NURS 5130 Final Exam V2 | NURS 5130
Comprehensive Assessment – Pediatric
Assessment Lab | Actual Q&A with
Rationale (NURS5130 Final Exam) | The
University of Texas at Arlington
1. When performing a physical assessment on a 15-month-old toddler, which approach by the
nurse is most appropriate to ensure cooperation?
A. Perform the assessment from head to toe to maintain a systematic approach.
B. Allow the child to remain on the parent’s lap and perform less invasive procedures first.
C. Conduct the assessment quickly while the child is crying to get accurate measurements.
D. Request the parent to leave the room so the child focuses only on the nurse.
Answer: B
Rationale: Toddlers often experience stranger anxiety and fear of physical restriction.
Keeping the child on the parent’s lap provides a sense of security and reduces distress. By
performing less invasive procedures like auscultation while the child is quiet, the nurse
obtains more accurate data before moving to more invasive tasks like examining the ears
or throat.
2. At what age should the nurse expect the anterior fontanel of a healthy infant to be
completely closed?
A. 12 to 18 months
,B. 4 to 6 months
C. 6 to 8 weeks
D. 24 to 36 months
Answer: A
Rationale: The anterior fontanel is the diamond-shaped soft spot located at the junction of
the coronal and sagittal sutures. While the posterior fontanel closes by 2 to 3 months, the
anterior fontanel typically closes between 12 and 18 months of age. Early or late closure
can be an indicator of underlying neurological or bone development issues.
3. Which assessment finding in a 6-month-old infant requires immediate follow-up by the
healthcare provider?
A. The infant is unable to sit unsupported for long periods.
B. The infant lacks a social smile when interacting with the nurse.
C. The infant continues to exhibit a strong Moro reflex.
D. The infant has not yet begun teething in the lower incisor area.
Answer: C
Rationale: The Moro (startle) reflex is a primitive reflex that should disappear by age 3 to
4 months. Persistence of primitive reflexes beyond the expected timeframe may indicate a
neurological abnormality or developmental delay. Social smiling typically appears at 2
,months, and sitting unsupported is a 6-to-8-month milestone, but the persistent Moro
reflex is a significant neurological red flag.
4. A nurse is assessing a 4-year-old child’s growth. Which growth chart is most appropriate to
use for this child?
A. WHO Growth Standard charts (0-2 years)
B. CDC Growth Charts (2-20 years)
C. Fenton Preterm Growth Chart
D. Down Syndrome specific growth charts
Answer: B
Rationale: According to the CDC and AAP guidelines, children from birth to 24 months
should be measured using the WHO growth standards. Once a child reaches age 2, clinical
practice shifts to using the CDC growth charts for children and adolescents aged 2 to 20
years. This allows for the tracking of Body Mass Index (BMI) which is a crucial component
of pediatric health assessment after infancy.
5. During a musculoskeletal assessment of a newborn, the nurse performs the Ortolani
maneuver. What is the purpose of this test?
A. To check for the presence of the Babinski reflex.
B. To reduce a dislocated hip and check for Developmental Dysplasia of the Hip (DDH).
C. To assess for clubfoot (talipes equinovarus).
, D. To evaluate the strength of the quadriceps muscles.
Answer: B
Rationale: The Ortolani maneuver is used alongside the Barlow test to screen for
developmental dysplasia of the hip in neonates. It involves abducting the hip while
applying upward pressure to the greater trochanter to see if the femoral head ‘clicks’ back
into the acetabulum. A positive test is indicated by a palpable clunk, which signifies a
dislocated hip being reduced.
6. A 10-year-old child presents with a sore throat. Which physical exam technique should be
performed last?
A. Auscultation of the heart and lungs.
B. Palpation of the cervical lymph nodes.
C. Inspection of the throat with a tongue blade.
D. Inspection of the skin for rashes.
Answer: C
Rationale: In pediatric assessment, it is a standard practice to perform distressing or
invasive procedures at the end of the examination. Using a tongue blade can trigger a gag
reflex and cause the child to become uncooperative for the remainder of the assessment. By
leaving the throat examination for last, the nurse ensures that heart and lung sounds are
heard while the child is calm.
Comprehensive Assessment – Pediatric
Assessment Lab | Actual Q&A with
Rationale (NURS5130 Final Exam) | The
University of Texas at Arlington
1. When performing a physical assessment on a 15-month-old toddler, which approach by the
nurse is most appropriate to ensure cooperation?
A. Perform the assessment from head to toe to maintain a systematic approach.
B. Allow the child to remain on the parent’s lap and perform less invasive procedures first.
C. Conduct the assessment quickly while the child is crying to get accurate measurements.
D. Request the parent to leave the room so the child focuses only on the nurse.
Answer: B
Rationale: Toddlers often experience stranger anxiety and fear of physical restriction.
Keeping the child on the parent’s lap provides a sense of security and reduces distress. By
performing less invasive procedures like auscultation while the child is quiet, the nurse
obtains more accurate data before moving to more invasive tasks like examining the ears
or throat.
2. At what age should the nurse expect the anterior fontanel of a healthy infant to be
completely closed?
A. 12 to 18 months
,B. 4 to 6 months
C. 6 to 8 weeks
D. 24 to 36 months
Answer: A
Rationale: The anterior fontanel is the diamond-shaped soft spot located at the junction of
the coronal and sagittal sutures. While the posterior fontanel closes by 2 to 3 months, the
anterior fontanel typically closes between 12 and 18 months of age. Early or late closure
can be an indicator of underlying neurological or bone development issues.
3. Which assessment finding in a 6-month-old infant requires immediate follow-up by the
healthcare provider?
A. The infant is unable to sit unsupported for long periods.
B. The infant lacks a social smile when interacting with the nurse.
C. The infant continues to exhibit a strong Moro reflex.
D. The infant has not yet begun teething in the lower incisor area.
Answer: C
Rationale: The Moro (startle) reflex is a primitive reflex that should disappear by age 3 to
4 months. Persistence of primitive reflexes beyond the expected timeframe may indicate a
neurological abnormality or developmental delay. Social smiling typically appears at 2
,months, and sitting unsupported is a 6-to-8-month milestone, but the persistent Moro
reflex is a significant neurological red flag.
4. A nurse is assessing a 4-year-old child’s growth. Which growth chart is most appropriate to
use for this child?
A. WHO Growth Standard charts (0-2 years)
B. CDC Growth Charts (2-20 years)
C. Fenton Preterm Growth Chart
D. Down Syndrome specific growth charts
Answer: B
Rationale: According to the CDC and AAP guidelines, children from birth to 24 months
should be measured using the WHO growth standards. Once a child reaches age 2, clinical
practice shifts to using the CDC growth charts for children and adolescents aged 2 to 20
years. This allows for the tracking of Body Mass Index (BMI) which is a crucial component
of pediatric health assessment after infancy.
5. During a musculoskeletal assessment of a newborn, the nurse performs the Ortolani
maneuver. What is the purpose of this test?
A. To check for the presence of the Babinski reflex.
B. To reduce a dislocated hip and check for Developmental Dysplasia of the Hip (DDH).
C. To assess for clubfoot (talipes equinovarus).
, D. To evaluate the strength of the quadriceps muscles.
Answer: B
Rationale: The Ortolani maneuver is used alongside the Barlow test to screen for
developmental dysplasia of the hip in neonates. It involves abducting the hip while
applying upward pressure to the greater trochanter to see if the femoral head ‘clicks’ back
into the acetabulum. A positive test is indicated by a palpable clunk, which signifies a
dislocated hip being reduced.
6. A 10-year-old child presents with a sore throat. Which physical exam technique should be
performed last?
A. Auscultation of the heart and lungs.
B. Palpation of the cervical lymph nodes.
C. Inspection of the throat with a tongue blade.
D. Inspection of the skin for rashes.
Answer: C
Rationale: In pediatric assessment, it is a standard practice to perform distressing or
invasive procedures at the end of the examination. Using a tongue blade can trigger a gag
reflex and cause the child to become uncooperative for the remainder of the assessment. By
leaving the throat examination for last, the nurse ensures that heart and lung sounds are
heard while the child is calm.
