NURS 5130 Final Exam V1 | 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 evaluating the Apgar score of a newborn at 1 minute. The infant has a heart rate
of 110 bpm, a strong cry, some flexion of extremities, sneezes when the bulb syringe is used,
and has a pink body with blue extremities. What score should the nurse assign?
A. 7
B. 8
C. 9
D. 10
Answer: B
Rationale: The infant receives 2 points for heart rate (>100), 2 points for respiratory effort
(strong cry), 1 point for muscle tone (some flexion), 2 points for reflex irritability
(sneezing), and 1 point for color (acrocyanosis). This totals 8 points. Assessing Apgar
scores at 1 and 5 minutes is standard practice to evaluate the newborn’s transition to
extrauterine life.
,2. When assessing a 6-month-old infant, which finding regarding the fontanels would the
nurse consider normal?
A. The posterior fontanel is open and measures 3 cm.
B. The anterior fontanel is open and soft.
C. The anterior fontanel is completely closed.
D. Both fontanels are sunken below the skull line.
Answer: B
Rationale: The anterior fontanel typically closes between 12 and 18 months of age, so it
should remain open and soft at 6 months. The posterior fontanel usually closes much
earlier, typically by 2 months of age. Sunken fontanels are an abnormal finding often
indicating dehydration in an infant.
3. According to the Denver II Developmental Screening Tool, at what age should the nurse
expect a child to begin sitting without support?
A. 6 months
B. 4 months
C. 9 months
D. 12 months
Answer: A
, Rationale: Most infants develop the core strength necessary to sit without support by 6
months of age. Failure to achieve this milestone may require further neurological or
musculoskeletal evaluation. It is important for the nurse to use standardized tools like the
Denver II to track progression accurately.
4. During a physical examination of a 2-year-old, the nurse notes the child has ‘bow-legs’.
What is the clinical term for this finding and is it expected at this age?
A. Genu valgum; expected
B. Genu valgum; abnormal
C. Genu varum; abnormal
D. Genu varum; expected
Answer: D
Rationale: Genu varum, commonly known as bow-legs, is a normal developmental finding
in toddlers until about age 2 or 3. As the child begins to walk and develop muscle strength,
the legs typically straighten. Genu valgum, or knock-knees, is more common in older
preschool children.
5. A nurse is performing a health history on an adolescent. Which approach is most effective
for obtaining sensitive information regarding sexual health?
A. Ask questions while the parents are in the room to ensure accuracy.
B. Interview the adolescent alone after establishing rapport.
C. Use medical jargon to sound professional and serious.
Comprehensive Assessment – Pediatric
Assessment Lab | Actual Q&A with
Rationale (NURS5130 Final Exam) | The
University of Texas at Arlington
1. A nurse is evaluating the Apgar score of a newborn at 1 minute. The infant has a heart rate
of 110 bpm, a strong cry, some flexion of extremities, sneezes when the bulb syringe is used,
and has a pink body with blue extremities. What score should the nurse assign?
A. 7
B. 8
C. 9
D. 10
Answer: B
Rationale: The infant receives 2 points for heart rate (>100), 2 points for respiratory effort
(strong cry), 1 point for muscle tone (some flexion), 2 points for reflex irritability
(sneezing), and 1 point for color (acrocyanosis). This totals 8 points. Assessing Apgar
scores at 1 and 5 minutes is standard practice to evaluate the newborn’s transition to
extrauterine life.
,2. When assessing a 6-month-old infant, which finding regarding the fontanels would the
nurse consider normal?
A. The posterior fontanel is open and measures 3 cm.
B. The anterior fontanel is open and soft.
C. The anterior fontanel is completely closed.
D. Both fontanels are sunken below the skull line.
Answer: B
Rationale: The anterior fontanel typically closes between 12 and 18 months of age, so it
should remain open and soft at 6 months. The posterior fontanel usually closes much
earlier, typically by 2 months of age. Sunken fontanels are an abnormal finding often
indicating dehydration in an infant.
3. According to the Denver II Developmental Screening Tool, at what age should the nurse
expect a child to begin sitting without support?
A. 6 months
B. 4 months
C. 9 months
D. 12 months
Answer: A
, Rationale: Most infants develop the core strength necessary to sit without support by 6
months of age. Failure to achieve this milestone may require further neurological or
musculoskeletal evaluation. It is important for the nurse to use standardized tools like the
Denver II to track progression accurately.
4. During a physical examination of a 2-year-old, the nurse notes the child has ‘bow-legs’.
What is the clinical term for this finding and is it expected at this age?
A. Genu valgum; expected
B. Genu valgum; abnormal
C. Genu varum; abnormal
D. Genu varum; expected
Answer: D
Rationale: Genu varum, commonly known as bow-legs, is a normal developmental finding
in toddlers until about age 2 or 3. As the child begins to walk and develop muscle strength,
the legs typically straighten. Genu valgum, or knock-knees, is more common in older
preschool children.
5. A nurse is performing a health history on an adolescent. Which approach is most effective
for obtaining sensitive information regarding sexual health?
A. Ask questions while the parents are in the room to ensure accuracy.
B. Interview the adolescent alone after establishing rapport.
C. Use medical jargon to sound professional and serious.
