Pediatric Nursing Assessment Practice
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1. Which assessment finding is considered normal in a newborn
during the first 24 hours after birth?
A. Persistent central cyanosis B. Heart rate of 90 beats/minute C.
Respiratory rate of 40 breaths/minute D. Absence of reflexes
Correct Answer: C. Respiratory rate of 40 breaths/minute
Rationale: A normal newborn respiratory rate ranges from 30 to 60
breaths per minute. Persistent central cyanosis is abnormal and
requires immediate attention. A heart rate of 90 beats/minute is lower
than the expected newborn range of 110 to 160 beats/minute.
Newborns should demonstrate normal primitive reflexes such as the
Moro and rooting reflexes.
2. Which pulse site is most appropriate for assessing circulation
in an infant younger than 1 year of age?
A. Radial pulse B. Carotid pulse C. Brachial pulse D. Femoral pulse
Correct Answer: C. Brachial pulse
,Rationale: The brachial pulse is the preferred site for pulse assessment
in infants because it is easier to palpate accurately. Radial pulses may
be difficult to locate in infants. Carotid pulses are generally reserved
for emergency situations. Femoral pulses are assessed when
evaluating lower extremity circulation.
3. Which developmental milestone would the nurse expect in a 6-
month-old infant?
A. Walking independently B. Rolling from back to abdomen C.
Speaking in full sentences D. Using a pincer grasp
Correct Answer: B. Rolling from back to abdomen
Rationale: By 6 months of age, infants commonly roll over and begin
sitting with support. Walking independently occurs closer to 12
months. Speaking in full sentences is expected in toddlers or
preschoolers. A mature pincer grasp develops around 9 to 12 months.
4. During a physical assessment, the nurse notices a sunken
anterior fontanel in an infant. What does this finding most
likely indicate?
A. Increased intracranial pressure B. Normal growth and
development C. Dehydration D. Hydrocephalus
Correct Answer: C. Dehydration
Rationale: A sunken anterior fontanel commonly indicates
dehydration in infants. Increased intracranial pressure and
hydrocephalus are associated with a bulging fontanel. The finding is
not considered a normal variation.
5. Which action should the nurse take first when assessing a
toddler?
,A. Examine the ears immediately B. Perform painful procedures
first C. Approach the child slowly and allow time to adjust D.
Separate the child from the parent
Correct Answer: C. Approach the child slowly and allow time to
adjust
Rationale: Toddlers may experience fear and anxiety during
assessments. Approaching slowly and allowing the child to become
comfortable helps establish trust. Painful or invasive procedures
should be performed last whenever possible. Separating the child from
parents can increase anxiety.
6. Which finding is expected in a healthy preschool-age child?
A. Blood pressure lower than an infant’s B. Potbelly appearance C.
Absence of all deciduous teeth D. Inability to hop on one foot
Correct Answer: B. Potbelly appearance
Rationale: Preschool-age children commonly have a potbelly
appearance due to abdominal muscle development. Blood pressure
gradually increases with age. Preschoolers typically retain most
deciduous teeth. Many preschoolers can hop on one foot by age 4
years.
7. Which assessment technique should the nurse use when
examining the abdomen of a child?
A. Palpation before auscultation B. Auscultation before palpation C.
Percussion before inspection D. Palpation before inspection
Correct Answer: B. Auscultation before palpation
Rationale: The correct abdominal assessment sequence is inspection,
auscultation, percussion, and palpation. Auscultation is performed
, before palpation because touching the abdomen can alter bowel
sounds.
8. A nurse is assessing pain in a 3-year-old child. Which pain
scale is most appropriate?
A. Numeric rating scale B. Glasgow Coma Scale C. FLACC scale D.
Apgar scale
Correct Answer: C. FLACC scale
Rationale: The FLACC scale evaluates facial expression, leg
movement, activity, cry, and consolability and is appropriate for young
children who cannot reliably self-report pain. Numeric scales are more
suitable for older children. The Glasgow Coma Scale measures
neurological status, and the Apgar scale is used for newborn
assessment.
9. Which respiratory finding in an infant requires immediate
intervention?
A. Periodic breathing B. Nasal flaring C. Abdominal breathing D.
Respiratory rate of 35 breaths/minute
Correct Answer: B. Nasal flaring
Rationale: Nasal flaring is a sign of respiratory distress and requires
prompt intervention. Periodic breathing and abdominal breathing can
be normal findings in infants. A respiratory rate of 35 breaths/minute
is within the normal range.
10. Which statement by a parent indicates understanding of
fever assessment in children?
A. “A rectal temperature is never accurate.” B. “An axillary
temperature is usually higher than a rectal temperature.” C. “A
Exam Merged With Correct Verified
Solutions | 2026 Latest Update |
Already Graded A+
1. Which assessment finding is considered normal in a newborn
during the first 24 hours after birth?
A. Persistent central cyanosis B. Heart rate of 90 beats/minute C.
Respiratory rate of 40 breaths/minute D. Absence of reflexes
Correct Answer: C. Respiratory rate of 40 breaths/minute
Rationale: A normal newborn respiratory rate ranges from 30 to 60
breaths per minute. Persistent central cyanosis is abnormal and
requires immediate attention. A heart rate of 90 beats/minute is lower
than the expected newborn range of 110 to 160 beats/minute.
Newborns should demonstrate normal primitive reflexes such as the
Moro and rooting reflexes.
2. Which pulse site is most appropriate for assessing circulation
in an infant younger than 1 year of age?
A. Radial pulse B. Carotid pulse C. Brachial pulse D. Femoral pulse
Correct Answer: C. Brachial pulse
,Rationale: The brachial pulse is the preferred site for pulse assessment
in infants because it is easier to palpate accurately. Radial pulses may
be difficult to locate in infants. Carotid pulses are generally reserved
for emergency situations. Femoral pulses are assessed when
evaluating lower extremity circulation.
3. Which developmental milestone would the nurse expect in a 6-
month-old infant?
A. Walking independently B. Rolling from back to abdomen C.
Speaking in full sentences D. Using a pincer grasp
Correct Answer: B. Rolling from back to abdomen
Rationale: By 6 months of age, infants commonly roll over and begin
sitting with support. Walking independently occurs closer to 12
months. Speaking in full sentences is expected in toddlers or
preschoolers. A mature pincer grasp develops around 9 to 12 months.
4. During a physical assessment, the nurse notices a sunken
anterior fontanel in an infant. What does this finding most
likely indicate?
A. Increased intracranial pressure B. Normal growth and
development C. Dehydration D. Hydrocephalus
Correct Answer: C. Dehydration
Rationale: A sunken anterior fontanel commonly indicates
dehydration in infants. Increased intracranial pressure and
hydrocephalus are associated with a bulging fontanel. The finding is
not considered a normal variation.
5. Which action should the nurse take first when assessing a
toddler?
,A. Examine the ears immediately B. Perform painful procedures
first C. Approach the child slowly and allow time to adjust D.
Separate the child from the parent
Correct Answer: C. Approach the child slowly and allow time to
adjust
Rationale: Toddlers may experience fear and anxiety during
assessments. Approaching slowly and allowing the child to become
comfortable helps establish trust. Painful or invasive procedures
should be performed last whenever possible. Separating the child from
parents can increase anxiety.
6. Which finding is expected in a healthy preschool-age child?
A. Blood pressure lower than an infant’s B. Potbelly appearance C.
Absence of all deciduous teeth D. Inability to hop on one foot
Correct Answer: B. Potbelly appearance
Rationale: Preschool-age children commonly have a potbelly
appearance due to abdominal muscle development. Blood pressure
gradually increases with age. Preschoolers typically retain most
deciduous teeth. Many preschoolers can hop on one foot by age 4
years.
7. Which assessment technique should the nurse use when
examining the abdomen of a child?
A. Palpation before auscultation B. Auscultation before palpation C.
Percussion before inspection D. Palpation before inspection
Correct Answer: B. Auscultation before palpation
Rationale: The correct abdominal assessment sequence is inspection,
auscultation, percussion, and palpation. Auscultation is performed
, before palpation because touching the abdomen can alter bowel
sounds.
8. A nurse is assessing pain in a 3-year-old child. Which pain
scale is most appropriate?
A. Numeric rating scale B. Glasgow Coma Scale C. FLACC scale D.
Apgar scale
Correct Answer: C. FLACC scale
Rationale: The FLACC scale evaluates facial expression, leg
movement, activity, cry, and consolability and is appropriate for young
children who cannot reliably self-report pain. Numeric scales are more
suitable for older children. The Glasgow Coma Scale measures
neurological status, and the Apgar scale is used for newborn
assessment.
9. Which respiratory finding in an infant requires immediate
intervention?
A. Periodic breathing B. Nasal flaring C. Abdominal breathing D.
Respiratory rate of 35 breaths/minute
Correct Answer: B. Nasal flaring
Rationale: Nasal flaring is a sign of respiratory distress and requires
prompt intervention. Periodic breathing and abdominal breathing can
be normal findings in infants. A respiratory rate of 35 breaths/minute
is within the normal range.
10. Which statement by a parent indicates understanding of
fever assessment in children?
A. “A rectal temperature is never accurate.” B. “An axillary
temperature is usually higher than a rectal temperature.” C. “A
