NURS 5130 Exam 2 V2 | NURS 5130
Comprehensive Assessment – Pediatric
Assessment Lab | Actual Q&A with
Rationale (NURS5130 Exam 2) | The
University of Texas at Arlington
1. During a newborn assessment, the nurse clinician notes the infant has a heart rate of 110
bpm, a slow/irregular respiratory effort, some flexion of extremities, a grimace in response to
stimulation, and a pink body with blue extremities. What is the calculated APGAR score at 1
minute?
A. 5
B. 6
C. 7
D. 8
Answer: B
Rationale: The APGAR score is calculated by assessing heart rate, respiratory effort,
muscle tone, reflex irritability, and color. In this scenario, the infant receives 2 points for
heart rate, 1 for respiration, 1 for muscle tone, 1 for reflex, and 1 for color. A total score of 6
indicates that the infant may require some resuscitative assistance or close monitoring
according to UTA clinical standards.
,2. When performing a physical examination on a 4-month-old infant, which fontanelle closure
finding would the nurse expect as a normal developmental milestone?
A. The posterior fontanelle is already closed.
B. The anterior fontanelle is completely closed.
C. Both fontanelles are wide open and pulsating.
D. The sagittal suture has fused completely.
Answer: A
Rationale: The posterior fontanelle typically closes by the age of 2 to 3 months. In contrast,
the anterior fontanelle remains open until approximately 12 to 18 months of age.
Assessment of fontanelles is vital for determining hydration status and intracranial
pressure in the pediatric population.
3. A nurse is assessing a 2-month-old infant and triggers the Moro reflex. What is the
characteristic response expected in a healthy infant?
A. The infant suddenly extends the arms and then brings them together in an embrace.
B. The toes fan out when the lateral aspect of the sole is stroked.
C. The infant turns the head toward the side of the cheek touched.
D. The infant steps upward when the dorsal surface of the foot touches a table edge.
Answer: A
, Rationale: The Moro reflex, also known as the startle reflex, involves the symmetrical
abduction and extension of the arms followed by adduction. This reflex is typically present
at birth and disappears by 4 to 6 months of age. Absence or asymmetry of this reflex may
indicate neurological damage or a fractured clavicle.
4. A 3-year-old child presents to the emergency department with a high fever, muffled voice,
and is sitting in a ‘tripod’ position while drooling. What is the priority nursing action?
A. Obtain a throat culture immediately to identify the pathogen.
B. Perform a thorough visual inspection of the throat using a tongue blade.
C. Place the child in a supine position to facilitate easier breathing.
D. Maintain a calm environment and prepare for emergency airway management.
Answer: D
Rationale: These symptoms are classic indicators of acute epiglottitis, which is a medical
emergency. Inspecting the throat with a tongue blade or swab can trigger a laryngospasm
and completely occlude the airway. The nurse must keep the child calm and have
intubation equipment ready at the bedside.
5. Which physical finding is pathognomonic for a diagnosis of hypertrophic pyloric stenosis in
a 4-week-old infant?
A. An olive-shaped mass palpable in the epigastrium.
B. A sausage-shaped mass in the right upper quadrant.
C. Ribbon-like, foul-smelling stools.
Comprehensive Assessment – Pediatric
Assessment Lab | Actual Q&A with
Rationale (NURS5130 Exam 2) | The
University of Texas at Arlington
1. During a newborn assessment, the nurse clinician notes the infant has a heart rate of 110
bpm, a slow/irregular respiratory effort, some flexion of extremities, a grimace in response to
stimulation, and a pink body with blue extremities. What is the calculated APGAR score at 1
minute?
A. 5
B. 6
C. 7
D. 8
Answer: B
Rationale: The APGAR score is calculated by assessing heart rate, respiratory effort,
muscle tone, reflex irritability, and color. In this scenario, the infant receives 2 points for
heart rate, 1 for respiration, 1 for muscle tone, 1 for reflex, and 1 for color. A total score of 6
indicates that the infant may require some resuscitative assistance or close monitoring
according to UTA clinical standards.
,2. When performing a physical examination on a 4-month-old infant, which fontanelle closure
finding would the nurse expect as a normal developmental milestone?
A. The posterior fontanelle is already closed.
B. The anterior fontanelle is completely closed.
C. Both fontanelles are wide open and pulsating.
D. The sagittal suture has fused completely.
Answer: A
Rationale: The posterior fontanelle typically closes by the age of 2 to 3 months. In contrast,
the anterior fontanelle remains open until approximately 12 to 18 months of age.
Assessment of fontanelles is vital for determining hydration status and intracranial
pressure in the pediatric population.
3. A nurse is assessing a 2-month-old infant and triggers the Moro reflex. What is the
characteristic response expected in a healthy infant?
A. The infant suddenly extends the arms and then brings them together in an embrace.
B. The toes fan out when the lateral aspect of the sole is stroked.
C. The infant turns the head toward the side of the cheek touched.
D. The infant steps upward when the dorsal surface of the foot touches a table edge.
Answer: A
, Rationale: The Moro reflex, also known as the startle reflex, involves the symmetrical
abduction and extension of the arms followed by adduction. This reflex is typically present
at birth and disappears by 4 to 6 months of age. Absence or asymmetry of this reflex may
indicate neurological damage or a fractured clavicle.
4. A 3-year-old child presents to the emergency department with a high fever, muffled voice,
and is sitting in a ‘tripod’ position while drooling. What is the priority nursing action?
A. Obtain a throat culture immediately to identify the pathogen.
B. Perform a thorough visual inspection of the throat using a tongue blade.
C. Place the child in a supine position to facilitate easier breathing.
D. Maintain a calm environment and prepare for emergency airway management.
Answer: D
Rationale: These symptoms are classic indicators of acute epiglottitis, which is a medical
emergency. Inspecting the throat with a tongue blade or swab can trigger a laryngospasm
and completely occlude the airway. The nurse must keep the child calm and have
intubation equipment ready at the bedside.
5. Which physical finding is pathognomonic for a diagnosis of hypertrophic pyloric stenosis in
a 4-week-old infant?
A. An olive-shaped mass palpable in the epigastrium.
B. A sausage-shaped mass in the right upper quadrant.
C. Ribbon-like, foul-smelling stools.
