Exam 2 pediatric questions Flashcards
The primary care pediatric nurse practitioner (PNP) is examining a 2-week-old infant and
auscultates a wide splitting of S during expiration. What condition may this finding
represent?
a. Atrial septal defect (ASD)
b. Coarctation of the aorta (COA)
c. Patent ductus arteriosis (PDA)
d. Ventricular septal defect (VSD)
ANS: A
A wide splitting of S without becoming a single sound on expiration may indicate increased
pulmonary flow, typical of atrial septal defect. Coarctation of the aorta may cause a systolic
ejection murmur. A patent ductus arteriosus has a characteristic machinery-like murmur. A
ventricular septal defect has a harsh, high-pitched, grade II to IV/VI holosystolic murmur.
The primary care pediatric nurse practitioner auscultates a new grade II vibratory,
mid-systolic murmur at the mid sternal border in a 4-year-old child that is louder when the
child is supine. What type of murmur is most likely?
a. Pathologic murmur
b. Pulmonary flow murmur
c. Still’s murmur
d. Venous hum
ANS: C
A Still’s murmur is characterized by a vibratory or musical low-grade sound, along the sternal
border, which is louder when the child is supine or during inspiration. It is usually heard in
children between the ages of 2 and 6 years old. Pathologic murmurs are usually harsh, not
vibratory. A pulmonary flow murmur has a soft, blowing sound and radiates to the lung fields.
A venous hum has a soft, high-pitched swishing sound.
During a well child assessment, the primary care pediatric nurse practitioner (PNP)
auscultates a harsh, blowing grade IV/VI murmur in a 6-month-old infant. What will the nurse
practitioner do next?
a. Get a complete blood count to rule out severe anemia.
b. Obtain an electrocardiogram to assess for arrhythmia.
c. Order a chest radiograph to evaluate for cardiomegaly.
d. Refer to a pediatric cardiologist for further evaluation.
ANS: D
A harsh, blowing murmur is suspicious for pathology, so a cardiology referral is warranted.
The cardiologist will determine which tests and procedures should be performed.
The primary care pediatric nurse practitioner provides primary care for a 4-month-old infant
who has a ventricular septal defect (VSD). The infant has been breastfeeding well but in the
past month has dropped from the 20th percentile to the 5th for weight. What will the nurse
practitioner recommend?
a. Adding solid foods to the infant’s diet to increase caloric intake
b. Fortifying breast milk to increase the number of calories per ounce
c. Stopping breastfeeding and giving 30 kcal/ounce formula
d. Supplementing breastfeeding with 24 kcal/ounce formula
ANS: B
Infants with heart defects who have congestive heart failure (CHF) may need modification of
formula or breast milk to increase calories. This infant is nursing well, so fortifying the breast
milk to increase calories is the first and best option. Adding solids does not significantly
increase caloric intake.
A 12-month-old infant who had cardiopulmonary bypass with red blood cell (RBC) and
plasma infusions during surgery at 8 months is seen for a well child examination. Which
vaccine may be administered at this visit?
a. Measles, mumps, and rubella (MMR)
b. oral polio vaccine (OPV)
c. Live-viruse (PCV-13)
d. Varivax
ANS: C
Live vaccines should be delayed until 6 months after cardiopulmonary bypass and exposure to
RBCs and plasma. The PCV-13 is not a live-virus vaccine and the others are.
The primary care pediatric nurse practitioner (PNP) performs a well child examination on a
12-month-old child who had repair of a congenital heart defect at 8 months of age. The child
has a normal exam. The parent reports that the child is not taking any medications. The nurse
practitioner will contact the child’s cardiologist to discuss whether the child needs which
medication?
a. Amoxicillin
b. Capoten
c. Digoxin
d. Furosemide
ANS: A
Children who have had complete repair of congenital heart defect (CHD) should have
subacute bacterial endocarditis (SBE) prophylaxis with amoxicillin for 6 months after the
procedure. Capoten, an antihypertensive, digoxin, an inotropic medication, and furosemide, a
diuretic, are given for specific symptoms as indicated
During a well baby examination of a 6-week-old infant, the primary care pediatric nurse
practitioner notes poor weight gain, acrocyanosis of the hands and feet, and a respiratory rate
of 60 breaths per minute. Oxygen saturation on room air is 93%. The remainder of the exam is
unremarkable. Which action is correct?
a. Follow-up in 1 week to assess the infant’s weight.
b. Order a chest radiograph and an electrocardiogram.
c. Reassure the parents that the exam is within normal limits.
d. Refer the infant to a pediatric cardiologist.
D
Infants with oxygen saturation less than 95% and those with poor feeding should be referred
emergently to a cardiologist. The infant may have congestive heart failure (CHF) and will
need to be evaluated.
A 3-month-old infant who was previously healthy now has a persistent cough, bilateral lung
crackles, and poor appetite. The primary care pediatric nurse practitioner auscultates a grade
III/VI, low-pitched, holosystolic murmur over the left lower sternal border and palpates the
liver at one centimeter below the ribs. What diagnosis is likely?
a. Atrial septal defect (ASD)
b. Coarctation of the aorta (COA)
c. Patent ductus arteriosis (PDA)
d. Ventricular septal defect (VSD)
ANS: D
The symptoms above are characteristic of a VSD and may not present at birth but appear later
as congestive heart failure (CHF) becomes more pronounced. An ASD typically does not have
a murmur until the child is 2 or 3 years old, but the provider can often hear a split S sound.
Coarctation of the aorta may cause a systolic ejection murmur. A PDA has a characteristic
machinery-like murmur.
An infant with trisomy 21 has a complete AV canal defect. Which finding, associated with
having both of these conditions, will the primary care pediatric nurse practitioner expect?
a. Crackles in both lungs
b. Hepatomegaly
c. Oxygen desaturation
d. Peripheral edema
ANS: C
Because infants with trisomy 21 maintain neonatal high pulmonary vascular resistance, they
often do not show signs of congestive heart failure (CHF) but instead will have signs of
pulmonary hypertension with loud single S and desaturation with agitation or effort.
Crackles, hepatomegaly, and edema are signs of congestive heart failure (CHF).
A 9-month-old infant has a grade III/VI, harsh, rumbling, continuous murmur in the left
infraclavicular fossa and pulmonic area. A chest radiograph reveals cardiac enlargement. The
primary care pediatric nurse practitioner will refer the infant to a pediatric cardiologist and
prepare the parents for which intervention to repair this defect?
a. Cardiopulmonary bypass surgery
b. Coil insertion in the catheterization laboratory
c. Indomethacin administration
d. Observation for spontaneous closure
ANS: B
This murmur is characteristic of a patent ductus arteriosus (PDA) and, because of cardiac
enlargement, represents a larger shunt, requiring repair. Infants older than 8 months of age
may have a coil or plug inserted into the shunt in the cardiac catheterization laboratory.
Cardiopulmonary bypass surgery is not indicated, even with ligation of the shunt.
Indomethacin is administered to premature infants in the early post-natal period and is not
useful in term or older infants. Because this infant is symptomatic, observation for
spontaneous closure is not recommended.
A 5-year-old child who had a repair for transposition of the great arteries shortly after birth is
growing normally and has been asymptomatic since the surgery. The primary care nurse
practitioner (PNP)notes mild shortness of breath with exertion and, upon questioning, learns
that the child has recently reported dizziness. What will the nurse practitioner do?
a. Order an echocardiogram and chest radiograph.
b. Perform pulmonary function testing.
c. Reassure the parent that these symptoms are common.
d. Refer the child to the cardiologist immediately.
ANS: D
Children with a history of transposition of the great arteries (d-TGA) who have a history of
palpitations, syncope, or shortness of breath should be referred to a cardiologist.
Echocardiograms should be performed annually under the supervision of the cardiologist.
Pulmonary function testing is not indicated. These symptoms may represent problems in
patency with the coronary arteries and are not common.
The primary care pediatric nurse practitioner (PNP) is performing a well child examination on
a school-age child who had complete repair of a tetralogy of Fallot (TOF)defect in infancy.
What is important in this child’s health maintenance regime?
a. Cardiology clearance for sports participation
b. Restriction of physical activity to avoid pulmonary complications
c. Sub-acute bacterial endocarditis prophylaxis precautions
d. Teaching about management of hypercyanotic episodes
ANS: A
Children who have had TOF repair must be cleared by cardiology before participation in
sports, but there is no need to restrict all physical activity. SBE prophylaxis is given prior to
surgery and for 6 months afterward. Hypercyanotic episodes occur before repair.
The primary care pediatric nurse practitioner (PNP) is performing a sports physical on an
adolescent whose history reveals mild aortic stenosis (AS). What will the nurse practitioner
recommend?
a. Avoidance of all sports to prevent sudden death
b. Clearance for any sports since this is mild
c. Evaluation by a cardiologist prior to participation
d. Low-intensity sports, such as golf or bowling
ANS: C
Children with mild AS may participate in any sport but must have annual cardiac evaluations.
Children with severe AS should avoid sports to prevent sudden death. The PNP should not
clear the child for sports without a cardiology evaluation. Low-intensity sports are
recommended for children with moderate AS
During a routine well child exam on a 5-year-old child, the primary care pediatric nurse
practitioner auscultates a grade II/VI, harsh, late systolic ejection murmur at the upper left
sternal border that transmits to both lung fields. The child has normal growth and
development. What will the nurse practitioner suspect?
a. Aortic stenosis (AS)
b. Patent ductus arteriosus (PDA)
c. Pulmonic stenosis
d. Tricuspid atresia
ANS: C
Pulmonic stenosis may be asymptomatic with a murmur as described above. Aortic stenosis is
characterized by a louder, harsh systolic crescendo-decrescendo murmur at the upper right
sternal border with radiation to the neck, LLSB, and apex. PDA has a machinery-like murmur.
Tricuspid atresia is characterized by cyanosis
A 5-year-old child has an elevated blood pressure during a well child exam. The primary care
pediatric nurse practitioner notes mottling and pallor of the child’s feet and lower legs and
auscultates a systolic ejection murmur in the left infraclavicular region radiating to the child’s
back. The nurse practitioner will suspect which condition?
a. Aortic stenosis (AS)
b. Coarctation of the aorta (COA)
c. Patent ductus arteriosus (PDA)
d. Pulmonic stenosis
ANS: B
Coarctation of the aorta may not have symptoms until later childhood and may present as high
blood pressure in the upper extremities and poor perfusion in the lower extremities. A systolic
ejection murmur at the left infraclavicular region with transmission to the back is
characteristic. Aortic stenosis is characterized by a louder, harsh systolic
crescendo-decrescendo murmur at the upper right sternal border with radiation to the neck,
lower left sternal border (LLSB), and apex. PDA has a machinery-like murmur. Pulmonic
stenosis may be asymptomatic or may have a harsh, late systolic ejection murmur at the upper
left sternal border that transmits to both lung fields.
