NURS 5130 Exam 3 V3 | NURS 5130
Comprehensive Assessment – Pediatric
Assessment Lab | Actual Q&A with
Rationale (NURS5130 Exam 3) | The
University of Texas at Arlington
1. When assessing a 12-month-old infant, which sequence of examination should the nurse
follow to minimize distress?
A. Head, chest, abdomen, then ears and throat
B. Auscultate heart and lungs, then proceed with less invasive assessments, and perform
ears and throat last
C. Ears, throat, chest, then abdomen
D. Perform a head-to-toe assessment strictly in order
Answer: B
Rationale: For infants and toddlers, it is essential to perform non-invasive procedures
such as auscultation while the child is quiet. Invasive or distressing assessments, like
checking the throat and ears, should be reserved for the end of the examination. This
sequence helps maintain the child’s cooperation for as long as possible.
2. A nurse is assessing a 4-month-old infant. At what age should the nurse expect the
posterior fontanelle to have closed?
A. 1 to 2 months
,B. 6 to 8 months
C. 12 to 18 months
D. 24 months
Answer: A
Rationale: The posterior fontanelle is typically much smaller than the anterior fontanelle
and closes early in infancy, usually by 1 to 2 months. In contrast, the anterior fontanelle
remains open longer to accommodate brain growth, closing between 12 and 18 months.
Delayed closure of fontanelles can indicate conditions like hydrocephalus or rickets.
3. During an ear examination of a 2-year-old child, how should the nurse manipulate the
pinna?
A. Pull the pinna up and back
B. Pull the pinna straight back
C. Pull the pinna down and back
D. Pull the pinna down and forward
Answer: C
Rationale: In children under the age of 3, the external auditory canal is short and directed
upward. Pulling the pinna down and back straightens the canal for better visualization of
the tympanic membrane. For children older than 3 years and adults, the pinna is pulled up
and back.
, 4. The nurse is assessing a newborn and notes a positive Ortolani sign. This finding is
indicative of which condition?
A. Developmental dysplasia of the hip
B. Talipes equinovarus
C. Fractured clavicle
D. Spina bifida occulta
Answer: A
Rationale: The Ortolani maneuver is used to detect hip stability in newborns and infants. A
positive sign is characterized by a ‘clunk’ as the femoral head relocates into the acetabulum
during abduction. This finding is a hallmark indicator of developmental dysplasia of the hip
and requires further orthopedic evaluation.
5. At what age is a child typically expected to use a pincer grasp to pick up small objects?
A. 4 months
B. 6 months
C. 9 months
D. 15 months
Answer: C
Rationale: The development of the pincer grasp, using the thumb and forefinger, is a
significant fine motor milestone typically achieved around 9 months of age. Prior to this,
Comprehensive Assessment – Pediatric
Assessment Lab | Actual Q&A with
Rationale (NURS5130 Exam 3) | The
University of Texas at Arlington
1. When assessing a 12-month-old infant, which sequence of examination should the nurse
follow to minimize distress?
A. Head, chest, abdomen, then ears and throat
B. Auscultate heart and lungs, then proceed with less invasive assessments, and perform
ears and throat last
C. Ears, throat, chest, then abdomen
D. Perform a head-to-toe assessment strictly in order
Answer: B
Rationale: For infants and toddlers, it is essential to perform non-invasive procedures
such as auscultation while the child is quiet. Invasive or distressing assessments, like
checking the throat and ears, should be reserved for the end of the examination. This
sequence helps maintain the child’s cooperation for as long as possible.
2. A nurse is assessing a 4-month-old infant. At what age should the nurse expect the
posterior fontanelle to have closed?
A. 1 to 2 months
,B. 6 to 8 months
C. 12 to 18 months
D. 24 months
Answer: A
Rationale: The posterior fontanelle is typically much smaller than the anterior fontanelle
and closes early in infancy, usually by 1 to 2 months. In contrast, the anterior fontanelle
remains open longer to accommodate brain growth, closing between 12 and 18 months.
Delayed closure of fontanelles can indicate conditions like hydrocephalus or rickets.
3. During an ear examination of a 2-year-old child, how should the nurse manipulate the
pinna?
A. Pull the pinna up and back
B. Pull the pinna straight back
C. Pull the pinna down and back
D. Pull the pinna down and forward
Answer: C
Rationale: In children under the age of 3, the external auditory canal is short and directed
upward. Pulling the pinna down and back straightens the canal for better visualization of
the tympanic membrane. For children older than 3 years and adults, the pinna is pulled up
and back.
, 4. The nurse is assessing a newborn and notes a positive Ortolani sign. This finding is
indicative of which condition?
A. Developmental dysplasia of the hip
B. Talipes equinovarus
C. Fractured clavicle
D. Spina bifida occulta
Answer: A
Rationale: The Ortolani maneuver is used to detect hip stability in newborns and infants. A
positive sign is characterized by a ‘clunk’ as the femoral head relocates into the acetabulum
during abduction. This finding is a hallmark indicator of developmental dysplasia of the hip
and requires further orthopedic evaluation.
5. At what age is a child typically expected to use a pincer grasp to pick up small objects?
A. 4 months
B. 6 months
C. 9 months
D. 15 months
Answer: C
Rationale: The development of the pincer grasp, using the thumb and forefinger, is a
significant fine motor milestone typically achieved around 9 months of age. Prior to this,
