NURS 5130 Exam 1 V1 | NURS 5130
Comprehensive Assessment – Pediatric
Assessment Lab | Actual Q&A with
Rationale (NURS5130 Exam 1) | The
University of Texas at Arlington
1. A nurse is preparing to assess a 2-year-old child during a well-child visit. Which approach is
most appropriate for this age group?
A. Perform the least invasive assessments first, such as auscultation, while the child is
quiet.
B. Follow a strict head-to-toe sequence to ensure no systems are missed.
C. Request the parent to leave the room to reduce the child’s anxiety.
D. Assess the throat and ears first to complete the most difficult parts early.
Answer: A
Rationale: For toddlers, the examination should be adapted to the child’s developmental
level by performing non-invasive procedures first. Auscultating the heart and lungs while
the child is calm provides the most accurate data before the child becomes agitated.
Traumatic or intrusive procedures, like the otoscopic exam, should always be saved for the
very end.
,2. When assessing a 4-month-old infant, the nurse notes that the infant is unable to hold
their head steady when pulled to a sitting position. What is the nurse’s best action?
A. Document this as a normal finding for a 4-month-old infant.
B. Document the finding and notify the provider for further developmental screening.
C. Reassure the parents that head lag usually disappears by 8 months.
D. Advise the parents to avoid ‘tummy time’ until the neck muscles are stronger.
Answer: B
Rationale: Head lag should be minimal by age 4 months and should completely disappear
by 6 months. Persistent head lag beyond 4 months can be an early indicator of motor delay
or neurological impairment. The nurse must document this finding and ensure the provider
is aware for a more comprehensive developmental evaluation.
3. The nurse is assessing the fontanelles of a 6-month-old infant. Which finding would be
considered a normal assessment?
A. The anterior fontanelle is soft, flat, and open.
B. The anterior fontanelle is sunken and pulsing.
C. The posterior fontanelle is open 3 cm.
D. The anterior fontanelle is firm and bulging while the infant is sleeping.
Answer: A
, Rationale: A normal anterior fontanelle should be soft and flat, potentially with slight
pulsations visible. It typically closes between 12 and 18 months of age. A sunken fontanelle
may indicate dehydration, while a bulging fontanelle when the infant is not crying could
suggest increased intracranial pressure.
4. According to Erikson’s stages of psychosocial development, a preschooler (ages 3-6) is in
which stage?
A. Initiative vs. Guilt
B. Trust vs. Mistrust
C. Autonomy vs. Shame and Doubt
D. Industry vs. Inferiority
Answer: A
Rationale: The preschool period is defined by the conflict of Initiative vs. Guilt. Children at
this stage explore their environment and engage in purposeful play. If they are over-
criticized or prevented from taking initiative, they may develop a sense of guilt regarding
their actions.
5. A nurse is measuring the head circumference of an 18-month-old. Where should the tape
measure be placed for an accurate measurement?
A. Around the forehead and the base of the neck.
B. Across the bridge of the nose and around the ears.
C. Around the most prominent part of the occiput and just above the eyebrows.
Comprehensive Assessment – Pediatric
Assessment Lab | Actual Q&A with
Rationale (NURS5130 Exam 1) | The
University of Texas at Arlington
1. A nurse is preparing to assess a 2-year-old child during a well-child visit. Which approach is
most appropriate for this age group?
A. Perform the least invasive assessments first, such as auscultation, while the child is
quiet.
B. Follow a strict head-to-toe sequence to ensure no systems are missed.
C. Request the parent to leave the room to reduce the child’s anxiety.
D. Assess the throat and ears first to complete the most difficult parts early.
Answer: A
Rationale: For toddlers, the examination should be adapted to the child’s developmental
level by performing non-invasive procedures first. Auscultating the heart and lungs while
the child is calm provides the most accurate data before the child becomes agitated.
Traumatic or intrusive procedures, like the otoscopic exam, should always be saved for the
very end.
,2. When assessing a 4-month-old infant, the nurse notes that the infant is unable to hold
their head steady when pulled to a sitting position. What is the nurse’s best action?
A. Document this as a normal finding for a 4-month-old infant.
B. Document the finding and notify the provider for further developmental screening.
C. Reassure the parents that head lag usually disappears by 8 months.
D. Advise the parents to avoid ‘tummy time’ until the neck muscles are stronger.
Answer: B
Rationale: Head lag should be minimal by age 4 months and should completely disappear
by 6 months. Persistent head lag beyond 4 months can be an early indicator of motor delay
or neurological impairment. The nurse must document this finding and ensure the provider
is aware for a more comprehensive developmental evaluation.
3. The nurse is assessing the fontanelles of a 6-month-old infant. Which finding would be
considered a normal assessment?
A. The anterior fontanelle is soft, flat, and open.
B. The anterior fontanelle is sunken and pulsing.
C. The posterior fontanelle is open 3 cm.
D. The anterior fontanelle is firm and bulging while the infant is sleeping.
Answer: A
, Rationale: A normal anterior fontanelle should be soft and flat, potentially with slight
pulsations visible. It typically closes between 12 and 18 months of age. A sunken fontanelle
may indicate dehydration, while a bulging fontanelle when the infant is not crying could
suggest increased intracranial pressure.
4. According to Erikson’s stages of psychosocial development, a preschooler (ages 3-6) is in
which stage?
A. Initiative vs. Guilt
B. Trust vs. Mistrust
C. Autonomy vs. Shame and Doubt
D. Industry vs. Inferiority
Answer: A
Rationale: The preschool period is defined by the conflict of Initiative vs. Guilt. Children at
this stage explore their environment and engage in purposeful play. If they are over-
criticized or prevented from taking initiative, they may develop a sense of guilt regarding
their actions.
5. A nurse is measuring the head circumference of an 18-month-old. Where should the tape
measure be placed for an accurate measurement?
A. Around the forehead and the base of the neck.
B. Across the bridge of the nose and around the ears.
C. Around the most prominent part of the occiput and just above the eyebrows.
