CHAPTER 16- Pediatrics

Question 1

A well 12-year-old child recently arrived from South Africa presents for a school physical. She received BCG immunization shortly after birth and is up to date with required immunizations. A PPD is placed and read at 48 hours. Likely findings include which of the following?

1. Negative PPD, no further follow-up
2. Negative PPD, child requires a follow-up chest X-ray
3. Positive PPD, no further follow-up
4. Positive PPD, child requires a follow-up chest X-ray

Answer 1

4. Positive PPD, child requires a follow-up chest X-ray

The BCG, or bacilli Calmette–Guérin, is a vaccine for TB. Many foreign-born persons have been vaccinated with the BCG vaccine, especially in countries where there is a high incidence of TB. It is likely that this child will have a positive PPD test. It is not possible to determine in this case, however, if the child has active TB without a chest X-ray.

Question 2

What behavior in a 2-year-old would be considered worrisome?

1. Ability to concentrate on a task for 2 minutes
2. Carrying a favorite toy around the house
3. Skipping pages in a book to find favorite shapes
4. Unable to walk downstairs holding a rail

Answer 2

4. Unable to walk downstairs holding a rail

The nurse practitioner should always be aware of typical expected growth and development parameters. At two years of age, normal expected gross motor skills include having the ability to walk up and down stairs without difficulty. The child should be evaluated further for other delays in gross motor, fine motor, or language/social skills.

Question 3

Baby Sabrina presents for her 6 month well child check-up. At 40 weeks gestation her documented birth weight was 6 lbs 6 oz, and length of 20 inches. Currently her weight is 10 lbs 4 oz and length is 24 inches. The nurse practitioner concludes the following:

1. The infant is failing to meet expected gains in weight only.
2. The infant is failing to meet expected gains in both weight and length.
3. All findings are within normal limits.
4. The findings are acceptable since the mother is 5 feet in height.

Answer 3

2. The infant is failing to meet expected gains in both weight and length.

Infants age 0–3 months gain approximately 1.4 inches in height per month. Baby Sabrina would be expected to have achieved 24 inches in height by 3 months of age. At 5–6 months of age, infants have usually doubled their birth weight.

Question 4

During a sports physical for an 18-year-old male high school student, which finding would require further follow-up?

1. Height of 5 feet 11 inches, and weight of 175 lbs
2. Tanner stage of 4
3. Snellen eye chart vision screening results of 20/25 in both right and left eyes
4. Scoliosis of the spine with a degree of curvature of approximately 10%

Answer 4

2. Tanner stage of 4

Typically, males age 13–18 will have developed to Tanner stage 5. An 18-year-old male that is in Tanner stage 4 should be evaluated for further growth and development deficits. Scoliosis of the spine of 10–15 degrees is generally not considered to be a problem unless the patient expressed concern or discomfort.

Question 5

A 7-year-old male child is brought to the clinic by his parents for evaluation. The child has no significant PMH. Approximately seven days ago he developed a cold and since then has had a persistent cough and fever. His older sister was also ill with cold symptoms at the same time. The NP performs a physical exam and notes that the child has mild tachypnea, with crackles in both bases and a pulse oximeter of 90%. His temperature is 100.8 °F. There are no wheezes auscultated. The NP suspects that the child has which of the following?

1. Bacterial pneumonia
2. Viral pneumonia
3. Bronchiolitis
4. Bronchitis

Answer 5

2. Viral pneumonia

The child presents clinically with pneumonia. Viral pneumonia generally has a gradual onset with less acute symptoms and a low-grade fever. It is usually preceded by an upper respiratory infection. Wheezes are not present in children with pneumonia.

Question 6

For the 7-year-old child described in the previous question, what does the FNP expect to find on auscultation of the lungs?

1. Crackles in a portion of a lung field, no wheezing
2. Wheezing in most of the lung fields
3. Rales and wheezing in the lower lung bases
4. Normal breath sounds in all but one lung field, which will have decreased breath sounds

Answer 6

1. Crackles in a portion of a lung field, no wheezing

The absence of wheezing is a positive predictor for children with pneumonia.

Question 7

For the 7-year-old child described earlier, what will the FNP have as part of the plan of care?

1. Supportive care, return to office in one week, call if worsening symptoms
2. CXR now, hospitalization to pediatric unit
3. Bronchodilator via nebulizer now, IV fluids in emergency department after nebulizer
4. CXR now, supportive care at home; call in one day or if any worsening of symptoms; return to office in 2 days for follow-up evaluation

Answer 7

4. CXR now, supportive care at home; call in one day or if any worsening of symptoms; return to office in 2 days for follow-up evaluation

All children with a diagnosis of pneumonia should be carefully monitored. The child has a classic viral pneumonia presentation, which tends to be less severe and can be cared for at home.

Question 8

A 6-month-old male is being seen with his caretaker for a barking cough which is making the caretaker anxious. The baby seems to have mild respiratory distress and the oximetry reads at 94%. The FNP sends the baby for a CXR. What findings are likely to be reported?

1. Ground glass appearance over affected lung field(s)
2. Pneumothorax of an upper lung field
3. Steeple-shaped appearance with narrowing in upper airway
4. CXR will have normal markings

Answer 8

3. Steeple-shaped appearance with narrowing in upper airway

Children with croup will usually present with a brassy bark sounding cough, inspiratory stridor, and a steeple sign (or wineglass) appearance on a chest X-ray.

Question 9

The most common organism responsible for otitis media is which of the following?

1. Haemophilus influenzae
2. Adenovirus
3. Streptococcus pneumonia
4. Staphylococcus aureus

Answer 9

3. Streptococcus pneumonia

Streptococcus pneumonia is the most common organism responsible for otitis media. Amoxicillin remains the first choice of treatment for otitis media with a suspected bacterial etiology.

Question 10

A 19-year-old mother brings her 2½-month-old-boy to your clinic with a concern that the baby has become less interested in his feedings over the past 2 or 3 days, taking in only about half the normal amount of formula before becoming tired and falling asleep. His birth history is normal and he has normal development and weight gain. His temperature is 100.2 °F (axillary) now. He has no respiratory symptoms and your physical examination reveals no identifiable source of fever. Which of the following questions/observations would be MOST helpful in establishing a diagnosis?

1. “Is anyone else at home ill at this time?”
2. “How sick do you think he is?”
3. “Has he ever had a temperature before?”
4. “Did you have any infection or rash when you were pregnant?”

Answer 10

1. “Is anyone else at home ill at this time?”

The child’s symptoms are consistent with the prodromal phase of a viral or bacterial infection. Asking if there are sick contacts would provide the most valuable information at this point in time.

Question 11

Which of the following infants are susceptible to respiratory syncytial virus (RSV) and bronchitis in the first year of life?

1. Term infant with chronic rhinitis
2. Very low birth weight infants
3. Term infant with hypospadias
4. 38-week gestation infant with feeding problems

Answer 11

2. Very low birth weight infants

Although all infants are at risk for RSV, low birth weight infants, infants younger than 6 months of age, premature infants, and infants with an underlying condition such as heart or lung disease are at highest risk. By two years of age, almost all children will have had RSV.

Question 12

A 4-week-old infant presents to the office in mid-January with a one-week history of nasal congestion and occasional cough. On the evening prior to this visit, she developed a temperature of 102 °F, refused to breast feed, had paroxysmal coughing, and noisy, labored breathing. Patient is an ill-appearing infant who is lethargic with tachypnea and intercostal retractions. She has a 4-year-old sibling who is in day care and who recently had a “cold.” Considering the clinical presentation, what is the most likely cause of this infant’s illness?

1. Mycoplasma pneumonia
2. RSV bronchiolitis
3. Aspiration pneumonia
4. Streptococcal infection of the pharynx

Answer 12

2. RSV bronchiolitis

The child has many risk factors associated with RSV, including a sibling in day care, along with the time of year. The child’s clinical presentation is consistent with RSV bronchiolitis.

Question 13

A 9-year-old child’s symptoms occur four times a week during the day and three times during the night, with an FEV1 of 80%. What would be the severity classification per the National Asthma Education and Prevention Program?

1. Severe persistent
2. Moderate persistent
3. Mild persistent
4. Mild intermittent

Answer 13

2. Moderate persistent

The child’s symptoms are consistent with the diagnosis of moderate persistent asthma per the GINA (Global Initiative for Asthma) guidelines.

Question 14

An 8-year-old male has mild persistent asthma. Appropriate daily medication should include which of the following?

1. An inhaled low-dose corticosteroid
2. Short-acting beta2-agonists
3. An oral systemic corticosteroid
4. A cough suppressant

Answer 14

1. An inhaled low-dose corticosteroid

A child with mild persistent asthma should be using the stepwise approach to management. Per GINA guidelines, the child with mild persistent asthma should be using an inhaled low-dose corticosteroid to control symptoms.

Question 15

A 3-month-old female is brought to the office for a routine examination and numerous bruises in varying stages are noted on the infant’s back and legs. The mother gets very upset when asked about the bruises and starts to cry. She refuses to talk any more about the bruises or how this may have happened. A necessary next step for this scenario is which of the following?

1. Explain to the mother that she has to leave the baby with the office staff for Department of Children and Families to come and get her.
2. Discuss with the mother that sometimes congenital bleeding issues can cause these types of bruises and make an appointment for her to return with the baby in 2 days for bloodwork.
3. Explain to the mother that bruises such as these are uncommon in a 4-month-old, and further assessment, including a skeletal body scan, is required.
4. Ask the mother to call the baby’s father to come to the office so that the family can be interviewed regarding child abuse.

Answer 15

3. Explain to the mother that bruises such as these are uncommon in a 4-month-old, and further assessment, including a skeletal body scan, is required.

Any child with unexplained bruises (especially in children who are not yet mobile) is required to have a full skeletal body scan.

Question 16

According to the developmental theory of Erikson, if the needs of the infant are met in a consistent manner, the infant will develop which of the following?

1. Independence
2. Responsibility
3. Trust
4. Love

Answer 16

3. Trust

According to the developmental theorist, Erikson, it is essential for an infant’s needs to be met so they may develop trust in the world around them (Trust vs. Mistrust stage).

Question 17

The ability of an infant to turn his head to the side when lying prone occurs during the _______ month of life.

1. first
2. second
3. fourth
4. sixth

Answer 17

1. first

A neonate’s normal gross motor skill development should include the ability to turn his/her head during the first month of life when placed in a prone position.

Question 18

According to the vaccination schedule recommendations, the IPV (polio) vaccine, the DTaP (diptheria—tetanus-acellular pertussis), Haemophilis influenzae type B (HIB), Rotavirus (RSV1) pneumoccal vaccine (Prevnar-13), and second hepatitis B vaccine are given at _______ month(s) of age.

1. 1
2. 2
3. 3
4. 4

Answer 18

2. 2

This is in accordance with the recommended vaccination schedule for children, as defined by the CDC.

Question 19

An infant would be expected to begin babbling and laughing by what age?

1. 0–3 months of age
2. 3–6 months of age
3. 6–9 months of age
4. 8 months of age

Answer 19

2. 3–6 months of age

Normal social development includes the ability for the infant to laugh and babble between the ages of 3 and 6 months. Infants that are not performing this behavior should be evaluated for further developmental delays.

Question 20

Most infants will begin to crawl around at ___________.

1. 4–6 months
2. 7–9 months
3. 8–10 months
4. 10–12 months

Answer 20

2. 7–9 months

This is the most common age for development of this gross motor skill.

Question 21

The first solid food item that should be introduced into an infant’s diet is ____________.

1. vegetables
2. meat
3. fruit
4. cereal

Answer 21

4. cereal

Rice cereal is the least likely food to cause an allergic reaction in an infant and is generally considered to be the first recommended solid food.

Question 22

The initial MMR (measles, mumps, rubella) vaccine is recommended at _____________.

1. 12 to 15 months of age
2. 6 months of age
3. birth
4. 9 months of age

Answer 22

1. 12 to 15 months of age

Per CDC guidelines for childhood vaccinations.

Question 23

An infant develops increased coordination between his index finger and thumb and is now able to pick up small objects. This is known as what?

1. Grasp reflex
2. Moro reflex
3. Pincer reflex
4. Palmar reflex

Answer 23

3. Pincer reflex

Infants typically develop the pincer reflex at approximately 12 months of age. Anticipatory guidance includes teaching the parents that the child is at higher risk for choking/poisoning and putting foreign objects in their nares, mouth, or ears.

Question 24

The fine motor developmental ability that would be demonstrated first in the infant would be the ability to ____________.

1. pinch with the fingers
2. grasp with the hands
3. throw an object
4. intentionally release an object

Answer 24

2. grasp with the hands

Grasping with the hands precedes the ability to perform more higher-level fine motor tasks such as throwing an object or intentionally releasing an object.

Question 25

An infant’s birth weight is 7 pounds 5 ounces. What would the nurse practitioner expect the infant to weigh at 6 months of age?

1. 12 pounds
2. 15 pounds
3. 18 pounds
4. 22 pounds

Answer 25

2. 15 pounds

An infant is expected to double his/her body weight at 6 months of age.

Question 26

A father brings his 2-year-old to the clinic. He verbalizes frustration with the child’s willfulness and states that he would like to know what the best form of discipline would be for his child. The nurse practitioner responds that:

1. A gentle spanking works best because it is the most effective.
2. A 5-minute time-out is most effective.
3. A 2-minute time-out is most effective.
4. Discipline should be individualized to the child and family and based on social and cultural preferences.

Answer 26

3. A 2-minute time-out is most effective.

The recommended form of discipline for a child is to use the “timeout” strategy. Most young children can sit in “timeout” for the same amount of minutes that is equal to what their age is in years.

Question 27

One indication that the toddler is ready to toilet train is:

1. The child has the ability to climb up on the toilet.
2. The child has the ability to stay dry for one hour.
3. The child is able to communicate that he or she is wet or needs to urinate or defecate.
4. The child is willing to sit on the potty for at least 5 minutes.

Answer 27

3. The child is able to communicate that he or she is wet or needs to urinate or defecate.

Children are ready to toilet train when they are able to communicate their need and interest in doing so to their parents.

Question 28

Which type of play do 2-year-old toddlers most commonly exhibit?

1. Associative play
2. Team play
3. Solitary play
4. Parallel play

Answer 28

4. Parallel play

Young toddlers will often prefer to sit near other children when playing but typically their play is not associated with the other children.

Question 29

The nurse practitioner provides anticipatory guidance to the parents/guardians at every well-child visit. The NP is aware that the leading cause of death in infants and children is _________.

1. accidents
2. child abuse
3. SIDS
4. drowning

Answer 29

1. accidents

Per U.S. national statistics, accidents remain the number one cause of death in children.

Question 30

A parent is frustrated with her 2-year-old’s inability to share her toys with siblings or playmates. The NP explains to the parent that a toddler has difficulty seeing anyone else’s point of view and that this is a normal part of development and is referred to as ________________.

1. negativism
2. ambivalence
3. egocentric thinking
4. autonomy

Answer 30

3. egocentric thinking

Egocentricity is commonly seen in toddlers as they develop a sense of self that is separate from their primary caregivers.

Question 31

The stage that Erikson identified as a developmental stage for a toddler is the stage of:

1. Trust versus mistrust.
2. Autonomy versus shame and doubt.
3. Initiative versus guilt.
4. Industry versus inferiority.

Answer 31

2. Autonomy versus shame and doubt.

Erikson associated the second developmental stage to occur in toddlerhood and is closely tied to the child’s ability to develop and accomplish tasks such as toilet training.

Question 32

A mother brings her child in for a well-child visit. She states that she is concerned that her child is exhibiting unusual behaviors. She states that her toddler insists on wearing his cowboy boots to bed and asks for the same bedtime story every night. The nurse practitioner reassures the parent that this is normal behavior for a toddler and that the behavior, which is known as “ritualism,” helps the child to develop ________________________.

1. control of his/her surroundings
2. a sense of security and mastery of the world around him/her
3. independent thinking and autonomy
4. a feeling of love and belonging

Answer 32

2. a sense of security and mastery of the world around him/her

Most toddlers will prefer consistency and daily rituals to increase their sense of understanding of the world around them and promote a sense of security and belonging.

Question 33

The nurse practitioner provides anticipatory guidance as well as education to the parents at each well-child visit. The parents of a preschool child verbalize that they are concerned because their child is still experiencing enuresis at night, although he has daytime dryness and control. The nurse practitioner tells the parents that the most effective way to manage this situation is for the parents to do which of the following?

1. Be firm and consistent and provide immediate discipline each time this happens
2. Teach the child to remove the sheets and put them in the hamper so that the child understands there are repercussions to this behavior.
3. Tell the child that he is behaving like a baby and that he may need to return to wearing diapers at night.
4. Recognize that it can be normal for a preschool child to experience enuresis.

Answer 33

4. Recognize that it can be normal for a preschool child to experience enuresis.

Children will often continue to have bed-wetting episodes during sleep for many months after they have achieved daytime dryness. Parents need to be educated that this is most likely not an intentional act by the child.

Question 34

When engaging in play, it is common for a 3-year-old to do which of the following?

1. Play cooperatively with other children for extended period of time
2. Play well with new friends
3. Revert to parallel play if placed in a situation with children they do not know
4. Share toys eagerly and willingly

Answer 34

3. Revert to parallel play if placed in a situation with children they do not know

Three-year-olds may begin to demonstrate associative play. However, when placed in an unfamiliar environment, the child may revert to a more comfortable type of play, such as parallel play.

Question 35

The nurse practitioner observes that a three-year-old has amblyopia. The nurse practitioner recommends that the parents patch the stronger eye for 2–6 hours every day. The NP explains to the parents that patching the unaffected (stronger) eye will:

1. Reinforce the connection between the brain and the weaker eye.
2. Cause a gradual change in the structure and function of the lens of the weaker eye.
3. Decrease abnormal eye muscle movement in the weaker eye.
4. Decrease sensory input to the brain from both eyes.

Answer 35

1. Reinforce the connection between the brain and the weaker eye.

Patching the stronger eye reinforces connections between the brain and the weaker eye. Occlusion therapy has been the mainstay of treatment for amblyopia. The endpoint eye goal of occlusive therapy is equal visual acuity in both eyes. Once visual acuity has stabilized, patching may be decreased slowly and the child should be monitored for reoccurrence.

Question 36

Erikson believed that the school-age child is in which stage?

1. Initiative versus guilt
2. Identity versus role confusion
3. Industry versus inferiority
4. Autonomy versus shame and doubt

Answer 36

3. Industry versus inferiority

According to Erikson, the school-age child is in the industry versus inferiority stage. During this stage, children become capable of performing increasingly complex tasks. Children who are encouraged to complete tasks may develop feelings of self-confidence. Children that do not receive encouragement from parents, teachers, or peers will doubt their ability to be successful and will feel inferior to others their own age.

Question 37

A 5-year-old female child is brought to the clinic by her mother. The mother verbalizes concern that the child has been sick for three days with a fever, malaise, and blisters in her mouth and on the palms of her hands. The NP performs a physical exam and notes a tympanic temperature of 101.2 °F and observes that the blisters are also observed on the soles of the child’s feet. With this information, the NP diagnoses the child with which of the following?

1. Coxsackie virus
2. Impetigo
3. Apthous ulcers
4. Bronchitis

Answer 37

1. Coxsackie virus

The child presents clinically with coxsackie virus. The mother should be reassured that the virus is self-limiting. Treatment is based on symptoms and the child should be monitored for any development of complications such as encephalitis.

Question 38

The nurse practitioner is evaluating a 3-month-old infant at the well-baby clinic. The NP places her hands on the infant’s knees and her thumbs on the middle of the thigh. She applies gentle pressure on the hips and slowly abducts the hips simultaneously. The NP hears and feels a “clunking” sound when she does this. This is known as what?

1. A positive Barlow maneuver
2. A positive test for Genu-varum
3. A positive Ortolani’s test
4. A positive test for Talipes equinovarus

Answer 38

3. A positive Ortolani’s test

The infant demonstrates a positive Ortolani’s test and needs to be further evaluated for hip dysplasia.

Question 39

A 16-year-old engages in a risky behavior such as driving while drunk. The parent asks the adolescent “Why would you do something that you know is so stupid?” The 16-year-old replies “I don’t know.” One possible explanation for this answer is that:

1. Most adolescents do not think of the repercussion of getting caught.
2. Most adolescents believe that bad things only happen to other people.
3. Most adolescents have not formed the physiological connections within the brain that connects the prefrontal cortex with the limbic system.
4. Most adolescents have not developed the ability to perform concrete operational thinking.

Answer 39

3. Most adolescents have not formed the physiological connections within the brain that connects the prefrontal cortex with the limbic system.

Behavioral neuroscientists have speculated that the “pruning” of neurons that occurs in the prefrontal cortex occurs gradually over the period of time between childhood and adulthood. This “pruning” allows for greater control of behavior and less impulsivity and poor decision making.

Question 40

The mother of a 14-year-old female child verbalizes concern that her daughter is losing weight and exercising for several hours a day. The NP performs a complete history and physical exam on the 14-year-old adolescent. Which of the following is not a characteristic associated with anorexia nervosa?

1. Amenorrhea that may last 3 months or longer
2. Low self-esteem
3. Improvement in body image as weight loss occurs
4. Feelings of helplessness

Answer 40

3. Improvement in body image as weight loss occurs

Anorexia nervosa is a mental illness with a high mortality rate. The patient demonstrates an intense fear of weight gain, obsession with weight, and a persistent behavior to prevent weight gain. Most patients are unable to recognize or appreciate the severity of the situation even in the presence of severe starvation and impending death.

Question 41

The nurse practitioner is performing an assessment on a preterm neonate. The neonate was born at 34 weeks gestation. The NP observes the following: acrocyanosis, heart rate is 90, facial grimacing in response to stimulation, a weak cry, and mild flexion of the extremities. The assessment is done at both 1 minute and 5 minutes and remains unchanged during that time. The APGAR score for this neonate is which of the following?

1. 3
2. 5
3. 7
4. 9

Answer 41

2. 5

Using the APGAR rating scale, each of the five characteristics the neonate is demonstrating is assigned 1 point each. Therefore, the neonate would receive a score of 5.

Question 42

The NP is performing a physical assessment on a 3-year-old child. The NP notes that there is a marked difference in blood pressure between the upper and lower extremities and observes that the lower extremities are slightly mottled in appearance. The NP suspects that the child may have which of the following?

1. Patent ductus arteriosis
2. Tetrology of Fallot
3. Coarctation of the aorta
4. Hypertrophic obstructive cardiomyopathy

Answer 42

3. Coarctation of the aorta

A child with coarctation of the aorta will exhibit a higher blood pressure above the area of coarctation and a lower pressure below the area of coarctation. Occasionally, the arterial flow to the lower extremities can be severe enough to cause mottling.

Question 43

A child with known tetralogy of Fallot may have hypercyanotic episodes, which are sometimes referred to as “TET” spells. During these spells, the child should be held or placed in a knee–chest position or squatting position. This maneuver will:

1. Increase systemic resistance which will decrease the right to left shunting of blood across the VSD and thus increase pulmonary blood flow.
2. Decrease systemic resistance and increase the right to left shunting, increasing pulmonary blood flow.
3. Increase pulmonary blood flow by increasing venous return and decreasing afterload.
4. Mimic the Valsalva maneuver, decrease the heart rate, and decrease pre-load.

Answer 43

1. Increase systemic resistance which will decrease the right to left shunting of blood across the VSD and thus increase pulmonary blood flow.

In the case of tetralogy of Fallot, increasing systemic resistance will allow for increased blood flow through the pulmonary artery. A characteristic of infants and children with tetralogy of Fallot is to place themselves in a squatting position. Frequent squatting is a compensatory mechanism of diagnostic significance.

Question 44

A nurse practitioner is performing a sports physical on a 15-year-old male entering high school. The young male wants clearance to be allowed to play on the high school football JV team. The NP auscultates a systolic murmur in between the apex and the LLSB when he performs the Valsalva maneuver. The NP asks the patient to squat and then stand, when standing after squatting, the murmur becomes markedly louder. The NP suspects which of the following?

1. An innocent murmur
2. Hypertrophic obstructive cardiomyopathy
3. Pulmonic stenosis
4. Coarctation of the aorta

Answer 44

2. Hypertrophic obstructive cardiomyopathy

It is essential that the nurse practitioner can distinguish an innocent or functional murmur from the murmur of hypertrophic obstructive cardiomyopathy. While many of the characteristics are similar, a person with HCM will have an increase in the intensity of the murmur during both the Valsalva maneuver and when standing after squatting.

Question 45

The NP is evaluating a 5-year-old female child that has been brought into the clinic by her mother for a sick visit. The mother states that the child has had a “cold” for approximately one week. The NP observes coryza, conjunctivitis, and the child’s temperature is 103 °F. The NP performs an oral exam and observes Koplik’s spots in the child’s mouth. Which of the following questions will be most helpful to assist the NP in formulating a diagnosis?

1. “What medications have you tried up to this point to treat the child?”
2. “Can you supply me with your child’s immunization records?”
3. “Is there anyone else sick at home?”
4. “Does the coughing awaken your child during the night?”

Answer 45

2. “Can you supply me with your child’s immunization records?”

The child presents with symptoms of the measles. It would be essential for the NP to ascertain if the child has received the MMR and if the child missed any doses of the recommended schedule for vaccinations.

Question 46

A 4-year-old African American female is brought in to the clinic by her mother. She has been complaining of intermittent abdominal pain around the right flank area. The NP performs an abdominal assessment and palpates a mass in the lower left quadrant. The NP suspects a Wilm’s tumor. The NP stops any further palpation of the abdomen and orders imaging. The reason for this is because:

1. Further palpation may interfere with the renal ultrasound results.
2. Further palpation may illicit the abdominal pain and promote guarding.
3. Further palpation may cause rupture of the mass into the peritoneal cavity.
4. Further palpation may elicit rebound tenderness.

Answer 46

3. Further palpation may cause rupture of the mass into the peritoneal cavity.

Physical exam often will reveal a palpable abdominal mass. The abdominal mass should be carefully examined. Palpating a mass too vigorously could lead to rupture of the Wilm’s tumor into the peritoneal cavity.

Question 47

An acyanotic heart condition can be characterized as a condition where:

1. There is a shunting of blood from the left side of the heart to the right side of the heart.
2. Spontaneous closure of the congenital heart malformation will commonly occur.
3. There is a shunting of blood from the right side of the heart to the left side of the heart.
4. Open heart surgery is commonly performed after the child reaches the age of 1 year.

Answer 47

1. There is a shunting of blood from the left side of the heart to the right side of the heart.

The shunting of blood from an area of high pressure (left side of the heart) to an area of lower pressure (right side of the heart) occurs when there is an opening between the two sides that allows for a mixing of deoxygenated and oxygenated blood.

Question 48

Transposition of the great arteries (TGA) is a cyanotic defect with a 90% mortality rate within the first year of life. Which of the following conditions will increase the infant’s chances of survival?

1. The infant was born at 42 weeks gestation.
2. The infant has at least one other heart defect.
3. The infant is female.
4. The infant has no other congenitally acquired defects.

Answer 48

2. The infant has at least one other heart defect.

Transposition of the great arteries (TGA) is a cyanotic defect that is not conducive to survival unless the infant has at least one other heart defect that would allow for the mixing of oxygenated and deoxygenated blood.

Question 49

A 7-year-old child is brought in to the office for a sick visit evaluation by both of her parents. The child’s parent’s state that the child has had a cold for 4 days that has been associated with fever and a headache. The NP observes that the child’s cheeks are reddened and appear as if the child was recently slapped on both sides of the face. With this information, the NP:

1. Suspects child abuse and files a report in good faith with the Department of Family and Children’s Services.
2. Suspects meningitis and refers the child to neurology for further workup.
3. Prescribes liquid Amoxicillin 30 mg/kg/day divided into Q12 hour doses for 7 days.
4. Explains to the parents that only supportive therapy is necessary to treat her symptoms, and that the condition will resolve on its own.

Answer 49

4. Explains to the parents that only supportive therapy is necessary to treat her symptoms, and that the condition will resolve on its own.

The child has a classic presentation of parvovirus B19 (Fifth disease). The parents should be educated that it is a viral disease that requires only supportive therapy, while allowing the virus to run its course. The parents should also be told that the child may develop a rash on the trunk or back within a few days. Most adults are immune to the disease. However, pregnant woman should be cautioned to avoid exposure to a child with known parvovirus as it has been associated with spontaneous abortion in pregnant women that do not have immunity.

Question 50

The NP is performing a physical exam on a 4-year-old male child at a well-child visit. The child falls within the 80th percentile for height and weight. The NP auscultates a systolic murmur that is grade II/VI and is most clearly auscultated at the LLSB. There is no radiation. The murmur disappears when the child performs a Valsalva maneuver or changes position. VS and ECG are all WNL. Based on these clinical findings, the nurse practitioner:

1. Suspects a ventricular-septal defect (VSD) and sends the child for a pediatric echocardiogram.
2. Suspects hypertrophic obstructive cardiomyopathy (HCOM) and refers the child for an immediate cardiology workup.
3. Suspects a physiologic murmur.
4. Suspects patent ductus arteriosis (PDA) and refers the child to cardiology for follow-up with an interventional radiologist.

Answer 50

3. Suspects a physiologic murmur.

The child exhibits symptoms of a physiologic murmur with a classic presentation. The NP would continue to assess the murmur at each visit and could expect that the child will remain asymptomatic and eventually outgrow the condition.