Obstetrics and Pediatrics

Question 1

Which of the following signs would you MOST likely observe in a 2-month-old infant with a fever?

A) Shivering
B) Bradypnea
C) Tachycardia
D) Skin mottling

Answer 1

Answer: C

Tachycardia is a common response of the child to many factors, both intrinsic and extrinsic. It is very common to see tachycardia and tachypnea in response to fever. Flushing (redness) of the skin also is common. Small children cannot shiver as readily as older children and adults. This puts them at greater risk for hypothermia.

Question 2

You are called to treat a 2-year-old boy with respiratory distress, fever, and poor feeding. The child’s mother states that her son has had a recent productive cough. Assessment reveals decreased breath sounds in the lower left lobe of the lung. These findings are MOST consistent with:

A) croup.
B) asthma.
C) pneumonia.
D) bronchiolitis.

Answer 2

Answer: C

Respiratory distress in a child with a history of recent lower respiratory tract infection symptoms (productive cough), fever, and poor feeding suggests pneumonia. This field impression is reinforced by the decrease in breath sounds to a localized lung field. Croup is unlikely because of the absence of the characteristic seal-like barking cough. Bronchiolitis and asthma are also unlikely because they both present with wheezing, which this child does not have.

Question 3

After delivery of a newborn, you note the presence of thick meconium in the amniotic fluid. Your assessment reveals that the infant is crying, has good muscle tone, and a heart rate of 120 beats/min. You should:

A) thoroughly suction the mouth and nose.
B) ventilate the infant with a bag-mask device.
C) give blow-by supplemental oxygen at 5 L/min.
D) stimulate the infant to increase its breathing rate.

Answer 3

Answer: A

Treatment for meconium-staining depends on whether or not the newborn is vigorous. If the newborn is vigorous (good muscle tone, strong cry, and adequate heart rate), thoroughly suction the mouth and nose and continue with your assessment. If the newborn is not vigorous, tracheal suctioning should be performed; however, this is a skill that can only be performed by a paramedic. The newborn in this scenario does not require further stimulation or assisted ventilation because he is breathing adequately. Blow-by oxygen may be required if the newborn has central cyanosis, but this assessment is made after ensuring a patent airway.

Question 4

The fragile parenchyma of a child’s lungs makes them prone to:

A) hypoxemi
B) pneumonia.
C) hypocarbia.
D) barotrauma.

Answer 4

Answer: D

The fragile parenchyma (tissue) of a child’s lungs makes them especially prone to barotrauma (pressure trauma), such as a pneumothorax, as the result of injury or overzealous ventilation. In general, infants and small children are more prone to pneumonia because of their relatively immature immune systems.

Question 5

A 5-year-old child presents with a decreased level of consciousness, respiratory distress, and cyanosis. His heart rate is 50 beats/min and weak. You should:

A) ventilate with a bag-mask device.
B) start an IV line and give a fluid bolus.
C) begin chest compressions at once.
D) insert an advanced airway device.

Answer 5

Answer: A

Considering the fact that respiratory failure is the most common cause of cardiac arrest in infants and children, any infant or child who presents with a heart rate of less than 60 beats/min and poor perfusion (decreased level of consciousness, cyanosis) should immediately receive positive-pressure ventilation with a bag-mask device. If bag-mask ventilation does not improve the child’s heart rate, begin chest compressions. If you are unable to effectively ventilate with a bag-mask device, an advanced airway device should be inserted. Fluid boluses may be indicated if the child has signs of dehydration; however, this should not precede the restoration of adequate ventilation and oxygenation.

Question 6

After providing the appropriate management to a child who you suspect has been physically abused, your next action should be to:

A) confront the caregiver about your suspicions.
B) report your suspicions to the receiving facility.
C) document that you believe the child was abused.
D) notify the police and have the caregiver arrested.

Answer 6

Answer: B

After treating the child’s injuries, you are legally obligated to report all cases of suspected abuse to the receiving facility. Verbally accusing parents or caregivers of abuse could lead to allegations of slander if you are wrong. Documenting that you believe a child has been abused could lead to allegations of libel. When you document this or any other case, remain objective and only document factual data, not your opinion.

Question 7

What is the MOST appropriate rate for fluid rehydration in a 6-month-old infant with a decreased level of activity, pallor, absence of tearing, and dry mucous membranes?

A) 10 mL/kg
B) 20 mL/kg
C) 125 mL/h
D) 200-mL bolus

Answer 7

Answer: B

The infant in this scenario is severely dehydrated and has signs of shock (decreased level of activity, pallor). According to the American Academy of Pediatrics, children older than 1 month of age should receive fluid boluses at 20 mL/kg, followed by reassessment. Neonates (birth to 1 month) should receive fluid boluses at 10 mL/kg, followed by reassessment. Normal saline, an isotonic crystalloid, is the preferred fluid for patients with dehydration and shock.

Question 8

Febrile seizures in children are caused by:

A) ear, nose, or throat infections.
B) an abrupt rise in body temperature.
C) toxic ingestions that produce fever.
D) dangerously high body temperatures.

Answer 8

Answer: B

Febrile seizures, which most commonly affect children, are the result of fever and fever alone. They are caused by an abrupt rise in body temperature in which the hypothalamus in the brain does not have time to accommodate. Any process that can result in fever can result in a febrile seizure. A febrile seizure is not necessarily caused by how high the fever rises, but how quickly it rises.

Question 9

A 7-year-old boy complains of abdominal pain. He is lying on the couch with his knees flexed and drawn up into his chest. He is conscious and alert, but in severe pain. Appropriate assessment of this child’s abdomen includes:

A) applying firm pressure to the painful area to determine if peritoneal inflammation is present.
B) auscultating bowel sounds for approximately 5 minutes to determine if the bowel is obstructed.
C) examining the remainder of the abdomen before focusing on and palpating the painful area.
D) palpating the most painful area first so that you can compare it with other, less painful areas.

Answer 9

Answer: C

When examining a patient who has abdominal pain, you should palpate the painful area last. Palpating the painful area first increases the patient’s pain and may skew further evaluation of the abdomen. This is especially true in children. Vigorous palpation of the abdomen should be avoided as this only increases the patient’s pain. Auscultation of bowel sounds in the prehospital setting is of minimal value.

Question 10

A mother of two other children is 38 weeks’ pregnant and is experiencing contractions. Which of the following BEST describes her obstetric history?

A) Gravida 1, para 2
B) Gravida 2, para 3
C) Gravida 3, para 2
D) Gravida 4, para 3

Answer 10

Answer: C

Gravida refers to the number of times a woman has been pregnant, regardless of whether she carried to term. Para refers to the number of pregnancies carried beyond 28 weeks, regardless of whether the baby was delivered dead or alive. This patient has two children and is 38 weeks’ pregnant with a third; therefore, she is gravida 3, para 2 (she has yet to deliver the third child). When she delivers, she will become gravida 3, para 3.

Question 11

A 3-year-old girl presents with respiratory distress after a recent upper respiratory infection. Your assessment reveals that she is listless and pale. Her heart rate is 70 beats/min and weak. Initial treatment for this child should include:

A) positive-pressure ventilations.
B) a nebulized bronchodilator.
C) blow-by oxygen at 5 L/min.
D) 20 mL/kg normal saline boluses.

Answer 11

Answer: A

This child is not ventilating adequately and needs positive-pressure ventilation assistance. The leading cause of atraumatic cardiac arrest in infants and children is respiratory failure; therefore, aggressive ventilatory support is critical. Signs of impending respiratory failure in a child include bradycardia, an altered mental status, and pale or cyanotic skin. If the child’s heart rate is less than 60 beats/min with signs of poor perfusion despite positive-pressure ventilation, you should begin chest compressions.

Question 12

A 4-year-old child has partial-thickness burns to the entire head and anterior chest. What percentage of the total body surface area does this represent?

A) 0.18
B) 0.21
C) 0.24
D) 0.28

Answer 12

Answer: C

The Rule of Nines is modified accordingly for infants and children. In infants less than 1 year of age, the head accounts for 18% of the total body surface area (TBSA). For each year of age over 1, you should subtract 1% from the head and add 0.5% to each leg. This formula should be used until the adult Rule of Nines values are reached. Therefore, a 4-year-old child’s head would account for 15% of the TBSA. The anterior torso (chest and abdomen) of an infant or child accounts for 18% of the TBSA; therefore, the anterior chest (half of the torso) would account for 9% of the TBSA. The head (15%) and anterior chest (9%) of a 4-year-old child would equal 24% of the TBSA.

Question 13

A 4-year-old girl is in cardiac arrest. The AED pads have been applied and you receive a shock advised message. After the shock has been delivered, you should:

A) reanalyze her cardiac rhythm in 30 seconds.
B) check for a carotid pulse for at least 5 seconds.
C) resume CPR, starting with chest compressions.
D) give two rescue breaths and resume compressions.

Answer 13

Answer: C

After the AED has delivered a shock, you should resume CPR, starting with chest compressions, for 2 minutes. This applies to patients of all ages. After 2 minutes of CPR, reanalyze the patient’s cardiac rhythm and follow its prompts. A pulse should not be checked immediately after defibrillation because this causes an unnecessary delay in performing chest compressions. It is important to minimize interruptions in chest compressions whenever possible. If compressions must be interrupted, you should limit the interruption to 10 seconds or less.

Question 14

During your assessment of a 2-year-old girl with a fever, the mother tells you that the child screams every time she picks her up. You note that the child is grabbing both sides of her head. These findings are MOST suggestive of:

A) meningitis.
B) encephalitis.
C) cerebral aneurysm.
D) impending seizure

Answer 14

Answer: A

Signs of meningitis include fever; headache; and nuchal rigidity (stiff neck). Normally, an ill child is consoled when picked up by a caregiver. A child with meningitis, however, often becomes more irritable and screams in pain when picked up. This is called paradoxical irritability and occurs because traction is being pulled on the inflamed spinal cord when he or she is picked up. Encephalitis, inflammation of the brain, presents similarly to meningitis; however, paradoxical irritability is usually not observed. A cerebral aneurysm would not present with fever. Fever precedes a febrile seizure; however, paradoxical irritability is not a sign of an impending seizure.

Question 15

During your assessment after delivery of a newborn, you note that the newborn’s respirations are of good quality and the heart rate is 120 beats/min. The newborn’s face, neck, and chest are cyanotic. Initial management of this newborn should include:

A) tactile stimulation.
B) chest compressions.
C) positive-pressure ventilations.
D) blow-by supplemental oxygen.

Answer 15

Answer: D

If central cyanosis (cyanosis of the face and trunk) is present after the newborn begins breathing adequately, you should give blow-by oxygen with oxygen tubing or a mask with the flowmeter set at 5 L/min. If central cyanosis persists after 30 to 45 seconds of blow-by oxygen, positive-pressure ventilations should be initiated. Tactile stimulation is not indicated because the newborn is breathing adequately. Chest compressions are not indicated because the newborn’s heart rate is well above 60 beats/min.

Question 16

How much crystalloid solution should you administer, per bolus, to a 6-year-old child with hypovolemic shock?

A) 200 mL
B) 400 mL
C) 500 mL
D) 650 mL

Answer 16

Answer: B

You must first estimate the child’s weight based on his or her age: (age [in years] × 2) + 8 = weight in kilograms. On the basis of this formula, an average 6-year-old child weighs 20 kg. Given a fluid bolus ratio of 20 mL/kg, you should give the child 400 mL of crystalloid per bolus.

Question 17

As soon as the newborn’s head has fully delivered, you should:

A) suction the nose and then the oropharynx.
B) apply gentle pressure to the top of the head.
C) quickly assess for the presence of a nuchal cord.
D) briskly dry the baby’s face off to stimulate breathing.

Answer 17

Answer: C

As soon as the baby’s head has delivered, quickly assess for the presence of a nuchal cord (cord wrapped around the neck). Next, suction the newborn’s oropharynx (mouth) and nose. It is important to clear the newborn’s airway of fetal lung fluid before the first breath. Once the baby has been delivered completely, suctioning of the mouth and nose is repeated. Drying, warming, and, if necessary, stimulating the baby to breathe, also are carried out.

Question 18

You and your partner are caring for a woman whose baby was born dead at 24 weeks. She has two healthy children from a previous marriage. How should you document her obstetric history?

A) Gravida-3, para-2
B) Gravida-2, para-3
C) Gravida-3, para-3
D) Gravida-4, para 3

Answer 18

Answer: A

Gravida refers to the number of times the patient has been pregnant, regardless of the duration or outcome of the pregnancy. Para refers to the number of pregnancies carried beyond 28 weeks, regardless of whether the baby was born dead or alive. The patient in this scenario has been pregnant 3 times; therefore, she is gravida 3. However, since this pregnancy was not carried beyond 28 weeks, she is para 2.

Question 19

Which of the following age groups best defines a toddler?

A) 6 to 12 months
B) 1 to 3 years
C) 3 to 5 years
D) 5 to 6 years

Answer 19

Answer: B

A toddler is between ages 1 and 3 years. It is at this point that they become upwardly mobile and frequently get into things that they should not. An infant is from age 1 month to 1 year. A preschooler is from age 3 to 5 years. A child is older than age 5 years. It is important to note that for purposes of performing cardiopulmonary resuscitation, a child is from 1 year of age to the onset of puberty (12 to 14 years of age).

Question 20

You are assessing the BP of a 7-year-old boy with signs of shock. What is the low normal systolic BP for a child of this age?

A) 76 mm Hg
B) 84 mm Hg
C) 90 mm Hg
D) 104 mm Hg

Answer 20

Answer: B

The low normal systolic BP for a child between 1 and 10 years of age is determined by multiplying the child’s age in years by 2 and adding 70. Therefore, the low normal systolic BP for a 7-year-old child is 84 mm Hg. The high normal systolic BP for this same age group is determined by multiplying the child’s age in years by 2 and adding 90; this yields a high normal systolic BP of 104 mm Hg for a 7-year-old child.

Question 21

A 2-year-old boy is experiencing respiratory distress and is receiving blow-by oxygen by pediatric nonrebreathing mask at 12 L/min. During your reassessment, you note that the child’s respiratory rate has decreased from 40 breaths/min to 16 breaths/min. He appears fatigued and is not as active as he previously was. You should:

A) insert a pediatric-sized Combitube and ventilate him.
B) assess his oxygen saturation to determine how to proceed.
C) begin assisting his ventilations with a bag-mask device.
D) increase the flow rate on the nonrebreathing mask to 15 L/min.

Answer 21

Answer: C

Children who remain tachypneic (rapid breathing) for prolonged periods of time become fatigued and their respirations begin to slow. A decreasing respiratory rate in a child with respiratory distress is NOT a sign of clinical improvement; it is an indicator of respiratory failure. A decreased level of activity further confirms that the child’s condition is deteriorating. You must begin assisting the child’s ventilations with a bag-mask device and monitor him for signs of clinical improvement. Although the child’s oxygen saturation will likely be low, you must not use this exclusively to determine how to proceed with your treatment. The Combitube is not used in infants and children. It is important to remember that the most common cause of cardiac arrest in the pediatric population is respiratory failure.

Question 22

You and your AEMT partner are performing CPR on a 3-month-old girl who is in cardiac arrest. After the paramedic inserts an advanced airway device, you should:

A) switch to cycles of 15 chest compressions and 2 breaths.
B) increase the volume of each rescue breath you deliver.
C) pause after every 30 compressions to deliver 2 breaths.
D) deliver 8 to 10 breaths/min and perform CPR continuously.

Answer 22

Answer: D

After an advanced airway device (endotracheal tube, LMA, or King LT) is inserted during CPR, you should no longer deliver cycles of CPR. Give one breath every 6 to 8 seconds (8 to 10 breaths/min) and perform continuous chest compressions at a rate of at least 100/min. Do not attempt to synchronize chest compressions and rescue breaths. Deliver each breath over a period of 1 second and observe for visible chest rise. Ventilating a patient with too much volume can cause barotrauma (especially in children); it can also impair venous return to the heart because of increased intrathoracic pressure.

Question 23

You are called to treat a 5-year-old girl who was found unconscious by her father. During your assessment, you obtain a blood glucose reading of 42 mg/dL. The correct dose of 25% dextrose for this child is:

A) 1 to 2 g/kg.
B) 2 to 4 mL/kg.
C) 5 to 10 mL/kg.
D) 10 to 20 mL/kg.

Answer 23

Answer: B

The recommended dose of intravenous dextrose for a child is 0.5 to 1 g/kg. If 25% dextrose (250 mg/mL) is used, give 2 to 4 mL/kg. If 50% dextrose (500 mg/mL) is used, give 1 to 2 mL/kg. If 10% dextrose (100 mg/mL) is used, give 5 to 10 mL/kg. If 5% dextrose (50 mg/mL) is used, give 10 to 20 mL/kg.

Question 24

Heavy vaginal bleeding in the mother immediately after delivery of a newborn is MOST effectively controlled by:

A) elevating the mother’s legs 6” to 12”.
B) positioning the mother on her left side.
C) firmly massaging the fundus of the uterus.
D) placing a trauma dressing inside the vagina.

Answer 24

Answer: C

The most effective means of controlling postpartum bleeding is to firmly massage the fundus (top) of the uterus, which results in constriction of the uterine vasculature. The release of the hormone oxytocin from the mother’s brain also results in uterine vasoconstriction and is achieved by allowing the newborn to nurse. You should never pack anything into the vagina. Elevation of the mother’s legs may be indicated if she is experiencing signs of shock.

Question 25

General treatment for a woman in early labor and stable vital signs includes:

A) high-flow oxygen and a 20 mL/kg fluid bolus.
B) oxygen and an IV line of a crystalloid solution.
C) two large-bore IV lines and supine positioning.
D) supplemental oxygen and monitoring only.

Answer 25

Answer: B

When caring for a woman in labor, you should administer supplemental oxygen; a nasal cannula is generally sufficient, although higher concentrations of oxygen should be given if she has signs of shock or if there are signs of fetal distress. An IV line should also be established in the event that she requires fluid replacement; set the IV to keep the vein open unless signs of shock are present. Transport the pregnant patient with her body tilted to the left; this relieves pressure off of the inferior vena cava and prevents supine hypotensive syndrome.

Question 26

When assessing an infant with respiratory distress, which of the following is an indicator of inadequate ventilation?

A) Pink oral mucosa
B) Expiratory grunting
C) Abdominal breathing
D) Heart rate of 120 beats/min

Answer 26

Answer: B

Expiratory grunting in a child is an ominous finding that suggests impending respiratory failure and results from the child’s attempts to maintain oxygen reserve in the lungs and the end of exhalation. Because infants and small children rely more heavily on their diaphragm to breathe, it is common to see more abdominal movement than chest movement during normal breathing. Bradycardia, a sign of hypoxemia and inadequate ventilation, exists when the infant’s heart rate falls below 100 beats/min. Pink oral mucosa suggests adequate oxygenation; however, the absence of cyanosis does not rule out hypoxemia.

Question 27

During the delivery of an infant’s head, you note that the umbilical cord is wrapped around its neck. You should:

A) immediately clamp and cut the cord.
B) gently slip the cord over the baby’s head.
C) clamp the cord and continue with the delivery.
D) administer oxygen to the mother and transport.

Answer 27

Answer: B

Initial management of a cord wrapped around the infant’s neck (nuchal cord) is to gently attempt to slip the cord over the baby’s head. If this is unsuccessful, you should clamp and cut the cord and then continue with the delivery. Administer oxygen to the mother because this is the only way to oxygenate the baby. Transport the mother and baby as soon as possible.

Question 28

A 23-year-old woman presents with dysuria, vaginal itching, and a yellow foul-smelling vaginal discharge. She denies abdominal pain or fever. You should suspect:

A) gonorrhe
B) chlamydia.
C) syphilis.
D) genital herpes.

Answer 28

Answer: A

Gonorrhea is caused by a bacterium that can grow and multiply rapidly in the warm, moist areas of the reproductive tract, including the cervix, uterus, and fallopian tubes in women and in the urethra in women and men. Women may be infected with gonorrhea for months but may not experience symptoms until the infection has spread to other parts of the reproductive system. When symptoms do appear in women, they generally manifest as dysuria (painful urination), with associated burning or itching; a yellowish or bloody foul-smelling vaginal discharge; and bleeding after intercourse. Chlamydia is also caused by a bacterium; symptoms include lower abdominal or back pain, nausea, fever, pain during intercourse, and bleeding between menstrual periods. Syphilis is also caused by a bacterium; however, it classically presents with an open lesion on the genitals called a chancre. Fever, vaginal discharge, and abdominal pain are not common with syphilis. Genital herpes, caused by a virus, is characterized by small clusters of painful blisters in the genital area; fever, vaginal discharge, and abdominal pain are typically not associated with genital herpes.

Question 29

A 4-year-old boy has a 3-day history of vomiting, diarrhea, and poor oral intake. When you assess him, you find that his extremities are cool and pale and his capillary refill time is 4 seconds. His BP is 84/42 mm Hg, pulse is 180 beats/min, and respirations are 46 breaths/min. Which of the following statements BEST describes this child’s condition?

A) Compensated shock with signs of adequate tissue perfusion
B) Compensated shock with signs of inadequate tissue perfusion
C) Decompensated shock with signs of inadequate tissue perfusion
D) Irreversible shock with signs of inadequate tissue perfusion

Answer 29

Answer: B

Although the child is clearly showing signs of inadequate peripheral perfusion (pale, cool extremities; delayed capillary refill time), he is in compensated shock because his BP, although on the low end of normal, is maintained. The low normal systolic BP for a child between 1 and 10 years of age is determined by the following formula: (age [in years] × 2) + 70. Therefore, the low normal systolic BP for a 4-year-old child is 78 mm Hg. If the child’s systolic BP falls below this value, he is said to be in decompensated (hypotensive) shock.

Question 30

After preventing injury in a 3-year-old child who is experiencing a generalized tonic-clonic seizure, the AEMT should:

A) administer oxygen.
B) assess the blood glucose.
C) call a paramedic unit.
D) obtain a patent airway.

Answer 30

Answer: D

Initial management for any patient who is experiencing a seizure includes protecting the patient from injury; move any furniture away from the patient and place soft padding under the head to prevent it from striking the ground. After this has been accomplished, you should turn your attention to the status of the patient’s airway, making sure it is open and clear of any secretions. After ensuring airway patency, administer high-flow oxygen or assist ventilations as needed. Consider requesting a paramedic unit because they can administer medications to terminate the seizure. Assessing the patient’s blood glucose level is also indicated to rule out hypoglycemia.

Question 31

The primary goal of management of a patient with third-trimester bleeding is to:

A) prevent hypoperfusion.
B) provide volume expansion.
C) massage the uterine fundus.
D) provide high-flow oxygen.

Answer 31

Answer: A

Management of third-trimester bleeding should focus on preventing hypoperfusion of the tissues and cells (shock), and includes providing high-flow oxygen, thermal management, and intravenous crystalloid boluses as needed. Uterine massage is indicated for postpartum bleeding; it is NOT performed before delivery.

Question 32

Low-grade fever and respiratory distress with a slow onset in a 2-year-old child is MOST characteristic of:

A) croup.
B) asthma.
C) bronchitis.
D) epiglottitis.

Answer 32

Answer: A

Croup, or laryngotracheobronchitis, is a viral upper respiratory illness that typically affects children between the ages of 6 months and 4 years. It is characterized by a low-grade fever (common with a viral infection) and a slow, progressive onset of respiratory distress. Epiglottitis, which is a bacterial infection, produces a rapid onset of high fever, difficulty breathing, and is accompanied by such signs as drooling, difficulty swallowing, and inspiratory stridor. Epiglottitis is not as common in children as it used to be, but when it occurs, it commonly affects children between 3 and 7 years of age. Asthma and bronchiolitis are lower airway problems and are typically associated with wheezing.

Question 33

When caring for a child with suspected bacterial meningitis, it is MOST important to:

A) be prepared for seizures.
B) take standard precautions.
C) give supplemental oxygen.
D) establish vascular access.

Answer 33

Answer: B

You should take standard precautions when caring for any patient. When caring for a patient with a suspected infectious disease, such as bacterial meningitis, you should also wear a face mask to minimize your risk of exposure. As with any infection of the central nervous system, the patient is prone to seizures and must be monitored closely. Supplemental oxygen should be given as tolerated, and the need to establish vascular access should be based on the child’s hemodynamic status and your transport distance to the closest appropriate hospital.

Question 34

In addition to cyanosis and apnea, a classic apparent life-threatening event (ALTE) in an infant is characterized by:

A) a disappearance of central pulses.
B) a heart rate greater than 150 beats/min.
C) limpness and choking or gagging.
D) rapid, irregular peripheral pulses.

Answer 34

Answer: C

Infants who are not breathing and are cyanotic and unresponsive when found by a caregiver sometimes resume breathing and color with stimulation. This type of episode is called an apparent life-threatening event (ALTE). In addition to cyanosis and apnea, a classic ALTE is characterized by a distinct change in muscle tone (limpness) and choking or gagging. After the event, the infant often appears healthy and shows no signs of illness or distress. If you cannot detect central (brachial) pulses in an unresponsive infant, you should begin CPR. Because an ALTE causes hypoxemia, you would likely encounter bradycardia, not tachycardia.

Question 35

Care for a 3-year-old child who experienced a febrile seizure should include:

A) rapid immersion in cool water.
B) 10 to 20 mL/kg IV fluid boluses.
C) providing supportive care and transport.
D) keeping the child warm to prevent shivering.

Answer 35

Answer: C

Most children with febrile seizures recover, and very few require hospitalization. General care for the child after the seizure has occurred is mainly supportive, consisting of monitoring the airway and offering the child oxygen. Cooling of a child with fever who has just had a seizure should be avoided because it may cause the child to shiver, resulting in an abrupt rise in body temperature and the possibility of another seizure. Conversely, you do not want to cover the child with blankets because this may entrap body heat. Most children who have experienced a febrile seizure do not require vascular access or fluid boluses in the prehospital setting.

Question 36

Positioning a pregnant patient with her body tilted to the left is important because:

A) she will be facing you instead of the ambulance wall.
B) most pregnant patients find this position to be most comfortable.
C) pressure on the aorta is relieved and cardiac output is maintained.
D) this position relieves pressure off of the inferior vena cava.

Answer 36

Answer: D

Positioning the mother so that her body is tilted to the left removes the pressure of the gravid (pregnant) uterus from the inferior vena cava and maintains cardiac output. Placing the patient in a supine position can result in supine hypotensive syndrome and subsequent shock, which would be detrimental to both mother and baby.

Question 37

A 30-year-old woman presents with acute lower quadrant abdominal pain and severe vaginal bleeding. She is conscious, but restless, and is hypotensive. She is 35 weeks pregnant and admits to using cocaine on a regular basis. You should suspect that:

A) she has developed abnormal blood-clotting caused by the cocaine.
B) the placenta has spontaneously separated from the uterine wall.
C) her uterus has ruptured secondary to excessive cocaine abuse.
D) some or all of the placenta has grown over the uterine opening.

Answer 37

Answer: B

Your patient’s presentation is consistent with abruptio placenta. In abruptio placenta, the placenta spontaneously separates from the uterine wall. Abruptio placenta most commonly occurs during the third trimester. The patient typically presents with an acute onset of severe abdominal pain, commonly described as a tearing sensation, and severe vaginal bleeding. Causes of abruptio placenta include abdominal trauma and cocaine use. Cocaine is a potent vasoconstrictor; over time, damage to the delicate vasculature that holds the placenta to the uterine wall may cause premature placental detachment. Placenta previa occurs when the placenta implants and grows at the bottom of the uterus over the cervix. When the fetus starts to descend, the placenta is slowly separated from the uterine wall, resulting in vaginal bleeding. In contrast to abruptio placenta, placenta previa commonly presents without abdominal pain, although this is not always the case. Both conditions can cause fetal demise and maternal shock or death. Uterine rupture occurs during labor; the patient may tell you that she initially had strong painful contractions, but then the contractions subsided. Severe vaginal bleeding may or may not be present with uterine rupture.

Question 38

When performing an assessment on a 3-year-old child, which of the following signs should alert you to the possibility of abuse?

A) The child cries during the assessment.
B) The child has bilateral bruises to the tibias.
C) The child shows no fear during the assessment.
D) The child clings to the parent during the assessment.

Answer 38

Answer: C

Abused children tend to lose the inherent fear that would normally occur during assessment and treatment. The possibility of abuse also is suggested in a child who is withdrawn or avoids contact with the parents. Tibial bruises are a common injury pattern in small children and occur from bumping into coffee tables while moving throughout the home; it is not a common injury pattern that is suggestive of abuse.

Question 39

You receive a call for a 36-month-old child who is not breathing. When you arrive, you immediately assess the child and note that he is unresponsive and not breathing. You should:

A) provide two rescue breaths.
B) assess for a carotid pulse.
C) begin chest compressions.
D) apply the AED immediately.

Answer 39

Answer: B

According to the most current emergency cardiac care guidelines, if a patient is unresponsive and not breathing, you should assess for a pulse for at least 5 seconds but no more than 10 seconds. If a pulse is present, provide rescue breathing. If a pulse is absent, perform 30 chest compressions if you are alone (15 compressions if two rescuers are present and the patient is an infant or child), then open the airway and deliver two rescue breaths. The technique of look, listen, and feel is no longer recommended because it delays the initiation of chest compressions if they are indicated. Apply the AED pads as soon as possible after beginning CPR.

Question 40

Approximately 20 minutes after giving birth, your 24-year-old patient suddenly develops a sharp pain to her left armpit area and tells you it is hard to breathe. Her blood pressure is 100/60 mm Hg, her heart rate is 120 beats/min, and her respirations are 24 breaths/min and labored. You should:

A) administer high-flow oxygen, place her in a semisitting position, and start an IV line.
B) assist her ventilations with a bag-mask device and elevate her legs 6 to 12 inches.
C) administer high-flow oxygen, start an IV, and administer 1 to 2 L of normal saline.
D) place her in the Trendelenburg position, administer high-flow oxygen, and start an IV.

Answer 40

Answer: A

Acute dyspnea, pleuritic (sharp) chest pain, and tachycardia are signs of a pulmonary embolism. This is one of the most common causes of maternal death during childbirth or postpartum. An embolus may form from a number of sources, but a blood clot arising in the pelvic circulation is a frequent cause. Leakage of amniotic fluid into the maternal circulation (amniotic embolism) and a clot arising from a pregnancy-related venous thromboembolism are other examples of potential embolic processes. Treatment is the same as for any other patient with a pulmonary embolism. Administer high-flow oxygen, place her in a position of comfort (usually a semisitting position), and transport without delay. Establish a large-bore IV line in case fluid resuscitation is needed and be prepared to assist the patient’s ventilations if her breathing becomes inadequate.

Question 41

When assessing a 20-year-old woman with bilateral lower abdominal quadrant pain, which of the following findings is MOST suggestive of an ectopic pregnancy?

A) Light vaginal discharge
B) Missed menstrual period
C) Denial of contraception use
D) Tachycardia and hypotension

Answer 41

Answer: B

Any woman of childbearing age who has abdominal pain should be assumed to have an ectopic pregnancy until it can be ruled out. Lower quadrant abdominal pain, especially with a history of a missed menstrual period is a classic finding of an ectopic pregnancy. There are many causes of vaginal discharge. Tachycardia and hypotension also can be the result of many other problems. Although a woman’s chances of becoming pregnant are significantly higher if not on some form of birth control, women do become pregnant while taking contraceptives.

Question 42

Cardiopulmonary arrest in infants and children is MOST often secondary to:

A) massive infection.
B) respiratory failure.
C) a lethal arrhythmia.
D) severe dehydration.

Answer 42

Answer: B

Infants and children generally have healthy hearts. Respiratory failure usually is what leads to cardiac arrest. Many cardiac arrests in children can be prevented by paying meticulous attention to their airway and ventilation status.

Question 43

Management of a female patient who was the victim of a sexual assault includes:

A) cleaning all nonbleeding wounds.
B) allowing the patient to take a shower.
C) recognizing the patient as a crime scene.
D) allowing a male AEMT to assess the patient.

Answer 43

Answer: C

Any patient who has been sexually assaulted should be considered a crime scene. Management of any life-threatening problems has priority; however, the patient should be discouraged from changing clothes, bathing, or douching. Unless open wounds are actively bleeding, in which case direct pressure should be applied, they should not be irrigated or cleaned; doing so may destroy potential evidence. Whenever possible, an AEMT of the same sex should perform any assessment and treatment of the patient.

Question 44

You are at the scene where a previously healthy 3-month-old infant was found dead in her crib by her mother. The infant’s mother asks you if you know what the infant died from. You should tell her that:

A) the infant likely died of sudden infant death syndrome.
B) you do not know why the infant died.
C) an autopsy will determine the cause of death.
D) it was likely the result of a respiratory illness.

Answer 44

Answer: B

You should expect that family members will ask specific questions when their previously healthy infant suddenly dies, such as what occurs with sudden infant death syndrome (SIDS). Let them know that their concerns will be addressed but that answers are not immediately available. A common question is, “What did my child die of?” Do not answer this question because you would only be speculating. Instead, express your condolences and tell the parent that you do not know why the infant died. Because a complete postmortem (autopsy) does not always reveal an appreciable cause of death, you should avoid telling the parent that it will.

Question 45

A 3-year-old boy with a tracheostomy tube is in respiratory distress. You can see thick secretions around the tube. The child’s heart rate is 80 beats/min and the pulse oximeter reading is 85%. Immediate treatment for this child should include:

A) chest compressions.
B) positive-pressure ventilations.
C) suctioning the tracheostomy tube.
D) removal of the tracheostomy tube.

Answer 45

Answer: C

A common complication in patients with tracheostomy tubes is obstruction of the tube by thick secretions. The child in this scenario is showing signs of hypoxemia (bradycardia and an SpO2 of 85%). You must first remove the secretions from the tracheostomy tube to clear the airway. In many cases, this is all that is needed to improve the patient’s clinical status. If the child remains hypoxemic after suctioning the tracheostomy tube, you should provide assisted ventilation. Chest compressions are indicated for children when their heart rate falls below 60 beats/min and is accompanied by signs of poor perfusion, despite ventilatory support. Do not remove the tracheostomy tube unless you are unable to clear the secretions from it or you find that it is otherwise nonpatent.

Question 46

Which of the following is the MOST appropriate action for you to take when child abuse is suspected?

A) Thorough objective documentation
B) Immediately notifying child protective services
C) Apprising the parents of your suspicions
D) Transporting the child against the parents’ wishes

Answer 46

Answer: A

Thorough, objective documentation of the scene and examination findings is vital in cases of suspected abuse. By law, you must report any and all cases of suspected abuse to the proper authority, which is the physician at the receiving hospital, who in turn has a legal obligation to notify child protective services. You should never confront or accuse parents or caregivers of abuse because this could result in slander on your part if you are wrong. You must obtain consent from at least one parent before transporting the child or you may be liable for kidnapping.

Question 47

Initial treatment for an unresponsive 6-month-old infant with closed head trauma and slow, irregular breathing includes:

A) inserting a nasopharyngeal airway.
B) applying oxygen by nonrebreathing mask.
C) starting an IV line and administering fluid boluses.
D) assisting ventilations with a bag-mask device.

Answer 47

Answer: D

Head trauma is the leading cause of traumatic death in the pediatric age group. Treatment for an unresponsive infant with closed head trauma and inadequate ventilation (slow, irregular breathing) includes assisted ventilation with a bag-mask device and high-flow oxygen. If the child is otherwise breathing adequately, apply high-flow oxygen by nonrebreathing mask. You should avoid inserting a nasopharyngeal airway in any patient with a head injury; if an occult skull fracture is present (cribriform plate fracture), the nasal airway may inadvertently enter the cranial vault through the fractured bone. You must protect the airway and ensure adequate ventilation and oxygenation first; then you should consider IV therapy.

Question 48

Which of the following questions will provide you with the MOST reliable information when determining whether or not delivery of a baby is imminent?

A) Do you feel the urge to push?
B) Has your amniotic sac ruptured?
C) Are you having any vaginal discharge?
D) How long were you in labor with the last child?

Answer 48

Answer: A

With the exception of crowning, one of the most reliable indicators of imminent delivery is when the mother feels the urge to push. This indicates that the baby is in the birth canal and is resting on top of the rectum. Rupture of the amniotic sac indicates that delivery is near, but not necessarily imminent. There may be a relative, but not absolute, correlation between the length of labor with her last child and imminent delivery with this child. Women who have had multiple children can remain in the second stage of labor for many hours and those who are pregnant for the first time can progress through all stages of labor in less than 2 hours. Generally speaking, however, the first stage of labor is shorter in multiparous women.

Question 49

After delivering an infant, you clear the airway and provide warming measures. As you assess the newborn, you note the presence of central cyanosis and a heart rate of 80 beats/min. Immediate treatment for this infant should include:

A) tactile stimulation.
B) chest compressions.
C) positive-pressure ventilations.
D) vigorous suctioning of the mouth.

Answer 49

Answer: C

Central cyanosis and a heart rate that is less than 100 beats/min are clinical indicators of hypoxia in the newborn and should be treated with immediate positive-pressure ventilation. Chest compressions should be started if the heart rate falls below 60 beats/min, despite adequate ventilation and oxygenation. Vigorous suctioning should be avoided because this may stimulate a vagal response, resulting in a further decrease in heart rate. Tactile stimulation can be provided simultaneously with assisted ventilation, but oxygenation is clearly the most important aspect in this scenario.

Question 50

A 26-year-old woman complains of pain to both lower abdominal quadrants. Her last menstrual period ended approximately 10 days ago. She first noted the pain about 3 days ago. She further tells you that she has been running a fever of 100.5° F for the past few days. The MOST likely cause of her symptoms is:

A) acute cystitis.
B) an ectopic pregnancy.
C) a ruptured ovarian cyst.
D) pelvic inflammatory disease.

Answer 50

Answer: D

Pelvic inflammatory disease (PID) typically presents within 7 to 10 days after the end of the menstrual cycle and is characterized by bilateral lower abdominal quadrant pain, fever, painful intercourse (dyspareunia), and vaginal discharge. PID frequently is the result of a sexually transmitted disease, such as chlamydia or gonorrhea. Acute cystitis (urinary bladder infection) may present with a fever in some cases, but is generally not associated with abdominal pain; instead, the patient’s complaint is dysuria and retropubic pain. A ruptured ovarian cyst and an ectopic pregnancy often present with abdominal pain, but are not usually associated with fever.

Question 51

You are treating a newborn with weak central pulses and pallor. Suspecting hypovolemia, you should administer crystalloid fluids at a rate of:

A) 10 mL/kg by rapid IV bolus.
B) 20 mL/kg by rapid IV bolus.
C) 10 mL/kg over 5 to 10 minutes.
D) 20 mL/kg over 5 to 10 minutes.

Answer 51

Answer: C

When signs of hypovolemia are present in a newborn (weak central pulses, pallor, tachycardia, and so forth), crystalloid fluids, such as normal saline or lactated Ringer’s solution, should be administered at a rate of 10 mL/kg over 5 to 10 minutes. Children older than 1 month of age should receive 20 mL/kg fluid boluses.

Question 52

An ectopic pregnancy is MOST accurately defined as an ovum that implants:

A) in a fallopian tube.
B) on the endometrium.
C) outside of the uterus.
D) in one of the ovaries.

Answer 52

Answer: C

Although ectopic pregnancies most commonly occur in the fallopian tube (tubal pregnancy), the most accurate definition of an ectopic pregnancy is the implantation of the ovum outside of the uterus. The word “ectopic” refers to an abnormal location. In a normal pregnancy, the ovum implants on the inner lining of the uterus (the endometrium).

Question 53

A woman began experiencing contractions 30 minutes ago. She is 38 weeks pregnant. You determine that she is gravida-5 and para-3. Which of the following statements regarding this patient is correct?

A) She will become para-4 when she delivers her baby
B) She has had 2 spontaneous abortions in the past
C) The first stage of labor will be lengthier than before
D) She is in preterm labor and may have complications

Answer 53

Answer: A

Gravida refers to the number of times a woman has been pregnant, regardless of the length or outcome of the pregnancy. Para refers to the number of pregnancies carried to more than 28 weeks’ gestation, regardless of whether the baby was born alive or dead. Gravida-5 indicates that your patient has been pregnant 5 times, including her current pregnancy. Para-3 indicates that she has delivered 3 babies beyond 28 weeks’ gestation. When she delivers her baby, she will become para-4 because her current pregnancy has surpassed 28 weeks. In general, the first stage of labor decreases in length with each pregnancy and delivery. A term pregnancy is 37 to 42 weeks. She is not in preterm labor, although this does not indicate that she will not experience any complications.

Question 54

After delivery of a newborn, you suction, warm, and position the newborn. The infant’s heart rate is 80 beats/min, so you begin positive-pressure ventilations. After 30 seconds, the newborn’s heart rate remains at 80 beats/min. You should:

A) resuction the child’s airway.
B) begin chest compressions.
C) increase your ventilation rate.
D) insert an oropharyngeal airway.

Answer 54

Answer: A

A heart rate of less than 100 beats/min is a sign of hypoxemia in the newborn. If after 30 seconds of assisted ventilation the heart rate remains less than 100 beats/min, the infant’s airway must be checked again to ensure patency, which may include repositioning of the head to ensure a neutral position, resuctioning any secretions from the mouth and nose, or ventilating the infant with its mouth slightly open. In many cases, these simple corrective actions yield improvement in the newborn’s clinical status. If the heart rate falls below 60 beats/min despite adequate ventilation and oxygenation, continue ventilations and begin chest compressions. The proper ventilation rate for the newborn is 40 to 60 breaths/min; as with the adult and child, you must use caution and avoid hyperventilation. Oral airways are rarely needed in newborns; in most cases, manual head positioning and suctioning of the airway maintains airway patency.

Question 55

While transporting a woman in labor, she tells you that she feels a great deal of pressure in her perineal area. You visualize the perineum and see the top of the baby’s head crowning from the vaginal opening. You should:

A) set up the obstetric kit for an imminent delivery.
B) ensure that the mother is in the delivery position.
C) time the interval and duration of her contractions.
D) tell your partner to stop the ambulance immediately.

Answer 55

Answer: D

If the mother begins to deliver her baby en route to the hospital, as evidenced by crowning, you should FIRST tell your partner to stop the ambulance immediately and assist you in the back with the delivery. Never attempt to deliver a baby in the back of a moving ambulance.

Question 56

A reliable early indicator of shock in a 2-year-old child is:

A) a rapid, weak pulse.
B) confusion and anxiety.
C) a slow, bounding pulse.
D) delayed capillary refill.

Answer 56

Answer: D

A delayed (> 2 seconds) capillary refill time is a reliable indicator of early shock in children younger than 6 years of age. Remember that factors such as cold temperatures can influence capillary refill time. Weak, rapid pulses are a later sign of shock in any patient. A slow, bounding pulse is indicative of closed head injury or a central nervous system infection (meningitis) with increased intracranial pressure. Confusion and anxiety are less reliable parameters in a 2-year-old child because they are difficult to assess.

Question 57

You are assessing a child with high fever and a severe headache. The child is listless and, according to the parent, had a seizure before your arrival. You note the presence of widespread petechiae, which is defined as:

A) purplish, red spots on the skin caused by intradermal hemorrhage.
B) nonraised red blotches resulting from an antigen-antibody response.
C) ecchymotic areas on the skin that are accompanied by a notable lump.
D) purple malignancies of the skin as the result of a weak immune system.

Answer 57

Answer: A

Petechiae are purplish, red spots on the skin caused by intradermal or submucous hemorrhage and indicate abnormal blood clotting as the result of a massive infection, such as meningitis. Nonraised red skin blotches that result from an allergic reaction are called urticaria (hives). Purple malignancies of the skin that signify a weakened immune system are called Kaposi sarcoma and are a sign of the late stages of AIDS. Ecchymosis with an accompanying lump is called a hematoma.

Question 58

Each month, certain hormones in the female body increase, which results in all of the following, EXCEPT:

A) production of an ovum.
B) thickening of the endometrium.
C) shedding of the inner uterine lining.
D) preparation of the uterus for implantation.

Answer 58

Answer: C

Each month, the release of hormones (estrogen and progesterone) in the female body results in the production of an ovum (egg) by the ovary and thickening of the inner uterine wall (endometrium) in preparation for implantation of a fertilized egg. If the egg is not fertilized, the endometrial lining sheds and is expelled from the vagina, which results in the menstrual period.

Question 59

You respond to a call for a 4-year-old girl who had a seizure. When you arrive, you find the child crying in her mother’s arms. Which of the following questions would be MOST pertinent to ask the mother initially?

A) Has your daughter been running a fever?
B) Does your daughter have a history of seizures?
C) Has your daughter recently complained of a stiff neck?
D) Has your daughter recently sustained trauma to the head?

Answer 59

Answer: B

The most important initial question to ask after a child, or any patient for that matter, has had a seizure is whether there is a history of seizures. This will allow you to adjust further questioning accordingly, such as whether there is a history of fever, recent head trauma, or a stiff neck (nuchal rigidity).

Question 60

Which of the following injuries sustained by infants and children is associated with the highest morbidity and mortality rate?

A) Head trauma
B) Chest trauma
C) Abdominal trauma
D) Cervical spine trauma

Answer 60

Answer: A

Because infants and children have a proportionately larger head compared with an adult, the head is especially vulnerable to trauma, especially from falls, in which gravity takes them head first. Deceleration incidents also are associated with head trauma in children, such as when they are not properly secured or not secured at all in a motor vehicle and their bodies become projectiles, with their head striking the first object it encounters.

Question 61

A 2-year-old child fell from a second story window. Based on your knowledge of the anatomic differences between children and adults, and the mechanism of injury described, you should suspect that the primary point of injury occurred to the:

A) head.
B) chest.
C) abdomen.
D) lower extremities.

Answer 61

Answer: A

Because a child has a proportionately large head compared with an adult, gravity causes a small child to land head first during a fall from a significant height. Therefore, falls with associated head trauma are the leading cause of traumatic death in the pediatric age group. If an adult fell from the same height, he or she would attempt to land feet first.