NURS 5130 Exam 4 V1 | NURS 5130
Comprehensive Assessment – Pediatric
Assessment Lab | Actual Q&A with
Rationale (NURS5130 Exam 4) | The
University of Texas at Arlington
1. When performing an otoscopic examination on a 2-year-old child, in which direction should
the practitioner pull the pinna?
A. Up and back
B. Straight back
C. Down and back
D. Down and forward
Answer: C
Rationale: In children younger than 3 years of age, the external auditory canal is shorter
and directed more upward than in adults. Pulling the pinna down and back straightens the
canal to provide the best visualization of the tympanic membrane. This technique is
essential for accurate assessment of pediatric ear health.
2. Which of the following findings is considered a normal variation in the respiratory
assessment of a healthy neonate?
A. Consistent respiratory rate of 80 breaths per minute
,B. Nasal flaring with inspiration
C. Periodic breathing with pauses less than 15 seconds
D. Sustained expiratory grunting
Answer: C
Rationale: Neonates often exhibit periodic breathing, which is characterized by a sequence
of vigorous breaths followed by a short pause. This is considered normal as long as the
pause is brief and not accompanied by cyanosis or bradycardia. Other signs like flaring and
grunting indicate respiratory distress and require immediate intervention.
3. During a well-child visit, a 4-year-old child’s blood pressure is measured at 118/78 mmHg.
How should the practitioner interpret this finding?
A. Normal blood pressure for age
B. Stage 1 Hypertension
C. Prehypertension
D. Stage 2 Hypertension
Answer: B
Rationale: According to pediatric blood pressure guidelines, values must be compared
against age, sex, and height percentiles. For a 4-year-old, a reading of 118/78 mmHg
typically exceeds the 95th percentile plus 12 mmHg, classifying it as Stage 1 Hypertension.
The practitioner must ensure the cuff size is appropriate before making a clinical diagnosis.
, 4. A practitioner is assessing a 6-month-old infant. Which developmental milestone should
the infant be able to demonstrate?
A. Sitting with support
B. Speaking two-word phrases
C. Walking while holding onto furniture
D. Pincer grasp of small objects
Answer: A
Rationale: By six months of age, most infants have developed sufficient trunk control to sit
with minimal support or by using their hands for balance (tripod position). Walking with
furniture (cruising) and pincer grasp are milestones typically achieved between 9 and 12
months. Speaking phrases is a toddler-level milestone.
5. What is the correct sequence for performing a physical examination on a sleeping 15-
month-old toddler?
A. Head, chest, abdomen, then extremities
B. Auscultate heart and lungs, then proceed with less invasive exams
C. Perform the Moro reflex first to wake the child
D. Examine ears and throat first while the child is still
Answer: B
Comprehensive Assessment – Pediatric
Assessment Lab | Actual Q&A with
Rationale (NURS5130 Exam 4) | The
University of Texas at Arlington
1. When performing an otoscopic examination on a 2-year-old child, in which direction should
the practitioner pull the pinna?
A. Up and back
B. Straight back
C. Down and back
D. Down and forward
Answer: C
Rationale: In children younger than 3 years of age, the external auditory canal is shorter
and directed more upward than in adults. Pulling the pinna down and back straightens the
canal to provide the best visualization of the tympanic membrane. This technique is
essential for accurate assessment of pediatric ear health.
2. Which of the following findings is considered a normal variation in the respiratory
assessment of a healthy neonate?
A. Consistent respiratory rate of 80 breaths per minute
,B. Nasal flaring with inspiration
C. Periodic breathing with pauses less than 15 seconds
D. Sustained expiratory grunting
Answer: C
Rationale: Neonates often exhibit periodic breathing, which is characterized by a sequence
of vigorous breaths followed by a short pause. This is considered normal as long as the
pause is brief and not accompanied by cyanosis or bradycardia. Other signs like flaring and
grunting indicate respiratory distress and require immediate intervention.
3. During a well-child visit, a 4-year-old child’s blood pressure is measured at 118/78 mmHg.
How should the practitioner interpret this finding?
A. Normal blood pressure for age
B. Stage 1 Hypertension
C. Prehypertension
D. Stage 2 Hypertension
Answer: B
Rationale: According to pediatric blood pressure guidelines, values must be compared
against age, sex, and height percentiles. For a 4-year-old, a reading of 118/78 mmHg
typically exceeds the 95th percentile plus 12 mmHg, classifying it as Stage 1 Hypertension.
The practitioner must ensure the cuff size is appropriate before making a clinical diagnosis.
, 4. A practitioner is assessing a 6-month-old infant. Which developmental milestone should
the infant be able to demonstrate?
A. Sitting with support
B. Speaking two-word phrases
C. Walking while holding onto furniture
D. Pincer grasp of small objects
Answer: A
Rationale: By six months of age, most infants have developed sufficient trunk control to sit
with minimal support or by using their hands for balance (tripod position). Walking with
furniture (cruising) and pincer grasp are milestones typically achieved between 9 and 12
months. Speaking phrases is a toddler-level milestone.
5. What is the correct sequence for performing a physical examination on a sleeping 15-
month-old toddler?
A. Head, chest, abdomen, then extremities
B. Auscultate heart and lungs, then proceed with less invasive exams
C. Perform the Moro reflex first to wake the child
D. Examine ears and throat first while the child is still
Answer: B
