pediatrics

Question 1

A parent brings her 7-year-old child into the clinic with the chief concern of a fever that lasted for 3 days and, upon resolution, was followed by flushed and red cheeks. Upon exam, the nurse practitioner notes a lacy, maculopapular rash along the arms and trunk. Which of the following is the most likely diagnosis for this patient?

Answer 1

Erythema infectiosum
Erythema infectiosum (A), also known as fifth disease, is caused by parvovirus B19. Classically, patients present with prodromal symptoms like fever, headache, myalgia, nausea, or diarrhea. After approximately 2–5 days, patients develop an erythematous facial rash often described as having a slapped-cheek appearance. A couple of days later, a reticulated or lacy rash develops on the patient’s trunk and extremities. Erythema infectiosum is a self-limited disease and only requires supportive care and symptom management. In certain populations, like pregnant individuals and children with hematologic disorders where red blood cell destruction is increased (e.g., sickle cell disease), parvovirus B19 can cause significant illness, and these patients should be closely monitored.

Question 2

Which of the following children would require asymptomatic screening for celiac disease?

Answer 2

Patient with Down Syndrome
While screening asymptomatic adults for celiac disease is often not recommended, there are certain pediatric patients who have a high risk for the condition who should undergo asymptomatic screening. Risk factors include first-degree relatives with celiac disease, type 1 diabetes, IgA deficiency, and certain genetic syndromes, including trisomy 21 (Down syndrome). Therefore, the appropriate patient to screen in this situation would be the 7-year-old girl with Down syndrome (B).

Question 3

The most common pathogenic organism that causes external otitis is

Answer 3

Pseudomonas aeruginosa

Question 4

Genu varum, or “bow legs,” occurs when the knees stay apart despite the child standing with their feet together. It is a common and normal finding in children that typically resolves spontaneously by

Answer 4

2 years old

Question 5

what is the preferred treatment for bullous impetigo in small children

Answer 5

amoxicillin

Question 6

The nurse practitioner has just diagnosed an adolescent patient with mononucleosis. This diagnosis is associated with an increased risk for which of the following latent onset cancers?

Answer 6

burkittt lymphoma

Question 7

genu recurvatum

Answer 7

This is a rare congenital anomaly that involves the dislocation or hyperextension of one or both knees. The most common precipitating factor is breech positioning in utero followed by oligohydramnios. Girls are more commonly affected. Nurse practitioners should recognize that this anomaly requires an immediate referral to a pediatric orthopedic surgeon because as the child grows, the ability to relocate the joints becomes increasingly difficult. When hyperextension is identified, physical therapy and serial splinting are often performed. Dislocation will require surgery.

Question 8

An 11-year-old patient reports a severe sore throat, fever, nausea, and headache. Upon exam, the nurse practitioner sees a strawberry red pharynx with petechiae on the hard palate. The remainder of the exam is benign. What would be the best initial test to order for this patient?

Answer 8

rapid antigen detection test

Question 9

A 3-year-old girl presents to the clinic after 48 hours of fever and irritability. Her fever responds well to acetaminophen and ibuprofen. Her parent states she has been pulling at her left ear, her appetite is decreased, and she has been irritable. Upon exam, you note marked erythema and bulging of the left tympanic membrane with effusion, a heart rate of 132 bpm, temperature of 102.3°F, and a cleft palate repair. Which of the following would be the appropriate diagnosis and management of this patient?

Answer 9

Antibiotics are proven to decrease the length of illness and pain associated with acute otitis media (AOM). The risk of tympanic membrane perforation is higher if AOM is left untreated. Antibiotic therapy should include coverage against Streptococcus pneumoniae. The first-line antibiotic preference is amoxicillin at a dose of 90 mg/kg by mouth per day (B).

Question 10

A newborn infant presents with hypotonia, poor moro reflex, hyperextensible joints, low-set ears, and slanted palpebral fissures. The prenatal history is signficant for low alpha fetoprotein level and increased nuchal translucency at 18 weeks gestation. Which of the following is the best plan of care for the infant at this time?

Answer 10

refer to neonatology for comphehensive exam and testing

he most appropriate next step is to refer to neonatology for a comprehensive examination and testing (D). A low alpha-fetoprotein (AFP) level in the first trimester can be indicative of trisomy 21 or Down syndrome. The exam findings of hypotonia, poor moro reflex, hyperextensible joints, low-set ears, redundant skin at the nape of the neck, and slanted palpebral fissures are indicative of trisomy 21. Newborns with trisomy 21 are at risk for poor cardiovascular function, metabolic disorders, and hematologic abnormalities and thus require close monitoring immediately after birth. A comprehensive exam and evaluation is required to rule out congenital heart defects, hypoglycemia, thyroid dysfunction, and abnormalities in red blood cells.

Question 11

A 10-year-old girl presents for a wellness exam today. Upon examination, breast budding is noted as well as a few fine pubic hairs. She and her parent mention that her breasts just began to grow and ask when they should expect her menses to start. What anticipatory guidance should be provided during this visit?

Answer 11

Menarche should start in the next 3 years (C) once a girl begins puberty or enters Tanner stage 2. Tanner stage 2 peaks in girls aged 12-13 years. In this stage, breast buds become palpable, areola enlarge, and minimal coarse pubic hair is visible on the labia.

Question 12

Newborns should pass meconium within the first 48 hours after birth. When this does not occur, the differential diagnosis will include conditions such as meconium ileus. Which of the following diseases is commonly associated with meconium ileus?

Answer 12

cystic fibrosis
Meconium ileus is considered a bowel obstruction and is most often diagnosed in the immediate newborn period. Meconium should form during fetal development and is expected to evacuate the large bowel within 48 hours of birth. Cystic fibrosis (A), the most common autosomal recessive inherited disorder diagnosed in newborns and is associated with a defect at the CFTR gene, resulting in deficient chloride channel function and the formation of thick, sticky mucus and stool.

Question 13

At what age is it most common to see iron deficiency anemia in children?

Answer 13

6-24 months

Question 14

A 4-year-old girl with a medical history of frequent UTIs presents to the office with her parent for abdominal pain with urination. This is her third visit over the past month for similar concerns, and her symptoms are worsening despite UTI prophylaxis and normal urinalysis and urine culture results. Her parent states the girl started wetting her pants despite being fully potty trained and is urinating frequently. On exam, the nurse practitioner is able to palpate hardened stool in the abdomen. Review of the results of a recent voiding cystourethrogram is significant for retrograde flow of urine without dilation of the ureters. What diagnosis is most likely?

Answer 14

vesicoureteral reflux
Vesicoureteral reflux (VUR) (D) is the most likely diagnosis. VUR can be primary or secondary. Primary VUR is congenital and caused by inadequate closure of the ureterovesical junction inside the bladder. Patients with VUR have a sphincter that is incompetent, causing urine to reflux from the bladder back into the ureters or kidneys. Secondary VUR happens as a result of separate bladder dysfunction. The most common symptoms of VUR are urinary frequency, urinary leakage, abdominal pain, constipation, and frequent UTIs. VUR is a common cause of hydronephrosis, in which the kidney and ureter dilate and swell due to backup of urine. This condition is most common in female individuals.

Question 15

A child was recently diagnosed with transfusion-dependent beta-thalassemia. When providing education to the parents about this condition, the nurse practitioner explains that treatment of this condition can potentially lead to which of the following complications?

Answer 15

hemochromatosis
Beta-thalassemia is treated with blood transfusions. However, this can lead to transfusional iron overload, or hemochromatosis (A), as the body does not have a way to excrete excess iron. Iron overload can lead to heart failure, cardiac dysrhythmias, and cirrhosis.

Thalassemia is a hereditary condition. Beta-thalassemia begins to manifest within the first year of life, and an individual’s lifespan may be dramatically shortened without aggressive treatment.

Question 16

Which of the following manifestations is not associated with Duchenne muscular dystrophy?

Answer 16

dipolopia
Duchenne muscular dystrophy (DMD) is an inherited condition in which the muscles become progressively weaker over time. Onset of weakness typically occurs at around 2 to 3 years of age. Additionally, those with this condition may also have delayed physical milestones in their early years. Beyond muscle weakness, DMD can impact many aspects of life, including cognitive function. Large calf muscles are normal in these children due to scar tissue buildup from muscle brea down. Due to proximal weakness, they also progress to eventually having a waddling gait. Diplopia (A) is unlikely to be seen with DMD and instead would be more likely to be seen with oculopharyngeal muscular dystrophy. A multidisciplinary approach is best to help improve quality of life for these patients, as DMD affects multiple body systems. Support in the form of physical therapy, occupational therapy, speech therapy, and language therapy is also important. Most patients will lose the ability to ambulate and will use a wheelchair by the age of 12. Life expectancy is shortened, but with medical advancements, patients may now live into adulthood.

Question 17

Asthma controlled with daily low- or medium-dose inhaled corticosteroids (ICS) (C) is defined

Answer 17

moderate asthma

Question 18

first line tx for scarlet fever is

Answer 18

amoxicillin for 10 days

Question 19

An 8-year-old boy presents to the clinic accompanied by his parents for his annual well-child visit. Physical exam reveals a small amount of axillary hair. They report no abnormal body odor. Which of the following describes the most appropriate plan of care?

Answer 19

refer to endocrinologist due to precocious puberty
The nurse practitioner should recommend a referral to an endocrinologist due to precocious puberty (A). Development of secondary sexual characteristics before the age of 9 years in male patients and 8 years in female patients is considered precocious puberty. This warrants a referral to endocrinology for further investigation. Specialist evaluation may include imaging to assess bone age and brain imaging and a comprehensive hormone laboratory evaluation.

Question 20

Which of the following symptoms is the least likely manifestation of epiglottitis in children?

Answer 20

preauricular adenopathy
Epiglottitis is a serious medical condition in which the upper airways begin to swell. It is caused by the organism Haemophilus influenzae type B. Children < 5 years old typically present with respiratory distress and an acute onset of sore throat and fever. The patient rapidly deteriorates with labored breathing and difficulty swallowing. The patient may have drooling and be seated in a tripod position in which the neck is hyperextended in an attempt to maintain the airway. Preauricular adenopathy (C) is not a typical symptom of epiglottis in children.

Question 21

The dx tool for both asthma and COPD is

Answer 21

spirometry

Question 22

Slipped capital fermoral epiphysis is

Answer 22

is a displacement of the proximal femoral epiphysis through the growth plate. Involvement of the growth plate categorizes this a Salter-Harris fracture, and it is further associated with a Salter-Harris type 1 fracture (B).

SCFE commonly occurs in adolescents. Stress on the femoral growth plate causes a shearing force to occur that will eventually result in proximal femoral displacement. Obesity causes increased stress on the femoral growth plate and is the most common risk factor for SCFE. SCFE can be classified as either stable or unstable based on the ability of the patient to bear weight on the extremity. It can occur acutely after a traumatic injury or can be associated with chronic leg pain. Patients may have a positive Trendelenburg test, which is a sagging of the pelvis when they stand on the affected leg. However, this test is not specific for SCFE alone. X-rays of the hip and pelvis can be used to confirm the diagnosis. Patients should be offered immediate orthopedic referral upon diagnosis as they are at risk for avascular necrosis of the hip.

Question 23

Which of the following primitive reflexes should begin to disappear at about 2-3 months of age in a normal infant?

Answer 23

rooting
A newborn infant will turn its head toward anything that strokes its cheek or mouth, searching for the object by moving its head in steadily decreasing arcs until the object is found. The rooting reflex starts to disappear at about 2-3 months of age.

Question 24

Turner syndrome is caused by a

Answer 24

deletion in the X chromosome

Question 25

There are three entities to the female athlete triad, which include

Answer 25

infrequent menstrual cycles (C) or amenorrhea, low availability of energy with or without an eating disorder, and low bone mineral density associated with osteopenia or osteoporosis. T

Question 26

Aphthous stomatitis ulcers are the most common mucosal lesions and are commonly referred to as canker sores. These typically present as a

Answer 26

shallow, tender, yellowish ulceration (B) on the inside of the mouth on the oral mucosa.

Question 27

Pterygium colli

Answer 27

webbed neck
s.s of turners

Question 28

What is a leading cause of death in infants in the United States?

Answer 28

SIDS

Question 29

A 3-month-old boy with a medical history of cryptorchidism presents to the office with his parent for evaluation of scrotal swelling. On exam, the scrotum is markedly swollen, and transillumination shows fluid surrounding the right testicle. The infant is otherwise asymptomatic, and the remainder of the exam is within normal limits. Which of the following is the most appropriate intervention?

Answer 29

The majority of infant hydroceles resolve spontaneously by 12–24 months (A). If the hydrocele is painful to palpation, is associated with skin breakdown, or there is a concomitant inguinal hernia, then an urgent referral to pediatric urology/surgery is indicated. Pain is associated with a high risk for testicular torsion and must be ruled out. Surgery is also recommended if the hydrocele does not resolve on its own by 12–24 months

Question 30

A 10-year-old child presents to the clinic with their parents for follow-up after their recent diagnosis of mononucleosis. They were diagnosed 1 week ago at a local urgent care facility and were instructed to treat themself symptomatically and to rest. The patient reports a worsening sore throat. The nurse practitioner notes exudates and petechiae on the roof of the child’s mouth, and a rapid Streptococcus test performed in the clinic is positive. Which of the following medications should be prescribe

Answer 30

cephalexin (keflex)

Question 31

A pregnant patient at 30 weeks gestation comes in for assessment of preterm labor. She is determined to be in labor and may deliver within the next few days. Which of the following pharmacologic agents can be administered to the patient to reduce neonatal morbidity and mortality associated with respiratory distress syndrome?

Answer 31

Bethamethasone

Question 32

The nurse practitioner is evaluating a 4-month-old infant at a well child check-up. Which of the following newborn reflexes should have disappeared by this age?

Answer 32

The asymmetric tonic neck reflex (A) disappears around the age of 4 months old. When this reflex is gone, infants will be able to examine objects in the midline and manipulate the objects with both hands. A normal asymmetric tonic reflex is noted when the upper and lower extremities extend on the side to which the head and neck are turned. The nurse practitioner should also notice flexion of the contralateral extremities. This reflex is noted at 35 weeks gestation and dissipates by 3 to 4 months of age.

Question 33

Turner syndrome is associated with

Answer 33

hearing loss

Question 34

A 4-year-old boy presents with ear pain and an erythematous, bulging tympanic membrane on examination. The nurse practitioner diagnoses him with acute otitis media. Which of the following are the three most common bacterial pathogens associated with acute otitis media in children?

Answer 34

Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae (C).

Question 35

is the leading cause of sudden cardiac death in young athletes. F

Answer 35

Hypertrophic cardiomyopathy

Question 36

An 8-year-old boy presents to the clinic with his parents who report concerns about his blood pressure as they have measured it at home and have gotten readings that were elevated. The nurse practitioner educates the parents the normal range for blood pressure in children varies based upon multiple factors. Which of the following choices correctly identifies factors associated with blood pressure variance in children?

Answer 36

Sex. age. height
Blood pressure levels are interpreted based on sex, age, and height (B), and normal values are published by the National High Blood Pressure Education Program Working Group.

Question 37

two strains of HPV that cause most genital warts are

Answer 37

6 and 11

Question 38

HPV 16 and 18 cause what

Answer 38

most cervical cancer cases

Question 39

A 15-year-old female patient reports not having started her period. The patient has minimal to no breast development. Her mother started her period when she was 12 years old. The patient has a negative pregnancy test. Which of the following is the next step in her management?

A.Order a bone age
B.Order CT of the sella turcica
C.Draw FSH, LH, and TSH levels
D.Reassure the patient that she will likely start her period soon

Answer 39

Answer: C. Draw FSH, LH, and TSH levels

For primary amenorrhea, the first step (after confirming that the patient is not pregnant) is to rule out hypogonadism by evaluating FSH, LH, and TSH. A bone age may be helpful to determine if the patient is a “late bloomer” or has familial constitutional delay (i.e., has skeletal maturity younger than her chronological age). A CT of the sella turcica is only done when/if prolactin levels are elevated. Given that the patient has no signs of puberty, reassurance is not appropriate at this time.

Question 40

A 16-year-old male patient presents to the urgent care clinic with acute onset of testicular pain. Which of the following characteristics would be most consistent with testicular torsion?

A.Loss of cremasteric reflex
B.Blue dot sign
C.Palpable scrotal mass
D.Enlarging testicle

Answer 40

Answer: A. Loss of cremasteric reflex

Testicular torsion is associated with scrotal edema; redness; a high-riding, transverse-lie testicle that is painful; and loss of ipsilateral cremasteric reflex. The blue dot sign is associated with torsion of the appendix testis, while a palpable scrotal mass is more likely to be testicular cancer. An enlarging testicle is a normal Tanner II developmental stage.

Question 41

A 16-year-old patient is being seen in the clinic for a health issue. What care can the nurse practitioner provide without first obtaining parental consent?

A.Rapid throat culture to rule out strep
B.Varicella vaccine
C.Intramuscular antibiotics for urinary tract infection
D.Urine testing for sexually transmitted infections (STIs)

Answer 41

Answer: D. Urine testing for sexually transmitted infections (STIs)

Minors do not need parental consent for any testing or treatment for STIs, contraception, or diagnosis and management of pregnancy. Performing other testing and giving in-office treatments or vaccines does require a parent (or guardian) to consent to the actions.

Question 42

Which of the following best describes Klinefelter syndrome?

A.It is the complete or partial absence of a second sex chromosome.
B.It is associated with short stature.
C.It is commonly associated with tibial tuberosity tenderness.
D.It causes primary hypogonadism.

Answer 42

Answer: D. It causes primary hypogonadism.

Klinefelter syndrome is a condition in which males are born with 47XXY. This genetic addition causes primary hypogonadism or a deficiency in testosterone, which then leads to delayed pubertal maturation. Turner syndrome, identified by complete or partial absence of the second sex chromosome 45XO in females, is associated with short stature, webbed neck, a high-arched palate, and primary ovarian failure. Osgood-Schlatter disease is due to repetitive stress on the patellar tendon at the tibial tuberosity, which becomes tender due to the swelling and microtears.

Question 43

A 14-year-old female patient is seen in the ED with nausea and vomiting and right upper quadrant pain for 2 days. The family reveals that they found an empty Tylenol bottle in the patient’s room 2 days ago and that she has been more depressed in the last couple of weeks. If this was intentional ingestion of Tylenol, which of the following would the nurse practitioner expect to see on the labs?

A.Elevated liver function
B.Decreased renal function
C.Elevated glucose level
D.Decreased bilirubin concentration

Answer 43

Answer: A. Elevated liver function

In the initial stage of acute acetaminophen poisoning, patients may be asymptomatic for up to the first 24 hours. In the second stage (hours 18 to 72), patients will typically present with elevated liver function test results, bilirubin, and prothrombin time, and possibly with elevated renal function. Hypoglycemia may be present in the third stage (hours 72 to 96).

Question 44

Which of the following is an example of an expected age-related neurological change?

A.Inability to recall the United States capital
B.Loss of memory of how to tie one’s shoes
C.Inability to recognize own daughter and son
D.Difficulty reciting the alphabet while walking around the room

Answer 44

Answer: D. Difficulty reciting the alphabet while walking around the room

While there are cognitive and behavioral changes associated with normal aging, certain memory performances, like procedural memory (memory of performing different actions or skills such as riding a bike or tying one’s shoes) and semantic memory (memory of objects, general facts, and concepts) are well preserved. The ability to recognize familiar objects and faces remains stable over the lifetime. Attention span decreases with simple attentive tasks as a result of aging; there is a decreased ability to focus on a task in a busy environment or perform multiple tasks at one time.

Question 45

A kindergarten-aged child presents with a fever to 102.5°F and has a decreased appetite. The child complains of a sore throat and headache. On exam, ulcers on an erythematous base are noted on the inside of the lower lip and cheeks, and three small blisters are noted on the right hand. Which of the following is appropriate anticipatory guidance for this patient’s parents?

A.Offer the child warm tomato soup
B.Use a lemon juice and water swish-and-spit solution
C.Offer aspirin every 4 to 6 hours for pain and fever
D.Use a salt-water gargle/rinse several times a day

Answer 45

Answer: D. Use a salt-water gargle/rinse several times a day

This child likely has coxsackie A16 virus (also referred to as hand-foot-mouth disease). A child with this illness will be bothered by warm or hot liquids. Acidic foods such as lemon or tomato juice can irritate the lesions. Aspirin should never be given to kindergarten-aged children.

Question 46

A child is seen for an annual well-child exam and is noted to be thinking in an abstract manner. This child’s age is most likely how many years?

A.5
B.7
C.9
D.11

Answer 46

Answer: D. 11

According to Piaget, early abstract thinking starts at about 11 years old, while 7- and 9-year-olds are typically concrete operational thinkers. The 5-year-old is still in pretend play and is considered in the preoperational thinking stage.

Question 47

A 5-year-old child is seen for a routine well visit. The child has been noted by their kindergarten teacher to be struggling to acquire some of the early literacy skills. The child also has difficulty with basic problem solving. Physical exam reveals a tall child with a large head, prominent forehead, and large ears. What is the most likely diagnosis?

A.Autism spectrum disorder
B.Marfan syndrome
C.Fragile X syndrome
D.Fetal alcohol syndrome

Answer 47

Fragile X syndrome

Question 48

A 5-year-old child is diagnosed with Kawasaki disease after 5 days of high fever. With whom should this child follow up on a routine basis to monitor for sequalae?

A.Infectious disease
B.Cardiology
C.Ophthalmology
D.Dermatology

Answer 48

Answer: B. Cardiology

Serious sequelae, such as aortic dissection, coronary artery aneurysms, and dilation, may not appear until the child is older, so routine follow-up with cardiology is recommended. Once the rash and other signs of inflammation resolve, usually in 4 to 8 weeks, the child should not need continued monitoring by dermatology, ophthalmology, or infectious disease.

Question 49

An infant is being seen for a 4-month well-child visit. The patient is up to date on immunizations at this point. Which of the following is the correct set of immunizations to order?

A.Hep B, Hib, PCV, IPV, rotavirus, DTaP, influenza
B.Hep B, Hib, PCV, IPV, rotavirus, DTaP
C.Hib, PCV, IPV, rotavirus, DTaP
D. MMR, varicella, Hep A

Answer 49

Answer: C. Hib, PCV, IPV, rotavirus, DTaP

If the patient is up to date on immunizations and requires an age-appropriate vaccine series, they would receive rotavirus #2, DTaP #2, Hib #2, pneumococcal #2, and IPV #2 today. The patient is too young for an influenza vaccine, and Hep B #2 should have been given at 1 to 2 months, as the first dose is typically given in the hospital immediately after delivery. MMR and varicella cannot be given until after 12 months. Hep A is typically given between 12 to 23 months.

Question 50

Which of the following in a newborn would be most concerning for an associated neurologic disorder?

A.Erythema toxicum found on the face
B.Congenital dermal melanocytosis on the sacral area
C.Café au lait spots (more than five lesions) on the chest
D.Nevus flammeus on the shoulders and upper chest area

Answer 50

Answer: C. Café au lait spots (more than five lesions) on the chest

Café au lait spots, particularly when there are more than five lesions, can be associated with neurofibromatosis. While port-wine stains (nevus flammeus) can be associated with neurologic involvement of cranial nerves V1 and V2 if located on the eyelid and with Sturge-Weber disease if found unilaterally over the face, port-wine stains found on other areas of the body are rarely associated with neurologic issues. Erythema toxicum can be a normal finding on the face of a newborn. Congenital dermal melanocytosis is most commonly found on the sacral and medial gluteal area. It is not associated with underlying neurologic issues.

Question 51

A child presents for a well-child visit, and their parent notes that the child plays well with others at daycare but primarily likes to play with an imaginary friend. The child’s four- to five-word sentences are somewhat difficult to fully understand, and the child draws a circle during the exam. This child is likely what age in months?

A.18
B.24
C.36
D.48

Answer 51

Answer: C. 36

A 3-year-old child performs interactive play with others, may have magical thinking, has a growing vocabulary with three quarters of the speech understandable, and has fine motor skills that allow drawing of a circle. Children younger than 3 years have significantly fewer words in their vocabulary and are not yet stringing words together in sentences; they have an immature pencil grasp, which makes drawing shapes more difficult; and they may only perform parallel play rather than interactive play. By 4 years old, the child should have completely understandable speech, be riding a bike with training wheels, and be engaging in cooperative/collaborative play with others.

Question 52

Which of the following statements regarding physiologic jaundice is correct?

A.It appears when bilirubin levels reach 3 mg/dL.
B.It first appears on the feet and progresses upward on the body.
C.It generally clears within 2 to 3 weeks with adequate feedings.
D.It begins within the first 24 hours of life.

Answer 52

Answer: C. It generally clears within 2 to 3 weeks with adequate feedings.

Physiologic jaundice represents a normal transitional state that resolves once the infant’s liver can keep up with the demand for bilirubin conjugation. It starts after the first 24 hours of life when the bilirubin level reaches 5 mg/dL or higher. The condition is initially apparent on the newborn’s face before it progresses downward on the body. It will usually clear within 2 to 3 weeks without intervention other than adequate feedings.

Question 53

Which of the following is an expected behavior for a 3-year-old child?

A.Speaks in two- to three-word sentences
B.Can draw a cross
C.Can copy a circle
D.Walks up stairs using the same foot

Answer 53

Answer: C. Can copy a circle

A 3-year-old child can copy a circle, speak in three- to five-word sentences, and walk up and down stairs using alternating feet. Speaking in shorter sentences and walking up stairs using the same foot are behaviors expected of a 2-year-old. The ability to draw a cross is expected of a 4-year-old.

Question 54

Which of the following statements is true regarding neuroblastoma?

A.It is a lateralized, well-demarcated mass.
B.It involves invasion of the renal capsule.
C.It can be diagnosed by urinary catecholamine levels.
D.It rarely presents as metastatic disease.

Answer 54

It can be diagnosed by urinary catecholamine levels.

Question 55

A 3-year-old boy is seen by the primary care provider for a 3-week history of limping. He is noted to be overall well-appearing, is afebrile, and is sitting with his hip and knee flexed. He is tender to palpation over the groin area, but no palpable abnormalities are found. Which of the following is the most likely diagnosis?

A.Developmental dysplasia of the hip
B.Normal gross motor development
C.Osteomyelitis
D.Septic arthritis

Answer 55

Answer: D. Septic arthritis

A child with septic arthritis at the hip typically will not have any palpable abnormalities due to the deep nature of the hip joint and may look uncomfortable but non-toxic. A child with osteomyelitis will likely be febrile, appear toxic, and have pain at the femoral metaphysis. Developmental dysplasia of the hip at age 3 years would be a missed diagnosis and typically would present with a leg-length difference and gait abnormalities. A limp in a child is not a normal developmental finding.

Question 56

A newborn infant is seen at a 2-week well-child visit and is noted to have a watery discharge from both eyes. The parent noted some blood in the discharge yesterday. The infant is otherwise well with no respiratory symptoms. Which of the following is the next best management step?

A.Treat empirically with ceftriaxone intramuscularly (Rocephin)
B.Treat with ophthalmic erythromycin ointment (Ilotycin)
C.Collect a swab of the inner eyelid
D.Order a chest x-ray

Answer 56

Answer: C. Collect a swab of the inner eyelid

The first step with this patient would be to collect a swab of the inner eyelid to gather a sample of the discharge and also one of the epithelium. Given the presentation, this infant appears to have a chlamydial infection in the eye. As the patient has no respiratory symptoms, a nasopharyngeal swab would be more appropriate than a chest x-ray at this time. Ophthalmic erythromycin (Ilotycin) is used prophylactically for gonorrheal infections of the eye, and ceftriaxone (Rocephin) is the treatment of choice for infants with gonococcal ophthalmia neonatorum.

Question 57

A child is seen for a well visit. Which of the following findings would require a consult or referral for further evaluation?

A.A 3-day-old with multiple 1- to 2-mm white papules on the forehead and nose
B.A 4-month-old with thick yellow scale behind the ears and on the eyebrows
C.A 6-month-old with a round, orange-red glow from each eye on fundoscopic exam
D.A 9-month-old with a Moro reflex

Answer 57

Answer: D. A 9-month old with a Moro reflex

Persistence of a Moro reflex after age 4 to 5 months is concerning for underlying brain pathology. A 3-day-old may present with the normal finding of milia, while seborrheic dermatitis is common in infants age 2 to 4 months. A 6-month-old should have a bilateral red reflex; failure to see a red reflex would be concerning.

Question 58

Which motor skill is within the parameters of normal growth and development for a 2-year-old child?

A.Throws a ball overhand
B.Pedals a tricycle
C.Stacks seven or more cubes
D.Runs, jumps, and climbs

Answer 58

Answer: D. Runs, jumps, and climbs

A 2-year-old child has the gross motor skills necessary to run, jump, and climb. Throwing a ball overhand, pedaling a tricycle, and stacking seven or more cubes are typical of a 3-year-old child.

Question 59

Which of the following is true regarding a caput succedaneum?

A.It is commonly associated with assisted deliveries.
B.It can be associated with jaundice.
C.It is described as diffuse edema that crosses the suture lines.
D.It is swelling that is localized to one area of the skull.

Answer 59

Answer: C. It is described as diffuse edema that crosses the suture lines.

A caput succedaneum is a diffuse swelling that is secondary to prolonged delivery or pressure on the head as the infant moves through the birth canal. The pressure causes fluid to build up under the scalp. Cephalohematoma is due to periosteal blood vessel rupture over a particular skull bone, usually secondary to an assisted delivery. As the blood is contained in the subperiosteal space, it is localized to one area of the skull and does not spread diffusely. The large collection of blood can increase the bilirubin levels in the infant’s bloodstream and put them at risk for jaundice.

Question 60

seperation anxiety begins at what age

Answer 60

12 months

Question 61

An infant is noted to have upward deviation of palpebral fissures, macroglossia, and hypotonia. Which of the following is most likely the infant’s underlying issue?

A.Amblyopia
B.Down syndrome
C.Esotropia
D.Fetal alcohol spectrum disorder

Answer 61

Answer: B. Down syndrome

Upward deviation of palpebral fissures, macroglossia, and hypotonia are classically found in infants born with trisomy 21, or Down syndrome. Fetal alcohol spectrum disorder ranges in presentation but most classically will have microcephaly with a flat nasal bridge and a thin lip with a smooth philtrum. Esotropia is the upward deviation of the eye, and amblyopia is a visual disturbance characterized by decreased vision due to abnormal visual development.

Question 62

A child is seen in the ED for not wanting to use their right arm after a fall. The provider is concerned for possible child abuse. Which of the following would increase the risk for abuse in this child?

A.Developmentally appropriate for age
B.Care sought immediately after fall
C.History consistent with injury
D.Metaphyseal avulsion fracture on x-ray

Answer 62

Answer: D. Metaphyseal avulsion fracture on x-ray

Metaphyseal avulsion fractures are thought to occur due to excessive force from shaking or twisting a limb, so higher suspicion for abuse should occur if these are seen. Children who are developmentally or physically disabled are at higher risk for abuse than their developmentally appropriate peers. Delayed care and an inconsistent history would also raise red flags.

Question 63

Which of the following findings would be consistent with right knee osteomyelitis?

A.Erythematous and swollen joint
B.Knee kept flexed and hip abducted and externally rotated
C.Exquisite tenderness over the distal femur
D.Weight bearing with antalgic gait

Answer 63

Answer: C. Exquisite tenderness over the distal femur

Osteomyelitis typically presents with exquisite tenderness over the metaphysis/bone, not usually the joint space. Typically, a child with a lower extremity osteomyelitis will not bear weight due to the pain, although it is possible they may bear weight (but guard in their walking) with a septic knee joint. Septic arthritis presents with true joint swelling and knee flexion with hip abduction and external rotation if the hip joint is involved.

Question 64

Which statement about Wilm’s tumor is correct?

A.Palpation causes significant pain in the child.
B.It is a congenital tumor of the bladder.
C.Microscopic or gross hematuria is sometimes present.
D.The tumor commonly crosses the midline of the abdomen when it is discovered.

Answer 64

Answer: C. Microscopic or gross hematuria is sometimes present

A Wilms’ tumor is a congenital tumor of the kidney. It is non-tender and smooth and rarely crosses the midline of the abdomen. Microscopic or gross hematuria may be present. Once diagnosed, it should not be palpated, since doing so increases the risk for rupture of the tumor capsule and spread of the tumor cells.

Question 65

A 3-year-old child presents with a red eye. Which of the following exam findings would be most indicative of preseptal cellulitis?

A.Proptosis
B.Painful extraocular movements
C.Leukocoria
D.Eyelid erythema and swelling

Answer 65

Answer: D. Eyelid erythema and swelling

Preseptal cellulitis does not involve the globe or orbit of the eye and is restricted to the eyelid and surrounding soft tissue. Proptosis and painful extraocular movements are hallmark signs of orbital cellulitis, while leukocoria can be found in children with glaucoma, cataracts, or retinoblastoma.