NUR 425 Pediatrics Exam 1 UPDATED
ACTUAL Exam Questions and CORRECT
Answers
Infant VS (1-12 mo) - CORRECT ANSWER - HR awake: 100-180
HR sleeping: 75-160
RR: 30-60
hypotension systolic: <70
Toddler VS (1-3 years) - CORRECT ANSWER - HR awake: 100-150
HR sleeping: 75-150
RR: 24-40
hypotension systolic: <70 + (2 x age in years)
Preschool VS (3-6 years) - CORRECT ANSWER - HR awake: 60-150
HR sleeping: 60-90
RR: 22-34
hypotension systolic: <70 + (2 x age in yrs)
School age VS (6-10 years) - CORRECT ANSWER - HR awake: 60-110
HR sleeping: 60-90
RR: 18-30
hypotension systolic: < 70 + (2 x age in yrs)
Pre-teen/Teenager VS (>10 yrs) - CORRECT ANSWER - HR awake: 50-110
HR sleeping: 50-90
RR: 12-16
,hypotension systolic: <90
Pediatric Assessment Triangle - CORRECT ANSWER - 1. appearance: tone,
interactiveness, consolability, look/gaze, speech/cry
2. work of breathing: abnormal breath sounds, abnormal positioning, retractions, nasal flaring
3. circulation to the skin: pallor, mottling, cyanosis
if any of the three are off, nurse should reassess
Assessments and communication for infant (up to 12 mo) - CORRECT ANSWER - 1.
development: dependent on parent, will look to parents for security and reacts to parent anxiety
2. exam: interview parents, least invasive first
3. position: before 4-6 mo: can be on table make sure parent is in view; after 6 mo: best in parent
arms or laying on parent lap (parent active part of exam, asses parent attachment)
4. sequence: if quiet, auscultate heart, lungs, abdomen; perform traumatic procedures last (eyes,
ears, mouth)
stranger anxiety will set in around 6 mo
Assessment and communication for toddlers (1-3 yrs) - CORRECT ANSWER - 1.
development: utilizes parent as safety, but begins to explore in sight of parent
2. interview: interview with parent, some anxiety to new faces, begin communication with child
based on their vocab
3. position: best to begin in parent arms or lap; assess on parent first and then child
, 4. sequence: warm child up to you first (toys, play), let them touch equipment before use, first
attempt to auscultate heart lung abdomen, invasive assessments last, may cooperate well at first
due to curiosity
Assessment and communication for preschoolers (3-5 yrs) - CORRECT ANSWER - 1.
development: increasing exploring; intentional limit pushing
2. interview: interview with parent, some anxiety to new faces, begin communication with child
based on their vocab, if timid try averting eye contact
3. position: child may want to begin on parents lap or holding hand, assess on parent first then
child
4. sequence: use play and toys to become acquainted and non-threatening; inspect body through
counting fingers with minimal contact; introduce equipment through play (let them feel/touch
equipment), auscultate ASAP
Assessment and communication for school age (5-12 yrs) - CORRECT ANSWER - 1.
development: seeking autonomy; exploring (self exploration/stimulation common); still prefers
parent close
2. interview: include child in interview/subjective info; the kids like to answer questions about
themselves
3. position: sitting alone
4. sequence: head to toe assessment; examine genitalia last
Assessment and communication for adolescent (12-18 yrs) - CORRECT ANSWER - 1.
development: autonomy important
ACTUAL Exam Questions and CORRECT
Answers
Infant VS (1-12 mo) - CORRECT ANSWER - HR awake: 100-180
HR sleeping: 75-160
RR: 30-60
hypotension systolic: <70
Toddler VS (1-3 years) - CORRECT ANSWER - HR awake: 100-150
HR sleeping: 75-150
RR: 24-40
hypotension systolic: <70 + (2 x age in years)
Preschool VS (3-6 years) - CORRECT ANSWER - HR awake: 60-150
HR sleeping: 60-90
RR: 22-34
hypotension systolic: <70 + (2 x age in yrs)
School age VS (6-10 years) - CORRECT ANSWER - HR awake: 60-110
HR sleeping: 60-90
RR: 18-30
hypotension systolic: < 70 + (2 x age in yrs)
Pre-teen/Teenager VS (>10 yrs) - CORRECT ANSWER - HR awake: 50-110
HR sleeping: 50-90
RR: 12-16
,hypotension systolic: <90
Pediatric Assessment Triangle - CORRECT ANSWER - 1. appearance: tone,
interactiveness, consolability, look/gaze, speech/cry
2. work of breathing: abnormal breath sounds, abnormal positioning, retractions, nasal flaring
3. circulation to the skin: pallor, mottling, cyanosis
if any of the three are off, nurse should reassess
Assessments and communication for infant (up to 12 mo) - CORRECT ANSWER - 1.
development: dependent on parent, will look to parents for security and reacts to parent anxiety
2. exam: interview parents, least invasive first
3. position: before 4-6 mo: can be on table make sure parent is in view; after 6 mo: best in parent
arms or laying on parent lap (parent active part of exam, asses parent attachment)
4. sequence: if quiet, auscultate heart, lungs, abdomen; perform traumatic procedures last (eyes,
ears, mouth)
stranger anxiety will set in around 6 mo
Assessment and communication for toddlers (1-3 yrs) - CORRECT ANSWER - 1.
development: utilizes parent as safety, but begins to explore in sight of parent
2. interview: interview with parent, some anxiety to new faces, begin communication with child
based on their vocab
3. position: best to begin in parent arms or lap; assess on parent first and then child
, 4. sequence: warm child up to you first (toys, play), let them touch equipment before use, first
attempt to auscultate heart lung abdomen, invasive assessments last, may cooperate well at first
due to curiosity
Assessment and communication for preschoolers (3-5 yrs) - CORRECT ANSWER - 1.
development: increasing exploring; intentional limit pushing
2. interview: interview with parent, some anxiety to new faces, begin communication with child
based on their vocab, if timid try averting eye contact
3. position: child may want to begin on parents lap or holding hand, assess on parent first then
child
4. sequence: use play and toys to become acquainted and non-threatening; inspect body through
counting fingers with minimal contact; introduce equipment through play (let them feel/touch
equipment), auscultate ASAP
Assessment and communication for school age (5-12 yrs) - CORRECT ANSWER - 1.
development: seeking autonomy; exploring (self exploration/stimulation common); still prefers
parent close
2. interview: include child in interview/subjective info; the kids like to answer questions about
themselves
3. position: sitting alone
4. sequence: head to toe assessment; examine genitalia last
Assessment and communication for adolescent (12-18 yrs) - CORRECT ANSWER - 1.
development: autonomy important
