NUR 213 HEALTH ASSESSMENT EXAM 3 2026 | Physical
Examination Actual Exam | Latest Update 2026/2027 | Verified
Answers | Pass Guaranteed - A+ Graded
Section 1: Pediatric Assessment: Birth to Adolescence (Q1-20)
Q1. A newborn is assessed at 1 minute of life: heart rate 110 bpm, respiratory effort
irregular and slow, some flexion of extremities, grimace with suctioning, and blue
extremities with a pink body. What is the 1-minute Apgar score?
A. 8
B. 7
C. 6 [CORRECT]
D. 5
Rationale: Heart rate >100 = 2; irregular respirations = 1; some flexion = 1; grimace = 1;
acrocyanosis = 1. Total = 6. A score of 7 would require regular respirations or active
motion, while 5 would indicate absent reflexes or cyanosis of the entire body.
Correct Answer: C
Q2. A newborn's physical assessment reveals a square window angle of 0°, heel-to-ear
maneuver with no resistance, and scrotal rugae covering the entire surface. Using the
Ballard score, what is the approximate gestational age?
A. 28 weeks
B. 32 weeks
C. 36 weeks
D. 40 weeks [CORRECT]
,Rationale: A square window of 0°, heel-to-ear without resistance, and complete scrotal
rugae are all physical maturity criteria consistent with term gestation (39-40 weeks) on
the New Ballard Score.
Correct Answer: D
Q3. During a newborn examination, the nurse strokes the infant's cheek and the infant
turns toward the stimulus with an open mouth. Which primitive reflex is being
demonstrated?
A. Moro reflex
B. Rooting reflex [CORRECT]
C. Grasp reflex
D. Tonic neck reflex
Rationale: The rooting reflex is elicited by stroking the cheek or corner of the mouth,
causing the infant to turn toward the stimulus with mouth opening in preparation for
feeding. The Moro reflex is elicited by sudden movement or startle.
Correct Answer: B
Q4. A mother brings her 3-month-old infant for a well-child visit and asks when the "soft
spots" will close. Which statement by the nurse is most accurate?
A. The anterior fontanelle closes by 2-3 months and the posterior by 12-18 months
B. The posterior fontanelle closes by 2-3 months and the anterior by 12-18 months
[CORRECT]
C. Both fontanelles close by 6 months
D. The anterior fontanelle never fully closes
,Rationale: The posterior fontanelle closes at 2-3 months, while the anterior fontanelle
closes between 12-18 months. Early or delayed closure can indicate underlying
pathology such as hypothyroidism or hydrocephalus.
Correct Answer: B
Q5. An infant weighs 7 lbs 8 oz at birth. At the 6-month well-child visit, the mother asks
about expected weight. Which response is most accurate?
A. The infant should weigh approximately 22 lbs
B. The birth weight should have tripled by 5-6 months
C. The birth weight should have doubled by 5-6 months [CORRECT]
D. The infant should weigh approximately 30 lbs
Rationale: Birth weight typically doubles by 5-6 months and triples by 12 months. For
this infant, expected weight at 6 months is approximately 15 lbs (double the birth
weight).
Correct Answer: C
Q6. During a 4-month well-child visit, the mother states her infant has not yet rolled from
front to back. Which response is most appropriate?
A. Refer the infant immediately for developmental delay
B. Reassure the mother that rolling from front to back typically occurs by 4 months, and
back to front by 6 months [CORRECT]
C. Schedule an early intervention evaluation
D. Explain that rolling is not expected until 8 months
Rationale: Rolling from prone to supine typically emerges around 4 months, with supine
to prone by 6 months. Not rolling at exactly 4 months may be within normal variation,
though rolling should be monitored by the next visit.
, Correct Answer: B
Q7. A mother asks at the 6-month visit when her infant should sit without support.
Which response is accurate?
A. Most infants sit without support by 4 months
B. Most infants sit without support by 6 months [CORRECT]
C. Most infants sit without support by 9 months
D. Sitting without support is not expected until 12 months
Rationale: Independent sitting without support is a 6-month gross motor milestone. By 4
months infants sit with support, and by 9 months they typically pull to stand.
Correct Answer: B
Q8. The nurse is using the Denver II developmental screening tool for an 18-month-old.
Which domain is assessed by asking the child to stack two blocks?
A. Personal-social
B. Fine motor-adaptive [CORRECT]
C. Language
D. Gross motor
Rationale: Stacking blocks assesses fine motor-adaptive skills on the Denver II.
Personal-social includes smiling and waving, language includes following directions and
word use, and gross motor includes walking and jumping.
Correct Answer: B
Q9. A mother reports her 7-month-old infant cries intensely when she leaves the room
and clings to her when strangers approach. Which interpretation is most accurate?
Examination Actual Exam | Latest Update 2026/2027 | Verified
Answers | Pass Guaranteed - A+ Graded
Section 1: Pediatric Assessment: Birth to Adolescence (Q1-20)
Q1. A newborn is assessed at 1 minute of life: heart rate 110 bpm, respiratory effort
irregular and slow, some flexion of extremities, grimace with suctioning, and blue
extremities with a pink body. What is the 1-minute Apgar score?
A. 8
B. 7
C. 6 [CORRECT]
D. 5
Rationale: Heart rate >100 = 2; irregular respirations = 1; some flexion = 1; grimace = 1;
acrocyanosis = 1. Total = 6. A score of 7 would require regular respirations or active
motion, while 5 would indicate absent reflexes or cyanosis of the entire body.
Correct Answer: C
Q2. A newborn's physical assessment reveals a square window angle of 0°, heel-to-ear
maneuver with no resistance, and scrotal rugae covering the entire surface. Using the
Ballard score, what is the approximate gestational age?
A. 28 weeks
B. 32 weeks
C. 36 weeks
D. 40 weeks [CORRECT]
,Rationale: A square window of 0°, heel-to-ear without resistance, and complete scrotal
rugae are all physical maturity criteria consistent with term gestation (39-40 weeks) on
the New Ballard Score.
Correct Answer: D
Q3. During a newborn examination, the nurse strokes the infant's cheek and the infant
turns toward the stimulus with an open mouth. Which primitive reflex is being
demonstrated?
A. Moro reflex
B. Rooting reflex [CORRECT]
C. Grasp reflex
D. Tonic neck reflex
Rationale: The rooting reflex is elicited by stroking the cheek or corner of the mouth,
causing the infant to turn toward the stimulus with mouth opening in preparation for
feeding. The Moro reflex is elicited by sudden movement or startle.
Correct Answer: B
Q4. A mother brings her 3-month-old infant for a well-child visit and asks when the "soft
spots" will close. Which statement by the nurse is most accurate?
A. The anterior fontanelle closes by 2-3 months and the posterior by 12-18 months
B. The posterior fontanelle closes by 2-3 months and the anterior by 12-18 months
[CORRECT]
C. Both fontanelles close by 6 months
D. The anterior fontanelle never fully closes
,Rationale: The posterior fontanelle closes at 2-3 months, while the anterior fontanelle
closes between 12-18 months. Early or delayed closure can indicate underlying
pathology such as hypothyroidism or hydrocephalus.
Correct Answer: B
Q5. An infant weighs 7 lbs 8 oz at birth. At the 6-month well-child visit, the mother asks
about expected weight. Which response is most accurate?
A. The infant should weigh approximately 22 lbs
B. The birth weight should have tripled by 5-6 months
C. The birth weight should have doubled by 5-6 months [CORRECT]
D. The infant should weigh approximately 30 lbs
Rationale: Birth weight typically doubles by 5-6 months and triples by 12 months. For
this infant, expected weight at 6 months is approximately 15 lbs (double the birth
weight).
Correct Answer: C
Q6. During a 4-month well-child visit, the mother states her infant has not yet rolled from
front to back. Which response is most appropriate?
A. Refer the infant immediately for developmental delay
B. Reassure the mother that rolling from front to back typically occurs by 4 months, and
back to front by 6 months [CORRECT]
C. Schedule an early intervention evaluation
D. Explain that rolling is not expected until 8 months
Rationale: Rolling from prone to supine typically emerges around 4 months, with supine
to prone by 6 months. Not rolling at exactly 4 months may be within normal variation,
though rolling should be monitored by the next visit.
, Correct Answer: B
Q7. A mother asks at the 6-month visit when her infant should sit without support.
Which response is accurate?
A. Most infants sit without support by 4 months
B. Most infants sit without support by 6 months [CORRECT]
C. Most infants sit without support by 9 months
D. Sitting without support is not expected until 12 months
Rationale: Independent sitting without support is a 6-month gross motor milestone. By 4
months infants sit with support, and by 9 months they typically pull to stand.
Correct Answer: B
Q8. The nurse is using the Denver II developmental screening tool for an 18-month-old.
Which domain is assessed by asking the child to stack two blocks?
A. Personal-social
B. Fine motor-adaptive [CORRECT]
C. Language
D. Gross motor
Rationale: Stacking blocks assesses fine motor-adaptive skills on the Denver II.
Personal-social includes smiling and waving, language includes following directions and
word use, and gross motor includes walking and jumping.
Correct Answer: B
Q9. A mother reports her 7-month-old infant cries intensely when she leaves the room
and clings to her when strangers approach. Which interpretation is most accurate?
