children under the age of 3, the nurse must pull the pinna down and back to
straighten the external ear canal. This anatomical adjustment is necessary because the
canal is shorter and straighter than in adults. Pulling up and back is the technique reserved
for children older than 3 and adults.
3. Which pain scale is most appropriate for a nurse to use when assessing a non-verbal 6-
month-old infant?
A. Wong-Baker FACES scale
B. Numerical Rating Scale (0-10)
C. Visual Analog Scale
D. FLACC Scale
Answer: D
Rationale: The FLACC scale assesses Face, Legs, Activity, Cry, and Consolability, making it
ideal for infants who cannot communicate pain. The Wong-Baker FACES scale is generally
used for children aged 3 and older who can point to a face. Numerical and Visual Analog
scales require cognitive levels not present in infancy.
, 4. The nurse notes a ‘strawberry tongue’ during a physical examination of a child. Which
condition should the nurse suspect?
A. Measles (Rubeola)
B. Oral Candidiasis
C. Diphtheria
D. Kawasaki Disease
Answer: D
Rationale: A strawberry tongue is a classic clinical manifestation of Kawasaki Disease,
which involves systemic vasculitis. It may also be seen in scarlet fever, but is a hallmark
sign in the diagnostic criteria for Kawasaki. Prompt recognition is critical to initiate IVIG
treatment and prevent coronary artery aneurysms.
5. What is the expected age for the closure of the anterior fontanelle in a healthy infant?
A. 2 to 3 months
B. 6 to 8 months
C. 24 to 30 months
D. 12 to 18 months
Answer: D
Rationale: The anterior fontanelle typically closes between 12 and 18 months of age.
Premature closure can indicate craniosynostosis, while delayed closure may suggest
