Peds: Newborns-Toddlers

Question 1

Danger Signals

Failure to _____

D___ Syndrome

Fetal _____ Syndrome

(1) (Undescended Testicle)

G______ Ophtalmia Neonatorum

Ch_____ Ophthalmia Neonatorum (Trachoma)

Chlamydial Pn______

Sudden Infant ______ Syndrome

Excessive Weight Loss (>___%)

De______

Answer 1

Failure to Thrive

Down Syndrome

Fetal Alcohol Syndrome

Cryptorchidism (Undescended Testicle)

Gonococcal Ophtalmia Neonatorum

Chlamydial Ophthalmia Neonatorum (Trachoma)

Chlamydial Pneumonia

Sudden Infant Death Syndrome

Excessive Weight Loss (>10%)

Dehydration

Question 2

Failure to Thrive

Defined as weight for age that falls below __-__ percentile for gestation-corrected age and gender when plotted on appropriate growth chart (on more than one occasion).

Also, infants whose rate of weight change decreases over ____ or more major percentile lines (90th, 75th, 50th, 25th, and 5th) exhibit failure to thrive (FTT; e.g., a child at the 50th percentile goes down to 5th percentile over a few months).

Use (1) charts until the age of 2 years, and then (1) growth charts.

In most cases seen in primary care, causes are usually inadequate di____ intake, dia____, mal______ (celiac disease, cystic fibrosis, food allergy), poor maternal b_____, frequent in_____, and others.

Answer 2

Defined as weight for age that falls below 3rd to 5th percentile for gestation-corrected age and gender when plotted on appropriate growth chart (on more than one occasion).

Also, infants whose rate of weight change decreases over two or more major percentile lines (90th, 75th, 50th, 25th, and 5th) exhibit failure to thrive (FTT; e.g., a child at the 50th percentile goes down to 5th percentile over a few months).

Use World Health Organization (WHO) growth charts until the age of 2 years, and then Centers for Disease Control and Prevention (CDC) growth charts.

In most cases seen in primary care, causes are usually inadequate dietary intake, diarrhea, malabsorption (celiac disease, cystic fibrosis, food allergy), poor maternal bonding, frequent infections, and others.

Question 3

Down Syndrome

A genetic defect caused by tr____ of chromosome ___ (three copies instead of two). The most common chromosomal disorder; the average life span is ___ years in the United States.

Affected persons have a round face that appears “___” (decreased anterior–posterior diameter), accompanied by __ward-slanting eyes (palpebral fissures) and ___-set ears.

Chronic open mouth caused by enlarged ______ (macroglossia), accompanied by a ______ neck. ____ fingers, ____ palms, and a broad hand with transverse palmar crease (S____ crease) are additional signs.

Newborns have h____tonia and poor M____ reflex. Higher risk of int______ disability, congenital ____ defects (50%), feeding difficulties, congenital h______ loss, th____ disease, cataracts, sleep apnea, and early onset of A______ disease (average age 54 years).

Answer 3

A genetic defect caused by trisomy of chromosome 21 (three copies instead of two). The most common chromosomal disorder; the average life span is 60 years in the United States.

Affected persons have a round face that appears “flat” (decreased anterior–posterior diameter), accompanied by upward-slanting eyes (palpebral fissures) and low-set ears.

Chronic open mouth caused by enlarged tongue (macroglossia), accompanied by a shorter neck. Short fingers, small palms, and a broad hand with transverse palmar crease (Simian crease) are additional signs.

Newborns have hypotonia and poor Moro reflex. Higher risk of intellectual disability, congenital heart defects (50%), feeding difficulties, congenital hearing loss, thyroid disease, cataracts, sleep apnea, and early onset of Alzheimer’s disease (average age 54 years).

Question 4

Down Syndrome

Educate parents about importance of cervical ____ positioning and monitoring for myelopathic signs and symptoms. Contact sports (football, soccer, gymnastics) may place at higher risk of (1) injury. Avoid tr_____ use unless under professional supervision. Special Olympics requires specific screening for some sports.

Answer 4

Educate parents about importance of cervical spine positioning and monitoring for myelopathic signs and symptoms. Contact sports (football, soccer, gymnastics) may place at higher risk of spinal cord injury. Avoid trampoline use unless under professional supervision. Special Olympics requires specific screening for some sports.

Question 5

Fetal Alcohol Syndrome

Also known as fetal alcohol spectrum disorder.

Classic fetal alcohol syndrome (FAS) f____ is a ____ head (microcephaly) with _____ palpebral fissures (____ eyes) with epic_____ folds and a ____ nasal bridge. There is a th___ upper lip with no vertical groove above the upper lip (smooth ph_____). E___ are underdeveloped.

Can range from neuro______ and be_____ problems (e.g., attention deficit disorder [ADD]) to more severe intellectual disabilities.

Is there any safe time or amount of alcohol during pregnancy?

Alcohol adversely affects the (1) system, somatic gr____, and f____ structure development.

Answer 5

Also known as fetal alcohol spectrum disorder.

Classic fetal alcohol syndrome (FAS) facies is a small head (microcephaly) with shortened palpebral fissures (narrow eyes) with epicanthal folds and a flat nasal bridge. There is a thin upper lip with no vertical groove above the upper lip (smooth philtrum). Ears are underdeveloped.

Can range from neurocognitive and behavioral problems (e.g., attention deficit disorder [ADD]) to more severe intellectual disabilities.

There is no safe dose or time for alcohol during pregnancy.

Alcohol adversely affects the central nervous system (CNS), somatic growth, and facial structure development.

Question 6

Cryptorchidism (Undescended Testicle)

____ scrotal sac(s). Most cases involve undescended testicles. One or two testicles may be missing. Testis does not descend with m_____ of the inguinal area.

Majority of cases (90%) of cryptorchidism are associated with p____ processus vaginalis. Infant should be sitting, and the exam room should be w____ to relax muscles when massaging the inguinal canal. Another option is to examine child after a warm bath.

Increased risk of testicular _____ if testicles are not removed from the abdomen. Surgical correction (1) necessary within the _____ year of life if testicle does not spontaneously descend.

Answer 6

Empty scrotal sac(s). Most cases involve undescended testicles. One or two testicles may be missing. Testis does not descend with massage of the inguinal area.

Majority of cases (90%) of cryptorchidism are associated with patent processus vaginalis. Infant should be sitting, and the exam room should be warm to relax muscles when massaging the inguinal canal. Another option is to examine child after a warm bath.

Increased risk of testicular cancer if testicles are not removed from the abdomen. Surgical correction (orchiopexy) necessary within the first year of life if testicle does not spontaneously descend.

Question 7

Gonococcal Ophtalmia Neonatorum

Symptoms usually show within 2 to 5 days after birth.

Infection can _____ spread, causing (1). Do not _____ treatment by waiting for culture results.

Symptoms include in____ (red) conjunctiva with profuse ______ discharge and sw____ eyelids.

Majority of cases of congenital gonorrhea infection are acquired _____ delivery (intrapartum).

Coinfection with ______ is common with gonococcal infection.

Any neonates with acute ____itis presenting within ___ days or less from birth should be tested for chlamydia, gonorrhea, herpes simplex, and bacterial infection.

Answer 7

Symptoms usually show within 2 to 5 days after birth.

Infection can rapidly spread, causing blindness. Do not delay treatment by waiting for culture results.

Symptoms include injected (red) conjunctiva with profuse purulent discharge and swollen eyelids.

Majority of cases of congenital gonorrhea infection are acquired during delivery (intrapartum).

Coinfection with chlamydia is common with gonococcal infection.

Any neonates with acute conjunctivitis presenting within 30 days or less from birth should be tested for chlamydia, gonorrhea, herpes simplex, and bacterial infection.

Question 8

Gonococcal Ophtalmia Neonatorum

Order ____ stain, gonococcal _____ (Thayer–Martin media) or P___ test for Neisseria gonorrhoeae, herpes simplex culture, and PCR for Chlamydia trachomatis of eye exudate.

Hospitalize and treat with high-dose intravenous or intramuscular Rx(1)

Preferred prophylaxis is with topical 0.5% Rx(1) ointment (1-cm ribbon per eye) immediately after birth.

Test (and treat) m____ and sexual ____ for STDs/sexually transmitted infections (STIs).

Answer 8

Order Gram stain, gonococcal culture (Thayer–Martin media) or polymerase chain reaction (PCR) test for Neisseria gonorrhoeae, herpes simplex culture, and PCR for Chlamydia trachomatis of eye exudate.

Hospitalize and treat with high-dose intravenous or intramuscular cefotaxime.

Preferred prophylaxis is with topical 0.5% erythromycin ointment (1-cm ribbon per eye) immediately after birth.

Test (and treat) mother and sexual partner for STDs/sexually transmitted infections (STIs).

Question 9

Chlamydial Ophthalmia Neonatorum (Trachoma)

Symptoms will show 4 to __ days after birth.

Eye___ become ed_____ and red with profuse _____ discharge initially that later becomes p_____.

When obtaining a sample, collect not only the exudate but also (1) cells. Rule out concomitant chlamydial pn_____.

Treated with ______ antibiotics such as oral _____ base or erythromycin ethylsuccinate QID × 14 days. Treatment only 80% effective. May need second course. Use only _____ antibiotics.

The prophylaxis used for gonococcal ophthalmia (t_____0.5% erythromycin) will not prevent neonatal chlamydial conjunctivitis or extraocular infections, thus the importance of prenatal sc_____ and treatment.

______ disease. Test (and treat) m____ and sexual _____ for STDs.

Answer 9

Symptoms will show 4 to 10 days after birth.

Eyelids become edematous and red with profuse watery discharge initially that later becomes purulent.

When obtaining a sample, collect not only the exudate but also conjunctival cells. Rule out concomitant chlamydial pneumonia.

Treated with systemic antibiotics such as oral erythromycin base or erythromycin ethylsuccinate QID × 14 days. Treatment only 80% effective. May need second course. Use only systemic antibiotics.

The prophylaxis used for gonococcal ophthalmia (topical 0.5% erythromycin) will not prevent neonatal chlamydial conjunctivitis or extraocular infections, thus the importance of prenatal screening and treatment.

Reportable disease. Test (and treat) mother and sexual partner for STDs.

Question 10

Chlamydial (1)

In infants with ophthalmia neonatorum, also rule out concomitant chlamydial _____.

Obtain n______ culture for chlamydia. Infant will have frequent c_____ with bibasilar r____, tachypnea, hyperinflation, and diffused inf______ on chest x-ray.

Treated with Rx(1) QID × 2 weeks. Daily follow-up. _____ disease.

Answer 10

Chlamydial Pneumonia

In infants with ophthalmia neonatorum, also rule out concomitant chlamydial pneumonia.

Obtain nasopharyngeal culture for chlamydia. Infant will have frequent cough with bibasilar rales, tachypnea, hyperinflation, and diffused infiltrates on chest x-ray.

Treated with erythromycin QID × 2 weeks. Daily follow-up. Reportable disease.

Question 11

Sudden Infant Death Syndrome

A sudden infant death in apparently h_____ infants

Higher risk with ___maturity, ____birth weight, maternal sm_____ and/or drug use, and poverty.

Cause hypothesized to be a multifactorial convergence of intrinsically vulnerable infant (g______ predisposition) during a critical development period with exogenous st______.

To decrease risk, position infants on their ____ (supine); use a f____ sleep surface; encourage b_____feeding and routine imm______; room share _____ bedsharing; offer a p_____ for sleep times; and avoid soft objects and _____ bedding in the sleep area, sm____ exposure, and over_____ infant.

Answer 11

A sudden infant death in apparently healthy infants <12 months, which cannot be explained after a thorough case investigation that includes a scene investigation, autopsy, and review of clinical history.

Higher risk with prematurity, low birth weight, maternal smoking and/or drug use, and poverty.

Cause hypothesized to be a multifactorial convergence of intrinsically vulnerable infant (genetic predisposition) during a critical development period with exogenous stressors.

To decrease risk, position infants on their backs (supine); use a firm sleep surface; encourage breastfeeding and routine immunizations; room share without bedsharing; offer a pacifier for sleep times; and avoid soft objects and loose bedding in the sleep area, smoke exposure, and overheating infant.

Question 12

Excessive Weight Loss (>___%)

Newborns are ex______ to lose weight during the first few days of life. Weight loss can vary by feeding method and delivery type; infants delivered by (1) tend to lose a larger percentage of birth weight than their (1)delivered counterparts. ______-fed infants may lose up to 5%, and _____-fed infants may lose 7% to 10% of their birth weight.

Any loss from birth weight should be regained within 10 to ___ days. Weight loss beyond ___% in neonates is considered abnormal. Assess the infant for de_____, el_____disturbances, and hyperbi______, and the mother and infant for lactation difficulties.

Answer 12

Excessive Weight Loss (>10%)

Newborns are expected to lose weight during the first few days of life. Weight loss can vary by feeding method and delivery type; infants delivered by cesarean section (C-section) tend to lose a larger percentage of birth weight than their vaginally delivered counterparts. Formula-fed infants may lose up to 5%, and breast-fed infants may lose 7% to 10% of their birth weight.

Any loss from birth weight should be regained within 10 to 14 days. Weight loss beyond 10% in neonates is considered abnormal. Assess the infant for dehydration, electrolyte disturbances, and hyperbilirubinemia, and the mother and infant for lactation difficulties.

Question 13

Dehydration

Signs of severe dehydration (>10% weight loss) in an infant are w___ and r____ pulse, ____pnea or deep breathing, par____ mucous membranes, anterior fontanelle that is markedly s____, skin turgor showing t_____, c____ skin, acrocy____, anuria, and change in LOC (lethargy to coma).

Refer severely dehydrated infants to the ___ for (1) hydration. Severe dehydration due to acute g______ is one of the leading causes of death of infants in the developing world.

Answer 13

Signs of severe dehydration (>10% weight loss) in an infant are weak and rapid pulse, tachypnea or deep breathing, parched mucous membranes, anterior fontanelle that is markedly sunken, skin turgor showing tenting, cool skin, acrocyanosis, anuria, and change in LOC (lethargy to coma).

Refer severely dehydrated infants to the ED for intravenous (IV) hydration. Severe dehydration due to acute gastroenteritis is one of the leading causes of death of infants in the developing world.

Question 14

(1)

Most common type of pigmented skin lesions in newborns. Present in almost all Asians (85%–100%) and in more than half of Native American, Hispanic, and Black neonates. Blue- to black-colored patches or stains. A common location is the lumbosacral area (but can be located anywhere on the body). May be mistaken for bruising or child abuse. Usually fade by age 2 to 3 years.

Answer 14

Congenital Dermal Melanocytosis (Mongolian Spots)

Question 15

(1)

Most common in neonates. Multiple white 1- to 2-mm papules located mainly on the forehead, cheeks, and nose. Due to retention of sebaceous material and keratin. Resolves spontaneously.

Answer 15

Milia, Miliaria, or “Prickly Heat”

Question 16

(1)

Small pustules (whitish-yellow color) that are 1- to 3-mm in size and surrounded by a red base. Erupt during the second to the third day of life. Located on the face, chest, back, and extremities. Last from 1 to 2 weeks and resolve spontaneously.

Answer 16

Erythema Toxicum Neonatorum

Question 17

(1)

Excessive thick scaling on the scalp of younger infants. Treated by softening and removal of the thick scales on the scalp after soaking scalp a few hours (to overnight) with vegetable oil or mineral oil. Shampoo scalp and gently scrub scales with soft comb. Prevention is by frequent shampooing with mild baby shampoo and removing scales with soft brush or comb. Self-limited condition that resolves spontaneously within a few months.

Answer 17

Seborrheic Dermatitis (“Cradle Cap”)

Question 18

(1)

Tufts of hair overlying spinal column usually at lumbosacral area. May be a sign of neural tube defects (spina bifida, spina bifida occulta). Perform neurologic exam focusing on lumbosacral nerves (fecal/urinary in______, problems with g___). Order (1) of lesion to rule out (1).

Answer 18

Faun Tail Nevus

Tufts of hair overlying spinal column usually at lumbosacral area. May be a sign of neural tube defects (spina bifida, spina bifida occulta). Perform neurologic exam focusing on lumbosacral nerves (fecal/urinary incontinence, problems with gait). Order ultrasound of lesion to rule out occult spina bifida.

Question 19

(1)

Flat light-brown to dark-brown spots >___ mm (0.5 cm). If ___ or more spots larger than 5 mm (0.5 cm) in diameter are seen, rule out neuro_______or von R_______ disease (e.g., neurologic disorder marked by seizures, learning disorders). Refer to pediatric (1) if the spots meet the same criteria to rule out neurofibromatosis.

Answer 19

Café Au Lait Spots

Flat light-brown to dark-brown spots >5 mm (0.5 cm). If six or more spots larger than 5 mm (0.5 cm) in diameter are seen, rule out neurofibromatosis or von Recklinghausen’s disease (e.g., neurologic disorder marked by seizures, learning disorders). Refer to pediatric neurologist if the spots meet the same criteria to rule out neurofibromatosis.

Question 20

(1)

A vascular lesion often referred to as “____ bites” or “____ kisses.” Flat pink patches found on the forehead, eyelids, and nape of neck (Figure 1). Usually appear on both sides of the ____line (i.e., on both eyelids or across the entire nape of neck). ____chable, but color changes with crying, breath holding, and room temperature changes. Consider Beckwith–Wiedemann or FAS if glabellar lesion seen. Typically f____ by 18 months.

Answer 20

Salmon Patches (Nevus Simplex)

A vascular lesion often referred to as “stork bites” or “angel kisses.” Flat pink patches found on the forehead, eyelids, and nape of neck (Figure 1). Usually appear on both sides of the midline (i.e., on both eyelids or across the entire nape of neck). Blanchable, but color changes with crying, breath holding, and room temperature changes. Consider Beckwith–Wiedemann or FAS if glabellar lesion seen. Typically fade by 18 months.

Question 21

(1)

Neonates with pink-to-red, flat, stain-like skin lesions located on the upper and lower eyelids or on the V1 and V2 branches of the _______ nerve (CN V) should be referred to a pediatric ophthalmologist to rule out congenital (1). Blanches to pressure. Irregular in size and shape. Usually unilateral. Large lesions located on half the facial area may be a sign of trigeminal nerve involvement and Sturge–Weber syndrome (rare neurologic disorder). The lesions do _____ regress and grow with the child. These lesions can be treated with (1) (PDL) therapy.

Answer 21

Port Wine Stain (Nevus Flammeus)

Neonates with pink-to-red, flat, stain-like skin lesions located on the upper and lower eyelids or on the V1 and V2 branches of the trigeminal nerve (CN V) should be referred to a pediatric ophthalmologist to rule out congenital glaucoma. Blanches to pressure. Irregular in size and shape. Usually unilateral. Large lesions located on half the facial area may be a sign of trigeminal nerve involvement and Sturge–Weber syndrome (rare neurologic disorder). The lesions do not regress and grow with the child. These lesions can be treated with pulse-dye laser (PDL) therapy.

Question 22

(1)

Raised vascular lesions ranging in size from 0.5 to 4.0 cm that are bright red in color and feel soft to palpation. Usually located on the head or the neck. The lesions often grow rapidly during the first 12 months of life, but the majority will involute gradually over the next 1 to 5 years. Watchful waiting is the usual strategy. Can be treated with (1) therapy.

Answer 22

Hemangioma (Strawberry Hemangioma)

Raised vascular lesions ranging in size from 0.5 to 4.0 cm that are bright red in color and feel soft to palpation. Usually located on the head or the neck. The lesions often grow rapidly during the first 12 months of life, but the majority will involute gradually over the next 1 to 5 years. Watchful waiting is the usual strategy. Can be treated with PDL therapy.

Question 23

Vision Screening

Newborn Vision

Newborns are ____-sighted (myopia) and have a vision of 20/400.

They can focus best at a distance of 8 to ___ inches.

During the first 2 months, the infant’s eyes may appear cr_____ (or wander) at times (normal finding). If one eye is consistently turned in or turned out, refer to pediatric ophthalmologist.

Human f____ is preferred by newborns.

Newborns do ___ shed ____ , because the lacrimal ducts are not fully mature at birth.

Caucasian neonates are born with blue-gray eyes. It is normal for their eye color to _____ as they mature.

R_____ (CN II) are immature at birth and reach maturity at age 6 years.

Answer 23

Newborns are nearsighted (myopia) and have a vision of 20/400.

They can focus best at a distance of 8 to 10 inches.

During the first 2 months, the infant’s eyes may appear crossed (or wander) at times (normal finding). If one eye is consistently turned in or turned out, refer to pediatric ophthalmologist.

Human face is preferred by newborns.

Newborns do not shed tears, because the lacrimal ducts are not fully mature at birth.

Caucasian neonates are born with blue-gray eyes. It is normal for their eye color to change as they mature.

Retinas (CN II) are immature at birth and reach maturity at age 6 years.

Question 24

Infant Screening

Match these descriptions with what an infant’s vision at 1, 3, 6, and 12 months

• (1)**:* Makes good eye contact. Turns head to scan surroundings with 180-degree visual field.
• (1)**:* Infant will hold the hands close to the face to observe them. Hold a bright object or a toy in front of the infant. Watch behavior as the infant fixates and follows the toy for a few seconds. Avoid using objects/toys that make noises when testing vision.
• (1):* Makes prolonged eye contact when spoken to. Will actively turn head around 180 degrees to observe people and surroundings for long periods. Recognizes self in a mirror and parents and favorite people from a longer distance.
• (1)**:* Infant can fixate briefly on the mother’s face. Prefers the human face.

Answer 24

• 6 months:* Makes good eye contact. Turns head to scan surroundings with 180-degree visual field.
• 3 months**:* Infant will hold the hands close to the face to observe them. Hold a bright object or a toy in front of the infant. Watch behavior as the infant fixates and follows the toy for a few seconds. Avoid using objects/toys that make noises when testing vision.
• 12 months:* Makes prolonged eye contact when spoken to. Will actively turn head around 180 degrees to observe people and surroundings for long periods. Recognizes self in a mirror and parents and favorite people from a longer distance.
• 1 month:* Infant can fixate briefly on the mother’s face. Prefers the human face.

Question 25

Abnormal Vision Findings in Newborns **(1):** Misalignment of the eye. **(1):** Reduced vision in one eye caused by abnormal visual development early in life. The weaker — or lazy — eye often wanders inward or outward- If corrected early, affected eye can have normal vision **(1):** Misalignment of one or both eyes (“cross-eyed”)

Answer 25

* Strabismus***:** Misalignment of the eye. * Amblyopia (“Lazy Eye”)**:***Reduced vision in one eye caused by abnormal visual development early in life**. The weaker — or lazy — eye often wanders inward or outward * Esotropia*: Misalignment of one or both eyes (“cross-eyed”)

Question 26

*Strabismus* Mis\_\_\_\_\_\_ of the eye. Horizontal strabismus may be \_\_\_tropia (inward turning of the eyes) or \_\_\_\_tropia (outward turning of the eyes). Vertical strabismus may be h\_\_\_\_tropia (one eye higher than the other) or h\_\_\_\_tropia (one eye lower than the other). Uncorrected strabismus can result in permanent visual ____ and abnormal vision such as _____ (double vision). Treatment can range from eyegl\_\_\_\_, eye ex\_\_\_\_, prism, and/or eye muscle s\_\_\_\_\_.

Answer 26

Misalignment of the eye. Horizontal strabismus may be esotropia (inward turning of the eyes) or exotropia (outward turning of the eyes). Vertical strabismus may be hypertropia (one eye higher than the other) or hypotropia (one eye lower than the other). Uncorrected strabismus can result in permanent visual loss and abnormal vision such as diplopia (double vision). Treatment can range from eyeglasses, eye exercises, prism, and/or eye muscle surgery.

Question 27

*Esotropia* Misalignment of one or both eyes (“\_\_\_\_-eyed”). Infants (\<20 weeks) may have intermittent esotropia, which usually resolves sp\_\_\_\_\_\_. Some infants with obvious epicanthal folds appear “cross-eyed” (\_\_\_\_\_strabismus), but corneal light reflex will be normal. Refer to pediatric ophthalmologist if in doubt.

Answer 27

Misalignment of one or both eyes (“cross-eyed”). Infants (\<20 weeks) may have intermittent esotropia, which usually resolves spontaneously. Some infants with obvious epicanthal folds appear “cross-eyed” (pseudostrabismus), but corneal light reflex will be normal. Refer to pediatric ophthalmologist if in doubt.

Question 28

**Indications for Referral** ## Footnote Abnormal ___ reflex (rule out retinoblastoma, cataract, glaucoma) Presence of _____ reflex (rule out retinoblastoma) Str\_\_\_\_\_\_ (rule out CN III, IV, and VI abnormalities, retinoblastoma) Greater than \_\_\_\_-line difference between each eye Esodeviation present after 3 to ___ months of age Corneal ____ reflex test with abnormal result Sh\_\_\_\_\_/appearance of pupils not equal New onset of st\_\_\_\_\_\_\_ (e.g., retinoblastoma, brain mass, bleeding, lead poisoning)

Answer 28

Abnormal red reflex (rule out retinoblastoma, cataract, glaucoma) Presence of white reflex (rule out retinoblastoma) Strabismus (rule out CN III, IV, and VI abnormalities, retinoblastoma) Greater than two-line difference between each eye Esodeviation present after 3 to 4 months of age Corneal light reflex test with abnormal result Shape/appearance of pupils not equal New onset of strabismus (e.g., retinoblastoma, brain mass, bleeding, lead poisoning)

Question 29

Red Reflex **Screening test for** **(2)** How to perform red reflex test? Abnormal if there are white-colored opacities (1) or white spots (1). Determine presence of white reflex, rule out **(1)**, and refer infant to (1) as soon as possible. Even if the test is normal during the visit, but a parent reports that one eye appears white on a digital ph\_\_\_\_\_\_\_, refer. If absence or decreased intensity of red reflex, rule out (1) and refer to pediatric ophthalmologist.

Answer 29

**Screening test for** **Cataracts and Retinoblastoma.** *Procedure:* Perform test in a darkened room. Use a direct ophthalmoscope and shine light about 12 to 18 inches away from the infant. Normal finding is symmetrical and round orange-red glow from each eye. Abnormal if there are white-colored opacities (cataracts) or white spots (leukocoria). Determine presence of white reflex, rule out retinoblastoma, and refer infant to pediatric ophthalmologist as soon as possible. Even if the test is normal during the visit, but a parent reports that one eye appears white on a digital photograph, refer. If absence or decreased intensity of red reflex, rule out cataract and refer to pediatric ophthalmologist.

Question 29

Red reflex exam on neonate shows a round, white-colored pupil.

Answer 29

*Congenital Cataracts*

Question 30

(1) Screening test for **strabismus**. Abnormal if corneal light reflex is **not clear** or if it is “**off**-**center**.” *Procedure =*

Answer 30

Light Reflex Test or Corneal Light Reflex (Hirschberg Test) *Procedure:* Shine light directly in eyes (24 inches away) using a fixation target. Infant or child must look directly forward with both eyes aligned. O**bserve for the symmetry and brightness of light reflecting from both eyes**.

Question 31

Hearing Screening Universal screening for hearing loss is done when? **Newborns** Each ____ has its own rules about neonatal hearing exams.

Answer 31

Universal screening for hearing loss is done while in nursery before discharge. **Newborns** Each state has its own rules about neonatal hearing exams.

Question 32

*Auditory Brainstem Response* Measures the CN ____ by the use of “\_\_\_\_” stimuli. * Procedure:* * Otoacoustic Emissions* * Gross hearing test*: As a response to ____ noise, look for st\_\_\_\_\_ response (neonates), bl\_\_\_\_, t\_\_\_\_\_ toward sound. Measures the _____ ear mobility only. ____ sensitive than the auditory brainstem response (ABR).

Answer 32

*Auditory Brainstem Response* Measures the CN VIII by the use of “click” stimuli. * Procedure:* An audiologist places small earphones in the child's ears and soft electrodes (small sensor stickers) near the ears and on the forehead. **Clicking sounds and tones go through the earphones, and electrodes measure how the hearing nerves and brain respond to the sounds**. * Otoacoustic Emissions* * Gross hearing test*: As a response to loud noise, look for startle response (neonates), blinking, turning toward sound. Measures the middle ear mobility only. Less sensitive than the auditory brainstem response (ABR).

Question 33

* High-Risk Factors for Hearing Loss Mnemonic* * (1)* Premature infants and infants admitted to NICUs have a ____ incidence of hearing loss compared with full-term infants.

Answer 33

*HEARS* **H** (hyperbilirubinemia) **E** (ear infections that are frequent) **A** (Apgar scores low at birth) **R** (rubella, cytomegalovirus [CMV], toxoplasmosis infections) **S** (seizures) Premature infants and infants admitted to NICUs have a higher incidence of hearing loss compared with full-term infants.

Question 34

Hearing Screening Laboratory Tests Testing varies from state to state. Blood is obtained by h\_\_\_\_ stick or from c\_\_\_\_ blood. A spot of blood is blotted into filter paper for stable transport. * **\_\_\_\_\_-Stimulating Hormone** * **Phenyl\_\_\_\_\_\_ (PKU)** * **\_\_\_\_\_ Cell Disease** * **H\_\_\_\_\_ and H\_\_\_\_\_\_** * **L\_\_\_\_\_ Screening**

Answer 34

Testing varies from state to state. Blood is obtained by heel stick or from cord blood. A spot of blood is blotted into filter paper for stable transport. * **Thyroid-Stimulating Hormone** * **Phenylketonuria** * **Sickle Cell Disease** * **Hemoglobin and Hematocrit** * **Lead Screening**

Question 35

**Thyroid-Stimulating Hormone** (Hearing Loss Screening) Thyroid-stimulating hormone (TSH) testing is f\_\_\_\_\_ mandated. Lack of thyroid hormone results in mental and somatic g\_\_\_\_ retardation. Treated by thyroid hormone s\_\_\_\_\_\_\_.

Answer 35

Thyroid-stimulating hormone (TSH) testing is federally mandated. Lack of thyroid hormone results in mental and somatic growth retardation. Treated by thyroid hormone supplementation.

Question 36

Phenylketonuria (PKU) (Hearing Loss Screening) Phenylketonuria (PKU) testing is f\_\_\_\_\_ mandated. Severe int\_\_\_\_\_\_ disability results if not treated early. Disorder is an inability to m\_\_\_\_\_\_ (1) to (1) because of a defect in the production of the en\_\_\_\_\_\_ phenylalanine hydroxylase. Perform test only after infant has pr\_\_\_\_\_\_ feeding (breast milk or formula) for at least ___ hours. Higher risk of false negatives if done too e\_\_\_\_ (\<48 hours). Treated by following special diet (**\_\_\_\_\_ free diet)**

Answer 36

Phenylketonuria (PKU) testing is federally mandated. Severe intellectual disability results if not treated early. Disorder is an inability to metabolize phenylalanine to tyrosine because of a defect in the production of the enzyme phenylalanine hydroxylase. Perform test only after infant has protein feeding (breast milk or formula) for at least 48 hours. Higher risk of false negatives if done too early (\<48 hours). Treated by following special diet (phenylalanine-free diet).

Question 37

Sickle Cell Disease The required test can detect four types of hemoglobin (4). Lead Screening High-risk children (e.g., children living below p\_\_\_\_\_ level or living in homes built prior to 19\_\_) should be screened at (2) ages

Answer 37

Sickle Cell Disease The required test can detect four types of hemoglobin (F, S, A, and C). Lead Screening High-risk children (e.g., children living below poverty level or living in homes built prior to 1978) should be screened at age 1 and 2 years (12 and 24 months).

Question 38

Hemoglobin and Hematocrit (Hearing Loss Screening) Normal newborns have (2) types of hemoglobin Healthy term infants have enough ____ stores to last up to __ months. Screening for anemia is done in late infancy (\_\_-\_\_ months) for healthy full-term infants. Why do we not screen for anemia/hemoglobin at birth?

Answer 38

Normal newborns have hemoglobin F (fetal hemoglobin) and hemoglobin A. Healthy term infants have enough iron stores to last up to 6 months. Screening for anemia is done in late infancy (9–12 months) for healthy full-term infants. Not screened at birth, because hemoglobin is elevated from maternal red blood cells (RBCs) mixed in fetal RBCs.

Question 39

Nutritional Intake Breastfeeding vs. Formula? If formula, start with one that is?

Answer 39

Breastfeeding \> Formula. If formula chosen, start with one **fortified with iron.**

Question 40

Breastfeeding What do you have to supplement with if breastfeeding? Why? * Breast milk or formula contains ___ calories per ounce. * Decreases risk of _____ (e.g., ____ media) during the first few weeks of life.

Answer 40

Give **vitamin D** drops (400 IU of vitamin D) starting in the first few days of life if breastfeeding because breast milk alone does not provide adequate levels of vitamin D. Infant formula is supplemented with vitamin D, iron, other vitamins, and essential fatty acids. ## Footnote Breast milk or formula contains 20 calories per ounce. Decreases risk of infections (e.g., otitis media) during the first few weeks of life.

Question 41

(1) Sticky and thick, yellowish fluid that comes before breast milk. Secreted first few days after the birth and contains large amounts of maternal **(1)** and nutrients.

Answer 41

Colostrum Sticky and thick, yellowish fluid that comes before breast milk. Secreted first few days after the birth and contains large amounts of maternal **antibodies** and nutrients.

Question 42

Cow's Milk in first year of life?

Answer 42

**Avoid** cow’s milk the first year of life (causes gastrointestinal **[GI] bleeding)** Common cause of **iron-deficiency anemia** in babies and young children

Question 43

Solid Foods When to start? What food should you start with? Frequency and before or after breast milk/formula? Why should you avoid feeding only rice cereal? Introduce one food at a time for 4-5 days why?

Answer 43

Recommended to wait until 4 to 6 months for complementary foods. Start with a single-grain, iron-fortified baby cereal, mix with four tablespoons of breast milk/formula. Serve once or twice a day after bottle or breastfeeding. Avoid feeding only rice cereal due to possible exposure to arsenic. Introduce one food at a time for 4 to 5 days (if allergic, easier to identify offending food).

Question 44

(1) **Thick dark-green to black-colored stool that is odorless. Most full-term neonates pass this stool within a few hours of birth.** Failure to pass this stool within 24 hours of birth is worrisome and may be a sign of intestinal _____ , Hir\_\_\_\_\_ disease, or c\_\_\_\_ f\_\_\_\_\_.

Answer 44

Meconium Failure to pass this stool within 24 hours of birth is worrisome and may be a sign of intestinal obstruction, Hirschsprung’s disease, or cystic fibrosis.

Question 45

Head Findings **Caput \_\_\_\_\_\_\_** is diffused edema of the scalp that crosses the midline. Caused by intrauterine and vaginal pr\_\_\_\_ from prolonged or difficult vaginal labor. The scalp becomes molded and “\_\_\_\_ -shaped.” \_\_\_\_-limited and resolves \_\_\_\_\_\_\_\_.

Answer 45

**Caput succedaneum** is diffused edema of the scalp that crosses the midline. Caused by intrauterine and vaginal pressure from prolonged or difficult vaginal labor. The scalp becomes molded and “cone shaped.” Self-limited and resolves spontaneously.

Question 46

Head Circumference Also known as the *occipitofrontal circumference (OFC)*. Use paper tape (cloth tape stretches) and place ____ the ear. Average head circumference at birth is ___ cm Head circumference is measured at each wellness visit until the age of ___ years In newborns, chest size relative the head circumference? Head circumference will increase by __ cm during the first 12 months. Fastest rate of head growth is during the first ___ months of life (2 cm per month)

Answer 46

Also known as the *occipitofrontal circumference (OFC)*. Use paper tape (cloth tape stretches) and place above the ear. ## Footnote Average head circumference at birth is 13.7 inches (35 cm). Head circumference is measured at each wellness visit until the age of 36 months (3 years). In newborns, chest is about 1 to 2 cm smaller in size than the head circumference. Head circumference will increase by 12 cm during the first 12 months. Fastest rate of head growth is during the first 3 months of life (2 cm per month)

Question 47

(1) Traumatic **subperiosteal** **hemorrhage**. Rule out skull fracture (order radiographs of the skull). Swelling does not cross the midline or suture lines.

Answer 47

Cephalohematoma *A cephalohematoma is* ***an accumulation of blood under the scalp****. During the birth process, small blood vessels on the head of the fetus are broken as a result of minor trauma*

Question 48

Birth Weight What happens to the weight of neonates in the first 2 weeks? What is their weight by 6 months, by 12 months?

Answer 48

Neonates lose up to 10% of body weight but should regain it by 2 weeks of age. They double their birth weight by 6 months and triple their birth weight by 12 months.

Question 49

Infant Weight and Length Gain * 0 to 6 months:* **(1)** ounces per week and **(1)** inch per month * 6 to 12 months:* **(1)** ounces per week and **(1)** inch per month

Answer 49

* 0 to 6 months:* 6 to 8 ounces per week and 1 inch per month * 6 to 12 months:* 3 to 4 ounces per week and 1/2 inch per month

Question 50

Infant Weight and Length Gain If the child’s weight and/or length decelerates across ____ or more major percentiles, rule out (1) (see “Danger Signals”). In addition, any child who is at the ____ to ___ percentile is considered to have FTT. Of the many causes of FTT, the most common in primary care are under or mal\_\_\_\_\_\_\_. Evaluate the child, but do not forget to assess maternal b\_\_\_\_ and dep\_\_\_\_\_\_

Answer 50

If the child’s weight and/or length decelerates across two or more major percentiles, rule out FTT (see “Danger Signals”). In addition, any child who is at the third to fifth percentile is considered to have FTT. Of the many causes of FTT, the most common in primary care are undernutrition and malnutrition. Evaluate the child, but do not forget to assess maternal bonding and depression.

Question 51

Length and Height ## Footnote Till what age do you measure a child's LENGTH (linear growth)? At what age should you start measuring a child's HEIGHT (standing up)? Plot the measurements on the infant’s or child’s percentile ___ chart.

Answer 51

Length (linear growth) of infants is measured from birth to about 24 months. Starting at the age of 2 years, measure height (child is standing up) and calculate body mass index (BMI). Plot the measurements on the infant’s or child’s percentile growth chart.

Question 52

Dentition Both the left and right teeth erupt bilaterally at the same time (symmetrical). Symptoms are dr\_\_\_\_, ch\_\_\_\_\_ on objects, irr\_\_\_\_\_\_, crying, and low-grade \_\_\_\_\_. * *6 to __ months of age:* (1) set of teeth that erupt first * *\_\_\_\_ years of age:* Has complete set of primary teeth (20 teeth) * Typically lose teeth in ____ order that they erupted

Answer 52

Both the left and right teeth erupt bilaterally at the same time (symmetrical). Symptoms are drooling, chewing on objects, irritability, crying, and low-grade fever. * *6 to 10 months of age:* **Lower central incisors** (lower front teeth) * *2½ years of age:* Has complete set of primary teeth (20 teeth) * Typically lose teeth in same order that they erupted

Question 53

First Permanent Teeth (Deciduous Teeth) When do they get their first permanent teeth? First permanent teeth to erupt are upper and lower (1)

Answer 53

*6 years of age* Shed central incisors, first permanent teeth to erupt are upper and lower first molars

Question 54

Genitourinary Anomalies ## Footnote * (1)**:* Urethral meatus located on the ventral aspect (underside) of the penis. Location may be at the glans or shaft. Some have two urethral openings; one opening is normal, and the other opening is lower on the glans or shaft. Refer to pediatric urologist. * (1)**:* Urethral meatus is located on the dorsal aspect (upper side) of the penis.

Answer 54

* Hypospadias**:* Urethral meatus located on the ventral aspect of the penis. Location may be at the glans or shaft. Some have two urethral openings; one opening is normal, and the other opening is lower on the glans or shaft. Refer to pediatric urologist. * Epispadias**:* Urethral meatus is located on the dorsal aspect (upper side) of the penis.

Question 55

Genitourinary Anomalies ## Footnote * (1):* Presence of fluid inside the scrotum (tunica vaginalis/processus vaginalis) that results in swelling of the affected scrotum. Skin is normal color and temperature. Fairly common in newborn males. Incidence rate is 10 to 20 cases out of every 1,000 live births. * (1):* Affected testicle(s) will show increased size in the “glow” of light compared with the normal scrotum. Darken the room and place the light source on the scrotal skin. Compare each scrotum.

Answer 55

* Hydrocele**:* Presence of fluid inside the scrotum (tunica vaginalis/processus vaginalis) that results in swelling of the affected scrotum. Skin is normal color and temperature. Fairly common in newborn males. Incidence rate is 10 to 20 cases out of every 1,000 live births. * Transillumination**:* Affected testicle(s) will show increased size in the “glow” of light compared with the normal scrotum. Darken the room and place the light source on the scrotal skin. Compare each scrotum.

Question 56

Genitourinary Anomalies ## Footnote * (1)**:* Newborn female vagina- Caused by withdrawal of maternal hormones and will disappear within a few days. * (1)*: Retention of one or both testicles in the abdominal cavity or the inguinal canal. Markedly increases risk of testicular ____ and in\_\_\_\_\_. Order inguinal and abdominal \_\_\_\_\_\_. Corrected s\_\_\_\_\_ before __ months of age.

Answer 56

* Newborn female vagina swollen with small amount of blood-tinged discharge**:* Caused by withdrawal of maternal hormones and will disappear within a few days. * Cryptorchidism*: Retention of one or both testicles in the abdominal cavity or the inguinal canal. Markedly increases risk of testicular cancer and infertility. Order inguinal and abdominal ultrasound. Corrected surgically before 12 months of age.

Question 57

Exam Tips ## Footnote Weight loss of (1)-(1)% starts after birth, but neonates should regain birth weight in __ weeks. Birth weight _____ at 6 months and _____ at 12 months. *Head circumference grows* by up to ___ cm (first 12 months). Caput succedaneum vs. Cephalohematoma presentation?

Answer 57

Weight loss of 7% to 10% starts after birth, but neonates should regain birth weight in 2 weeks. Birth weight doubles at 6 months and triples at 12 months. *Head circumference grows* by up to 12 cm (first 12 months). Caput succedaneum crosses midline, and cephalohematoma does not (blood blocked by scalp sutures).

Question 58

Exam Tips ## Footnote (1) (IgG \_\_\_\_\_\_) looks like thick, yellowish fluid and is secreted the first few days of breastfeeding before milk release. Avoid cow's milk during first 12 months of life (causes (2)) * Breastfeeding:* Supplement with (1) the first few days of life. * (1):* White papules found on gum line resembles an erupting tooth. Do not confuse questions asking for the “first tooth” (when and which?) with the “first permanent tooth. (when and which?)

Answer 58

Colostrum (IgG antibodies) looks like thick, yellowish fluid and is secreted the first few days of breastfeeding before milk release. Avoid cow’s milk during first 12 months of life (causes GI bleeding, iron-deficiency anemia). * Breastfeeding:* Supplement with vitamin D the first few days of life. * Epstein’s pearls:* White papules found on gum line resembles an erupting tooth. Do not confuse questions asking for the “first tooth” (6-10m, lower central incisors) with the “first permanent tooth.” (6 years, first upper and lower molars)

Question 59

Exam Tips ## Footnote * (1):* Urethral opening under glans/shaft (refer to (1)). * (1):* Urethral opening on top of glans/shaft (refer to (1)). Cryptorchidism increases risk of (1). Refer to (1) for evaluation between __ and __ months of age.

Answer 59

* Hypospadias:* Urethral opening under glans/shaft (refer to pediatric urologist). * Epispadias:* Urethral opening on top of glans/shaft (refer to pediatric urologist). Cryptorchidism increases risk of testicular cancer. Refer to pediatric urologist for evaluation between 6 and 12 months of age.

Question 60

Exam Tips ## Footnote (1) is used to assess for hydrocele, empty scrotal sac, and scrotal masses. (1) is fluid collection inside the scrotum (tunica vaginalis/processus vaginalis). * Infant with hydrocele and transillumination:* Scrotal sac with hydrocele will appear “br\_\_\_\_\_” or will have more light gl\_\_\_ compared with scrotum with a testicle (solid objects block light, so less glow of light).

Answer 60

Transillumination is used to assess for hydrocele, empty scrotal sac, and scrotal masses. Hydrocele is fluid collection inside the scrotum (tunica vaginalis/processus vaginalis). *Infant with hydrocele and transillumination:* Scrotal sac with hydrocele will appear “brighter” or will have more light glow compared with scrotum with a testicle (solid objects block light, so less glow of light).

Question 61

Anal Wink Reflex How to perform? Expected result? Abnormal result and what it means?

Answer 61

Gently stroke the anal region. Look for contraction of the perianal muscle. Absence is abnormal and suggestive of a lesion on the spinal cord (e.g., spina bifida).

Question 62

Plantar Reflex (Babinski Reflex) How to perform? Normal reflex up to how long?

Answer 62

Upward extension of the big toe with fanning of the other toes. Starting on the heel, stroke firmly the outer side of the sole toward the front of the foot ([**Figure 1**](https://examprepconnect.springerpub.com/app/family-nurse-practitioner-fnp#)). Should dissappear by 1-2 years

Question 63

Palmar Reflex (Grasp Reflex) =

Answer 63

Place a finger on the infant’s open palm. The infant closes its hand around the finger. Pulling away the examiner’s finger causes the infant’s grip to tighten.

Question 64

Moro Reflex (Startle Reflex) How to perform? When should this reflex disappear? * Absence on ___ side*: Rule out brachial plexus injury, fracture, or shoulder dystocia. * Absence on ____ sides*: Rule out spinal cord or brain lesion. * Older infant*: Per\_\_\_\_\_ of Moro reflex is abnormal. Rule out br\_\_\_pathology.

Answer 64

Sudden loud noise will cause symmetric abduction and extension of the arms followed by adduction and flexion of the arms over the body. Disappears by 3 to 4 months. * Absence on one side*: Rule out brachial plexus injury, fracture, or shoulder dystocia. * Absence on both sides*: Rule out spinal cord or brain lesion. * Older infant*: Persistence of Moro reflex is abnormal. Rule out brain pathology.

Question 65

Step Reflex How to perform? Absent with par\_\_\_\_ and br\_\_\_\_ births. Should disappear by?

Answer 65

Hold baby upright and allow the dorsal surface of one foot to touch the edge of a table. Baby will flex the hip and knee and place the stimulated foot on the tabletop (stepping motion). Absent with paresis and breech births. Disappears by 6 weeks.

Question 66

Blink Reflex =

Answer 66

Eyelids will close in response to bright light or touch.

Question 67

Tonic Neck Reflex (Fencing Reflex) =

Answer 67

Turning head to one side with jaw over shoulder causes the arm and leg on the same side to extend. The arm and leg on the opposite side will flex.

Question 68

Rooting Reflex = Should disappear by?

Answer 68

Stroking the corner of the mouth causes baby to turn toward stimulus and suck. Disappears by 3 to 4 months.

Question 69

Exam Tip ## Footnote A strong Moro reflex in an older infant (\>6m) is? and is indicative of?

Answer 69

A strong Moro reflex in an older infant (age ≥6 months) is abnormal and indicative of brain damage.

Question 70

Immunizations Immunization Schedule (Birth to 6 Years) It contains only the childhood vaccines that must be given by a definite age (no “wiggle room”).

Answer 70

Question 71

Mumps, Measles, and Rubella and Varicella Vaccine \_\_\_ attenuated virus vaccine. Not recommended before the age of \_\_\_months (not effective due to immaturity of immune system). If dose given before 12 months of age, must be \_\_\_\_\_. Avoid Rx(1) for 6 weeks (theoretical risk of Reye’s syndrome). Children (aged birth to __ years) should not be given any as\_\_\_\_\_or any aspirin products (e.g., Pepto-Bismol, Pamprin, Alka Seltzer, Kaopectate).

Answer 71

Live attenuated virus vaccine. Not recommended before the age of 12 months (not effective due to immaturity of immune system). If dose given before 12 months of age, must be repeated. Avoid salicylates for 6 weeks (theoretical risk of Reye’s syndrome). Children (aged birth to 12 years) should not be given any aspirin or any aspirin products (e.g., Pepto-Bismol, Pamprin, Alka Seltzer, Kaopectate).

Question 72

Mumps, Measles, and Rubella and Varicella Vaccine ## Footnote * First dose (mumps, measles, and rubella [MMR] and varicella):* * Second dose (MMR and varicella):* * Proof of varicella:* Documentation of ch\_\_\_\_\_\_\_ or herpes ____ on the chart by a healthcare provider, record of ____ doses, or a positive varicella \_\_\_\_

Answer 72

* First dose (mumps, measles, and rubella [MMR] and varicella):* 12 months * Second dose (MMR and varicella):* Age 4 to 6 years (preschool age) * Proof of varicella:* Documentation of chickenpox or herpes zoster on the chart by a healthcare provider, record of two doses, or a positive varicella titer

Question 73

Influenza Vaccine Beginning with the 2016 to 2017 influenza season, the CDC recommended use of (1) flu vaccines. The (1) form (live attenuated influenza vaccine) is not to be used. * Do not give influenza vaccines before age __ months, because they are not effective (immature immune system). It takes __ weeks to produce antibodies after vaccination. * Recommended for everyone age __ months or older (with rare exceptions), but especially for children 6 months to 4 years of age; people with congenital h\_\_\_\_ disease, as\_\_\_, cystic fibrosis, _____ cell anemia, heart disease, and C\_\_\_\_; women who will be pr\_\_\_\_\_ during the influenza season; Native Americans/Alaska Natives; \_\_\_\_care personnel; el\_\_\_\_\_\_; and others.

Answer 73

Beginning with the 2016 to 2017 influenza season, the CDC recommended use of injectable flu vaccines. The nasal spray form (live attenuated influenza vaccine) is not to be used. * Do not give influenza vaccines before age 6 months, because they are not effective (immature immune system). It takes 2 weeks to produce antibodies after vaccination. * Recommended for everyone age 6 months or older (with rare exceptions), but especially for children 6 months to 4 years of age; people with congenital heart disease, asthma, cystic fibrosis, sickle cell anemia, heart disease, and chronic obstructive pulmonary disease (COPD); women who will be pregnant during the influenza season; Native Americans/Alaska Natives; healthcare personnel; elderly; and others.

Question 74

Influenza Vaccine * Trivalent inactivated influenza vaccines (protect against ____ types of influenza virus). * Minimum age is __ months. Administer fall to ____ as injection. * Quadrivalent influenza vaccines (protect against ___ types of influenza virus).

Answer 74

* Trivalent inactivated influenza vaccines (protect against three types of influenza virus). * Minimum age is 6 months. Administer fall to winter as injection. * Quadrivalent influenza vaccines (protect against four types of influenza virus).

Question 75

Contraindications *Influenza Injection (Trivalent Inactivated Vaccine)* **Age (1)** **Severe (1)**

Answer 75

Age younger than 6 months Severe egg allergy

Question 76

Influenza Injection (Trivalent Inactivated Vaccine) CI Severe Egg Allergy If history of egg allergy (\_\_\_\_\_ *only*), can receive the flu vaccine injection. *But*, if severe reaction to eggs (h\_\_\_tension, wh\_\_\_\_, nausea and vomiting) requiring medical treatment or ep\_\_\_\_\_, the patient can only receive the flu vaccine in an outpatient or inpatient clinic that has a health provider who can treat an\_\_\_\_\_ (e.g., epinephrine, intubation, O2). m\_\_\_\_-to-s\_\_\_\_\_ illness with fever (\_\_\_\_ until patient is better) History of (1) syndrome

Answer 76

If history of egg allergy (hives *only*), can receive the flu vaccine injection. *But*, if severe reaction to eggs (hypotension, wheezing, nausea and vomiting) requiring medical treatment or epinephrine, the patient can only receive the flu vaccine in an outpatient or inpatient clinic that has a health provider who can treat anaphylaxis (e.g., epinephrine, intubation, O2). Moderate-to-severe illness with fever (wait until patient is better) History of Guillain–Barré syndrome

Question 77

Live Influenza Nasal Spray (FluMist) Use of live influenza nasal spray (FluMist) recommendations change annually. See CDC website for updates ([**www.cdc.gov**](http://www.cdc.gov/)). **Avoid giving the FluMist vaccine to the following groups of children.** Use the inactivated injection form of the influenza vaccine. * Children younger than age __ years * Children aged 2 to 4 years who had wh\_\_\_\_\_ within the past 12 months * Children who have any other ______ condition that predisposes them to influenza complications; use inactivated form of the influenza vaccine (injection form) for these children

Answer 77

* Children younger than age 2 years * Children aged 2 to 4 years who had wheezing within the past 12 months * Children who have any other underlying condition that predisposes them to influenza complications; use inactivated form of the influenza vaccine (injection form) for these children

Question 78

Diphtheria, Tetanus, Pertussis Vaccines (1) is the form of vaccine used in the United States. It has fewer side effects compared with older DTP form. * (1):* This form is used for infants and children younger than age 7 years unable to tolerate pertussis component. * (1) vaccine:* For age 7 years and older. At age 11- to 12-year visit, give this one. Or if due for tetanus booster, give Tdap once in a \_\_\_\_\_. Then tetanus diphtheria (Td) every __ years for lifetime.

Answer 78

**Diphtheria, tetanus, acellular pertussis (DTaP)** is the form of vaccine used in the United States. It has fewer side effects compared with older DTP form. ## Footnote *Diphtheria–tetanus (DT):* This form is used for infants and children younger than age 7 years unable to tolerate pertussis component. ***Tdap vaccine**:* For age 7 years and older. At age 11- to 12-year visit, give the Tdap. Or if due for tetanus booster, give Tdap once in a lifetime. Then tetanus diphtheria (Td) every 10 years for lifetime.

Question 79

Diphtheria, Tetanus, Pertussis Vaccines If incomplete DTaP series and child aged 7 years or older, give (1) instead (Immunization Action Coalition, 2019). Can be given to pregnant and breastfeeding mothers? Tdap given to children younger than age 7 years is ___ valid (use (1)).

Answer 79

If incomplete DTaP series and child aged 7 years or older, give Tdap instead (Immunization Action Coalition, 2019). Can be given to pregnant and breastfeeding mothers. Tdap given to children younger than age 7 years is *not* valid (use DTaP).

Question 80

Side Effects: DTaP/DT ## Footnote F\_\_\_\_ (defined as 100.4°F) in up to 50% of patients Swelling, pain, and/or redness at _____ site in up to 50% of patients Irr\_\_\_\_\_\_ in up to 50% of patients Acute en\_\_\_\_\_\_\_ 1 in 110,000

Answer 80

Fever (defined as 100.4°F) in up to 50% of patients Swelling, pain, and/or redness at injection site in up to 50% of patients Irritability in up to 50% of patients Acute encephalopathy 1 in 110,000

Question 81

DTaP *Contraindications* ## Footnote \_\_\_\_\_\_ allergic reaction Enc\_\_\_\_\_\_\_\_ (i.e., prolonged seizures, change in level of consciousness [LOC]) not attributable to another cause within 7 days of administration of the vaccine)

Answer 81

Severe allergic reaction Encephalopathy (i.e., prolonged seizures, change in level of consciousness [LOC]) not attributable to another cause within 7 days of administration of the vaccine)

Question 82

DTaP Precautions ## Footnote Fever ≥10\_.0°F (within 48 hours of dose) S\_\_\_\_\_ (within 3 days or less of dose) Collapse or sh\_\_\_\_-like state within 48 hours after dose

Answer 82

Fever ≥105.0°F (within 48 hours of dose) Seizures (within 3 days or less of dose) Collapse or shock-like state within 48 hours after dose

Question 83

*Not Considered Contraindications to DTP/DTaP Vaccination* ## Footnote \_\_\_\_\_ history of s\_\_\_\_ \_\_\_\_ history of (1) syndrome Fever \_\_105°F from prior DTaP vaccination

Answer 83

Family history of seizures Family history of sudden infant death syndrome (SIDS) Fever \<105°F from prior DTaP vaccination

Question 84

(1) A national postmarketing vaccine safety surveillance program in the United States managed by both the CDC and the Food and Drug Administration (FDA). Report vaccine adverse events at [**www.vaers.hhs.gov**](http://www.vaers.hhs.gov/).

Answer 84

Vaccine Adverse Event Reporting System

Question 85

Immunization Tips By age 15 to 18 months, the following vaccines are usually completed (for most infants): (5)

Answer 85

Hepatitis B vaccine (three doses) *Haemophilus influenzae* type b (Hib) vaccine (several types of Hib vaccines; may require two, three, or four doses) Pneumococcal vaccine (PCV 13; four doses) Rotavirus vaccine (two or three doses) Hepatitis A (HepA; 2 doses)

Question 86

Exam Tips ## Footnote Do not give (2) vaccine before age 12 months. Youngest age for influenza vaccine is? Only vaccine given at birth is (1) If hepatitis B surface antigen (HBsAg)-positive mother, give the neonate (2)

Answer 86

Do not give varicella and MMR vaccine before age 12 months. Youngest age for influenza vaccine is 6 months. Only vaccine given at birth is hepatitis B. If hepatitis B surface antigen (HBsAg)-positive mother, give the neonate hepatitis B immunoglobulin (HBIG) and the hepatitis B vaccine.

Question 87

Exam Tips ## Footnote Do not use DTaP if what age? Use what form of vaccine if older than 7? Give Tdap vaccine at age of \_\_**-**\_\_ years as a booster. If older, then replace one dose of Td with a Tdap (\_\_\_\_ in a lifetime). Any vaccine that has a time range (e.g., third dose of inactivated polio [IPV] can be given from 6 to 18 months; third dose of hepatitis B can be given between 6 and 18 months) does NOT appear on the exam.

Answer 87

Do not use DTaP if age 7 years or older. Use Td or Tdap form of vaccine. Give Tdap vaccine at age of 11 to 12 years as a booster. If older, then replace one dose of Td with a Tdap (once in a lifetime). Any vaccine that has a time range (e.g., third dose of inactivated polio [IPV] can be given from 6 to 18 months; third dose of hepatitis B can be given between 6 and 18 months) does not appear on the exam.

Question 88

Growth and Development: Newborns ## Footnote Strong primitive _______ (e.g., Moro, rooting, fencing) Head l\_\_\_ Grasps finger tightly if placed on the baby’s hand (\_\_\_\_ reflex) S\_\_\_\_ y\_\_\_\_\_ stool after each feeding (if breastfed)

Answer 88

Strong primitive reflexes (e.g., Moro, rooting, fencing) Head lag Grasps finger tightly if placed on the baby’s hand (grasp reflex) Seedy yellow stool after each feeding (if breastfed)

Question 89

Growth and Development: Newborns ## Footnote Eats every \_\_**-**\_\_ hours or nurse 8 to 10 times a day When babies cry, what doesn't happen, why? Sleeps ___ hours per day Report \_\_\_\_-pitched cry, “catlike” cry, hypotonic microcephaly

Answer 89

Eats every 2 to 3 hours or nurse 8 to 10 times a day Does not produce tears when crying; tear ducts are not mature at birth Sleeps 16 hours per day Report high-pitched cry, “catlike” cry, hypotonic microcephaly

Question 90

2 Months Old Growth and Development \_\_\_\_\_ objects past midline C\_\_\_\_ vowels (e.g., “aa”) and makes g\_\_\_\_\_ sounds \_\_\_\_ head ___ degrees when prone S\_\_\_\_\_ in response to another

Answer 90

Follows objects past midline Coos vowels (e.g., “aa”) and makes gurgling sounds Lifts head 45 degrees when prone Smiles in response to another

Question 91

4 Months Old Growth and Development * S\_\_\_\_\_ spontaneously (social smile) * Begins to b\_\_\_\_\_ Fine Motor * Brings hands to \_\_\_\_\_ * Can sw\_\_\_\_\_ at dangling toys Gross Motor * Holds _____ steady and unsupported * Rolls from ____ to \_\_\_\_

Answer 91

* Smiles spontaneously (social smile) * Begins to babble Fine Motor * Brings hands to mouth * Can swing at dangling toys Gross Motor * Holds head steady and unsupported * Rolls from front to back (prone to supine)

Question 92

6 Months Old Growth and Development Fine Motor * Has ______ grasp of objects * Reaches for toys using _____ grasp * Brings th\_\_\_\_\_ to mouth * Starts to p\_\_\_\_ things from one hand to the other Gross Motor * Begins to ___ up independently without support * Rolls over in ____ directions (back/supine to stomach and stomach to the back/supine)

Answer 92

Fine Motor * Has palmar grasp of objects * Reaches for toys using palmar grasp * Brings things to mouth * Starts to pass things from one hand to the other Gross Motor * Begins to sit up independently without support * Rolls over in both directions (back/supine to stomach and stomach to the back/supine)

Question 93

6 Months Old Growth and Development Language * Starts to say ________ (e.g., “da-da, ba-ba”) * Is very c\_\_\_\_ and will look around env\_\_\_\_\_\_\_ Other * Report failure to f\_\_\_\_\_ objects past \_\_line (180 degrees), poor eye \_\_\_\_

Answer 93

Language * Starts to say consonants (e.g., “da-da, ba-ba”) * Is very curious and will look around environment Other * Report failure to follow objects past midline (180 degrees), poor eye contact

Question 94

9 Months Old Growth and Development Fine Motor * _____ grasp starts and can pick up things (e.g., food) between thumb and forefinger * Waves “b\_\_-b\_\_” * May _____ hands and play clapping games such as pat-a-cake Gross Motor * ____ self up to \_\_\_\_ * Cr\_\_\_\_\_ and “cruises” * Bears w\_\_\_\_ well

Answer 94

Fine Motor * Pincer grasp starts and can pick up things (e.g., food) between thumb and forefinger * Waves “bye-bye” * May clap hands and play clapping games such as pat-a-cake Gross Motor * Pulls self up to stand * Crawls and “cruises” * Bears weight well

Question 95

9 Months Old Growth and Development Language * Plays p\_\_\_\_-a-b\_\_\_\_ * “St\_\_\_\_\_ anxiety” very obvious * Report absence of b\_\_\_\_\_, inability to s\_\_\_ alone, st\_\_\_\_\_ primitive reflexes such as the Moro (startle reflex) or fencing (tonic neck reflex)

Answer 95

Language * Plays peek-a-boo * “Stranger anxiety” very obvious * Report absence of babble, inability to sit alone, strong primitive reflexes such as the Moro (startle reflex) or fencing (tonic neck reflex)

Question 96

12 Months Old Growth and Development: Fine Motor * Can use “\_\_\_\_\_” cup Gross Motor * S\_\_\_\_\_ independently * May w\_\_\_\_\_ independently * Starts to cr\_\_\_\_\_ (moves from one piece of furniture to the next for support)

Answer 96

Fine Motor * Can use “sippy” cup Gross Motor * Stands independently * May walk independently * Starts to cruise (moves from one piece of furniture to the next for support)

Question 97

12 Months Old Growth and Development: Language * Can say how many words? other than repetitive sounds (e.g., mama, dada) * Can say exclamations, such as “u\_\_-o\_\_!” * Knows first \_\_\_\_ Other * Growth rate ____ down * Follows simple dir\_\_\_\_\_\_, such as “Pick up toy” * Report absence of w\_\_\_\_ bearing, inability to transfer objects h\_\_\_\_ to h\_\_\_\_

Answer 97

Language * Can say 1 to 2 words other than repetitive sounds (e.g., mama, dada) * Can say exclamations, such as “uh-oh!” * Knows first name Other * Growth rate slows down * Follows simple directions, such as “Pick up toy” * Report absence of weight bearing, inability to transfer objects hand to hand

Question 98

15 Months Old Growth and Development Fine Motor * Feeds self with \_\_\_\_ * Can drink from a \_\_\_ Gross Motor * ____ independently for ______ distances Language * Follows commands with g\_\_\_\_\_\_ * Vocabulary of ___ to ___ words

Answer 98

Fine Motor * Feeds self with spoon * Can drink from a cup Gross Motor * Walks independently for longer distances Language * Follows commands with gestures * Vocabulary of four to six words

Question 99

18 Months Old Growth and Development Fine Motor * Turns ____ of book Gross Motor * Can walk up \_\_\_\_ Language * Can point to four ____ parts * Vocabulary of __ to __ words

Answer 99

Fine Motor * Turns pages of book Gross Motor * Can walk up steps Language * Can point to four body parts * Vocabulary of 10 to 20 words

Question 100

Safety Education ## Footnote Advise parent to learn infant cardiopulmonary \_\_\_\_\_\_\_ Avoid doing what to formula? Do not do what when using a baby changing table? Do not position cribs next to? And do what to cords when the child is crawling? \_\_\_\_\_ toilet seats (safety lock); ____ bathroom doors; ____ cabinets with cleaning products. How should you position pots and pans when using the stove? What burners to use? Use safety ____ for stove handles, low cabinets, and doors.

Answer 100

Advise parent to learn infant cardiopulmonary resuscitation (CPR; basic life support [BLS] course). Avoid heating formula in the microwave. Do not leave a baby on the changing table (e.g., to answer phone). Do not position cribs next to strings or cords. When the child is crawling, hide electrical cords. Close toilet seats (safety lock); lock bathroom doors; lock cabinets with cleaning products. Turn pot handles away from the edge of stove; use rear burners on the stove. Use safety locks for stove handles, low cabinets, and doors.

Question 101

Choking Prevention ## Footnote \_\_\_\_\_ objects smaller than 2 inches. Cut up food into ____ pieces (e.g., hot dogs, carrots, grapes). Examples of choking sources are gr\_\_\_\_, raw c\_\_\_\_, hot \_\_\_, latex ball\_\_\_\_, c\_\_\_, and b\_\_\_\_\_ Avoid giving hard c\_\_\_\_\_ to children younger than 6 years of age. Encourage at least one parent to attend infant/child B\_\_\_ course.

Answer 101

Remove objects smaller than 2 inches. Cut up food into small pieces (e.g., hot dogs, carrots, grapes). Examples of choking sources are grapes, raw carrots, hot dogs, latex balloons, coins, and buttons. Avoid giving hard candy to children younger than 6 years of age. Encourage at least one parent to attend infant/child BLS course.

Question 102

Car Safety ## Footnote Infants and toddlers up to the age of __ years should be in a rear-facing car seat ([**Table 1**](https://examprepconnect.springerpub.com/app/family-nurse-practitioner-fnp#)). Safest place in the car for infant or child younger than 13 years is in the ____ seat. \_\_\_\_ used infant safety seat if its parts are missing or if it is damaged. \_\_\_\_ bags in cars can cause serious brain injury if they hit the child’s head or neck area. Turn ____ the air bag on the front seat if the person who is using the seat is under the weight limit, which is usually set at ____ lb (check car manual).

Answer 102

Infants and toddlers up to the age of 2 years should be in a rear-facing car seat ([**Table 1**](https://examprepconnect.springerpub.com/app/family-nurse-practitioner-fnp#)). Safest place in the car for infant or child younger than 13 years is in the back seat. Avoid used infant safety seat if its parts are missing or if it is damaged. Air bags in cars can cause serious brain injury if they hit the child’s head or neck area. Turn off the air bag on the front seat if the person who is using the seat is under the weight limit, which is usually set at 100 lb (check car manual).

Question 103

Car Safety Seats: Infants and Toddlers Type of Seat = *Notes:* Children under age __ years are 75% less likely to be killed or injured in a car crash if they are in a \_\_\_\_-facing seat

Answer 103

Rear-facing car seat with harness system until age of 2 years; convertible car seats can be used as rear- and front-facing car seats *Notes:* Children under age 2 years are 75% less likely to be killed or injured in a car crash if they are in a rear-facing seat

Question 104

Car Safety Seats: Toddler to Preschool Type of Seat = *Note**s*: Children aged __ years or older (or if over the weight or height limit for rear-facing car seat) until they have reached the \_\_\_\_limit

Answer 104

Safest if rear-facing seat up to age of 2 years; forward-facing car seat with harness system Weight limit ranges from 80 to 100 lb (depends on brand) *Note**s*: Children aged 2 years or older (or if over the weight or height limit for rear-facing car seat) until they have reached the weight limit

Question 105

Car Safety Seats: School Age Type of Seat = *Notes:* Use until child has reached __ feet, __ inches or is \_\_–\_\_ years of age, Shoulder belt should cross the ____ of the child’s chest and shoulders

Answer 105

Booster seats (belt-positioning booster seats) *Notes:* Use until child has reached 4 feet, 9 inches or is 8–12 years of age, Shoulder belt should cross the middle of the child’s chest and shoulders

Question 106

Car Safety Seats: Older Child to Teenager Type of Seat = *Notes*: All children aged __ years or younger should sit in the ___ seat and use a seat belt with the ___ belt

Answer 106

Seat belt with lap belt *Notes*: All children aged 13 years or younger should sit in the back seat and use a seat belt with the lap belt

Question 107

Vaccine Notes ## Footnote \*Rotarix (RV) requires ___ doses, and RotaTeq (RV5) requires ____ doses. \*\*There are five forms of Hib vaccine that require ____ or four doses, with varying administration schedules. This dose is not recommended when using the \_\_\_\_vaxHIB vaccine. \*\*\*The first time IIV is given, a _____ dose __ weeks after the initial dose is recommended. Subsequent IIV vaccination is needed only once ann\_\_\_\_\_. *Note:* Most vaccines have a range (from _ to _ months) when they can be given. For a complete list of all vaccine schedules : www.cdc.gov/vaccines.

Answer 107

\*Rotarix (RV) requires two doses, and RotaTeq (RV5) requires three doses. \*\*There are five forms of Hib vaccine that require three or four doses, with varying administration schedules. This dose is not recommended when using the PedvaxHIB vaccine. \*\*\*The first time IIV is given, a second dose 4 weeks after the initial dose is recommended. Subsequent IIV vaccination is needed only once annually. *Note:* Most vaccines have a range (from 3 to 6 months) when they can be given. For a complete list of all vaccine schedules : www.cdc.gov/vaccines.

Question 108

Toxic Exposures Chronic exposure to second-hand smoke increases rates of (1) syndrome, otitis \_\_\_\_\_, br\_\_\_\_, pn\_\_\_\_, and wh\_\_\_\_ and coughing. It also affects lung development and exacerbates as\_\_\_\_.

Answer 108

Chronic exposure to second-hand smoke increases rates of SIDS, otitis media, bronchitis, pneumonia, and wheezing and coughing. It also affects lung development and exacerbates asthma.

Question 109

Jaundice (Hyperbilirubinemia) Elevation is due to increased breakdown of fetal (1) exceeding the infant’s liver capacity to ____ bilirubin. Free, unbound, \_\_conjugated bilirubin (breakdown product from old RBCs) is t\_\_\_\_to cells and can be deposited in tissue, such as the br\_\_\_\_ and nerve cells, causing n\_\_\_\_. Elevated conjugated hyperbilirubinemia may indicate an underlying disorder *but* is ____ toxic to the CNS**.**

Answer 109

Elevation is due to increased breakdown of fetal RBCs exceeding the infant’s liver capacity to conjugate bilirubin. Free, unbound, unconjugated bilirubin (breakdown product from old RBCs) is toxic to cells and can be deposited in tissue, such as the brain and nerve cells, causing necrosis. Elevated conjugated hyperbilirubinemia may indicate an underlying disorder *but* is not toxic to the CNS

Question 110

Jaundice (Hyperbilirubinemia) Pathologic Jaundice within first 24 hours of life * _____ pathologic; evaluate for s\_\_\_\_, congenital T\_\_\_\_ infections, occult hem\_\_\_\_, or erythrobl\_\_\_\_ fetalis * Caucasian infant’s color is yellow or orangish tinge, or the soles of the feet are yellow; jaundice more difficult to detect visually in infants with _____ skin, so bl\_\_\_\_tests should be done. Jaundice of full-term infant after 2 weeks of age * Requires evaluation; consider s\_\_\_\_, hemol\_\_\_\_ disease, met\_\_\_\_ disorders, and intestinal \_\_\_\_\_\_ * Bilirubin level increases too rapidly (\>\_\_ mg/dL per day) * Total bilirubin levels \>\_\_ mg/dL

Answer 110

Jaundice within first 24 hours of life * Always pathologic; evaluate for sepsis, congenital TORCH infections, occult hemorrhage, or erythroblastosis fetalis * Caucasian infant’s color is yellow or orangish tinge, or the soles of the feet are yellow; jaundice more difficult to detect visually in infants with darker skin, so blood tests should be done. Jaundice of full-term infant after 2 weeks of age * Requires evaluation; consider sepsis, hemolytic disease, metabolic disorders, and intestinal obstruction * Bilirubin level increases too rapidly (\>5 mg/dL per day) * Total bilirubin levels \>17 mg/dL *Torch =* *TORCHes infection includes* ***toxoplasmosis, others (syphilis, hepatitis B), rubella, cytomegalovirus, herpes simplex****.*

Question 111

Jaundice (Hyperbilirubinemia) Nonpathologic (2) jaundice most common Consider (1) jaundice if full-term exclusively breastfed infant with jaundice after __ weeks of age

Answer 111

Physiologic and Breastfeeding jaundice most common Consider breast milk jaundice if full-term exclusively breastfed infant with jaundice after 3 weeks of age

Question 112

Physiologic Jaundice Also known as *neonatal _______ hyperbilirubinemia* or *neonatal ic\_\_\_\_\_*. Jaundice appears when bilirubin level is ≥\_\_ mg/dL. Jaundice first appears on the head/f\_\_\_\_ (sclera is yellow) and progresses \_\_\_\_ward to the chest, abdomen, legs, and soles of the feet. \_\_\_\_\_\_ infant’s color is yellow or orangish tinge, or the soles of the feet are yellow. Jaundice more difficult to detect visually in infants with darker skin, so ____ tests should be done.

Answer 112

Also known as *neonatal unconjugated hyperbilirubinemia* or *neonatal icterus*. Jaundice appears when bilirubin level is ≥5 mg/dL. Jaundice first appears on the head/face (sclera is yellow) and progresses downward to the chest, abdomen, legs, and soles of the feet. Caucasian infant’s color is yellow or orangish tinge, or the soles of the feet are yellow. Jaundice more difficult to detect visually in infants with darker skin, so blood tests should be done.

Question 113

Physiologic Jaundice Physiologic jaundice starts after ___ hours and will usually clear up within \_\_**-**\_\_ weeks. The total bilirubin levels in Caucasian and African American infants can peak at __ to __ mg/dL, but Asian infants have _____ peak values (\_\_–\_\_\_ mg/dL).

Answer 113

Physiologic jaundice starts after 24 hours and will usually clear up within 2 to 3 weeks. The total bilirubin levels in Caucasian and African American infants can peak at 7 to 9 mg/dL, but Asian infants have higher peak values (10–14 mg/dL).

Question 114

Breast Milk Jaundice Onset is ____ than physiologic jaundice. Breast milk jaundice usually starts to show after __ to __ days of life. It peaks at __ to __ days and can take more than __ month to clear. It is thought to be caused by a substance in breast milk that inhibits (1) of bilirubin. Bilirubin levels may exceed __ mg/dl. Often a b\_\_\_\_(12-hour) period of breastfeeding \_\_\_\_\_, with pumping to maintain milk supply and fluid and caloric supplementation for the infant, will lower bilirubin levels enough to resume breast milk as the sole nutritional source. Some infants will also need \_\_\_\_\_therapy.

Answer 114

Onset is later than physiologic jaundice. Breast milk jaundice usually starts to show after 4 to 5 days of life. It peaks at 7 to 14 days and can take more than 1 month to clear. It is thought to be caused by a substance in breast milk that inhibits hepatic conjugation of bilirubin. Bilirubin levels may exceed 20 mg/dl. Often a brief (12-hour) period of breastfeeding cessation, with pumping to maintain milk supply and fluid and caloric supplementation for the infant, will lower bilirubin levels enough to resume breast milk as the sole nutritional source. Some infants will also need phototherapy.

Question 115

Breastfeeding Jaundice In contrast to breast milk jaundice, breastfeeding jaundice is actually a downstream sequalae of ____ intake of cal\_\_\_\_ and failure to produce s\_\_\_\_\_. This can also occur in bottle-fed infants with poor intake but is less common.

Answer 115

In contrast to breast milk jaundice, breastfeeding jaundice is actually a downstream sequalae of poor intake of calories and failure to produce stool. This can also occur in bottle-fed infants with poor intake but is less common.

Question 116

Breastfeeding Jaundice Treatment Plan ## Footnote Check b\_\_\_\_\_ level. Use \_\_\_invasive methods first (transcutaneous bilirubin testing). If suspect pathologic jaundice, order serum fr\_\_\_\_\_\_ bilirubin level, C\_\_\_\_\_ test, C\_ *,* ret\_\_\_\_\_ count, and peripheral \_\_\_\_. Medical intervention is usually ____ needed unless total bilirubin levels are approaching or exceeding hour-specific values on a risk-based nomogram.

Answer 116

Check bilirubin level. Use noninvasive methods first (transcutaneous bilirubin testing). If suspect pathologic jaundice, order serum fractionated bilirubin level, Coombs test, complete blood count (CBC), reticulocyte count, and peripheral smear. Medical intervention is usually not needed unless total bilirubin levels are approaching or exceeding hour-specific values on a risk-based nomogram.

Question 117

Breastfeeding Jaundice Treatment Plan First Line Treatment = Light used in the ___ spectrum is the most effective wavelength. The skin converts bilirubin into a nontoxic water-soluble form so that it is excreted in the \_\_\_\_. Keep baby well-\_\_\_\_\_\_with breast milk or formula. Feed infant every __ to __ hours (10–12 times per day). All newborns should be seen for follow-up within the first __ days of life to check for jaundice.

Answer 117

Phototherapy Light used in the blue spectrum is the most effective wavelength. The skin converts bilirubin into a nontoxic water-soluble form so that it is excreted in the urine. Keep baby well-hydrated with breast milk or formula. Feed infant every 2 to 3 hours (10–12 times per day). All newborns should be seen for follow-up within the first 5 days of life to check for jaundice.

Question 118

Complications of Jaundice (1) Neurologic disorder caused by high levels of unbound bilirubin in circulation that **damaged the infant’s CNS**. Associated with severe **intellectual disability** and **seizures**.

Answer 118

*Bilirubin encephalopathy*/*kernicterus*

Question 119

Physiologic Anemia of Infancy Hemoglobin d\_\_\_\_ at the lowest level in life (nadir) at __ to 12 weeks of age. Full-term infants’ hemoglobin decreases to __ to __ g/dL. Number of RBCs declines after birth because of an increase in _____ availability and a decrease in ______ production by the kidneys. When the hemoglobin level is at its lowest, oxygen needs ex\_\_\_\_\_ the body’s ability to deliver it, thus st\_\_\_\_\_ ery\_\_\_\_\_ production and R\_\_\_ production from the bone marrow.

Answer 119

Hemoglobin drops at the lowest level in life (nadir) at 8 to 12 weeks of age. Full-term infants’ hemoglobin decreases to 9 to 11 g/dL. Number of RBCs declines after birth because of an increase in oxygen availability and a decrease in erythropoietin production by the kidneys. When the hemoglobin level is at its lowest, oxygen needs exceed the body’s ability to deliver it, thus stimulating erythropoietin production and RBC production from the bone marrow.

Question 120

Classic Case of (1) An infant’s mother reports **_persistent tearing**_ and _**eyelash matting_** in the morning on one or both of the baby’s eyes, but no conjunctival erythema. **When the lacrimal duct is palpated**, **reflux of _mucoid_ discharge or tears** may be seen.

Answer 120

Congenital Lacrimal Duct Obstruction (Dacryostenosis)

Question 121

Dacryostenosis Also known as *(1)*. Occurs in approximately 6% of newborns. Usually ______ resolves within 6 months in the majority (90%) of infants. Yellow- to green-colored purulent eye discharge is \_\_normal in the absence of other signs of infection (rule out acute dacryo\_\_\_), can occur with ______ dacryostenosis, and is suggestive of a bacterial overgrowth in the lacrimal sac. A short course of t\_\_\_\_\_ antibiotics can be beneficial if copious or extremely bothersome.

Answer 121

Also known as *congenital nasolacrimal duct obstruction*. Occurs in approximately 6% of newborns. Usually spontaneously resolves within 6 months in the majority (90%) of infants. Yellow- to green-colored purulent eye discharge is abnormal in the absence of other signs of infection (rule out acute dacryocystitis), can occur with chronic dacryostenosis, and is suggestive of a bacterial overgrowth in the lacrimal sac. A short course of topical antibiotics can be beneficial if copious or extremely bothersome.

Question 122

Dacryostenosis Treatment = How to perform?

Answer 122

*Lacrimal sac massage/compression* lace a clean finger on the lacrimal sac and apply moderate downward pressure over the lacrimal sac for 2 to 3 seconds. Perform maneuver two or three times per day.

Question 123

Complication of Dacryostenosis (1) Look for r\_\_\_ness, w\_\_\_\_, tenderness, and swelling on one of the lacrimal ducts. Occurs commonly with dacryocystoceles. C\_\_\_\_\_ discharge and treat with s\_\_\_\_\_\_ antibiotics for 7 to 10 days to prevent complications of preseptal or orbital cellulitis. Usually caused by st\_\_\_\_\_ or st\_\_\_\_\_\_ organisms.

Answer 123

Acute Dacryocystitis ## Footnote Look for redness, warmth, tenderness, and swelling on one of the lacrimal ducts. Occurs commonly with dacryocystoceles. Culture discharge and treat with systemic antibiotics for 7 to 10 days to prevent complications of preseptal or orbital cellulitis. Usually caused by streptococcal or staphylococcal organisms.

Question 124

**Infant Colic (Rule of 3s)** Goal when evaluating colic is to?

Answer 124

**Crying** ***for no apparent reason*** that lasts **≥3 hours** a day in an **infant younger than 3 months**. Crying usually occurs at the same time each day. Crying occurs **\>3 days** in a week. The excessive crying usually **resolves by 3 to 4 months.** The goal when evaluating an infant with colic is to rule out conditions causing pain and/or discomfort, infections, environment, and formula “allergy.”

Question 125

Coarctation of the Aorta Congenital n\_\_\_\_\_\_ of a portion of the aorta. Most commonly the coarctation is distal to the (1) artery and is typically noted at the area where the (1) attaches. Newborn may be asymptomatic if mild case of _____ ductus arteriosus (PDA). Severe cases will have heart f\_\_\_\_\_ or sh\_\_\_\_ when PDA \_\_\_\_\_. Up to 30% of infants with this condition have _____ syndrome. Female infants noted to have a coarctation should get a \_\_\_type analysis.

Answer 125

Congenital narrowing of a portion of the aorta. Most commonly the coarctation is distal to the subclavian artery and is typically noted at the area where the ductus arteriosus attaches. Newborn may be asymptomatic if mild case of patent ductus arteriosus (PDA). Severe cases will have heart failure or shock when PDA closes. Up to 30% of infants with this condition have Turner’s syndrome. Female infants noted to have a coarctation should get a karyotype analysis.

Question 126

Coarctation of the Aorta Screening Compare (2) Diagnostic = If abnormal order (3)

Answer 126

Compare the femoral and brachial pulses simultaneously Absence or delay of the femoral pulse when it is compared with the brachial pulse is diagnostic If abnormal, order ECHO, EKG, CXRAY

Question 127

Coarctation of the Aorta Neonate * Is p\_\_\_, irr\_\_\_\_\_, \_\_\_\_neic, and dia\_\_\_\_\_\_ **Older Infants** * May be \_\_symptomatic. Take (1) measurements of both (2) * *Normal finding:* Systolic BP is higher in (1) vs. (1) * *Abnormal:* Systolic BP higher in (1) vs. (1). * Palpate pulse in all four extremities. There is a de\_\_\_\_ or change in amp\_\_\_\_\_ of pulses. Bounding ____ pulses are compared with ____ pulse.

Answer 127

Neonate * Neonate is pale, irritable, dyspneic, and diaphoretic **Older Infants** * May be asymptomatic. Take blood pressure (BP) measurements of both arms and thighs. * *Normal finding:* Systolic BP is higher in legs than in arms. * *Abnormal:* **Systolic BP higher in arms** than in thighs. Palpate pulse in all four extremities. There is a delay or change in amplitude of pulses. Bounding radial pulses are compared with femoral pulse.

Question 128

Developmental Dysplasia of the Hip There is higher risk with * (1) position births * _____ gender * _____ history * \_\_\_\_\_\_hydramnios.

Answer 128

* breech births * female gender * family history * oligohydramnios.

Question 129

Developmental Dysplasia of the Hip: *Birth to 3 Months* Look for as\_\_\_\_\_ in the cr\_\_\_\_\_ of the legs. Examine infant front and back without diapers. Check that gluteal, thigh, and popliteal f\_\_\_\_ match. (2) Maneuvers

Answer 129

Look for asymmetry in the creases of the legs. Examine infant front and back without diapers. Check that gluteal, thigh, and popliteal folds match. Ortolani and Barlow Maneuvers

Question 130

Barlow Maneuver How to perform? What does it do to the hip? *Positive =*

Answer 130

Place your index and middle finger over the greater trochanter. Gently push both knees together at midline downward, then pull upward Displaces the hip *Positive = “clunk”* sound when trochanter slips back into the acetabulum (socket of hipbone) or palpating trochanter being displaced by index/middle finger

Question 131

Ortolani Maneuver How to perform? What does it do to the hip? *Positive =*

Answer 131

Hold each knee and place your middle finger over the greater trochanter (outer thigh over the hips). Rotate the hips in the frog leg position (abduction, then adduction - *From an adducted position, the hip is gently abducted while lifting or pushing the femoral trochanter anteriorly.* Reduces a dislocated hip *Positive =* “Click” or “clunk” sound

Question 132

Developmental Dysplasia of the Hip ## Footnote **What should you do if Barlow and/or Ortolani is abnormal? (2)**

Answer 132

If either screening exam is positive, refer to a **pediatric orthopedist**. Order an **ultrasound** of the hips.

Question 133

Developmental Dysplasia of the Hip *Older Infants (≥4 Months)* \_\_\_\_\_ to perform the Barlow and Ortolani maneuvers until the child is fully (1) Look for leg that is turned \_\_\_\_ward. One femur appears shorter when infant is supine (\_\_\_\_\_\_\_ sign). Hip has limited range of \_\_\_\_\_. *Abnormal:* If preceding findings are present, order a hip (1) and refer to (1) specialist.

Answer 133

Continue to perform the Barlow and Ortolani maneuvers until the child is fully weight bearing/walking. Look for leg that is turned outward. One femur appears shorter when infant is supine (Galeazzi sign). Hip has limited range of motion. *Abnormal:* If preceding findings are present, order a hip ultrasound and refer to orthopedic specialist.

Question 134

Developmental Dysplasia of the Hip NOTE Avoid performing both tests too many times per visit, why?

Answer 134

Avoid performing both tests too many times per visit, because the ligaments on the hips can become damaged.

Question 135

Exam Tips ## Footnote Barlow and Ortolani are screening tests for **(1)**. Positive sign is if “\_\_\_\_” or “\_\_\_\_” sound is heard, and/or if examiner palpates the trochanter becoming displaced (temporarily) from the hip socket. Refer to pediatric ______ specialist. *Asymmetry of thigh/gluteal \_\_\_\_:* Rule out congenital hip dysplasia or hip fracture. Developmental milestones: Rolls from front to back and back to front at __ months; plays pat-a-cake and peek-a-boo at __ months.

Answer 135

Barlow and Ortolani are screening tests for developmental dysplasia of the hip (DDH). Positive sign is if “click” or “clunk” sound is heard, and/or if examiner palpates the trochanter becoming displaced (temporarily) from the hip socket. Refer to pediatric orthopedic specialist. *Asymmetry of thigh/gluteal folds:* Rule out congenital hip dysplasia or hip fracture. Developmental milestones: Rolls from front to back and back to front at 6 months; plays pat-a-cake and peek-a-boo at 9 months.

Question 136

Toddlers (Ages 2-3) Danger Signals N\_\_\_\_blastoma \_\_\_\_\_’ Tumor (Nephroblastoma) E\_\_\_\_\_itis Ost\_\_\_\_litis S\_\_\_\_ Arthritis O\_\_\_\_\_ Cellulitis Pre\_\_\_\_\_ Cellulitis (Periorbital Cellulitis) Non\_\_\_\_\_\_ Trauma (Child Abuse)

Answer 136

Neuroblastoma Wilms’ Tumor (Nephroblastoma) Epiglottitis Osteomyelitis Septic Arthritis Orbital Cellulitis Preseptal Cellulitis (Periorbital Cellulitis) Nonaccidental Trauma (Child Abuse)

Question 137

Neuroblastoma Most common presentation is an **ab\_\_\_\_\_** (retroperitoneal or hepatic) **mass** that **is fi\_\_\_, fi\_\_, and irregular and frequently _____ the midline.** The most common site is the **\_\_\_\_\_ medulla** (sits on top of the kidneys). About half of patients present with met\_\_\_\_ disease. May be accompanied by weight loss; fever; subcutaneous n\_\_\_\_; _____ syndrome (miosis, ptosis, anhidrosis); periorbital _____ (“racoon eyes”); bone pain; hypertension; and, rarely, opsoclonus myoclonus syndrome. Most are diagnosed in children between the ages of 1 and __ years. Elevated urinary cat\_\_\_\_\_\_ help with diagnosis. After ruling out bowel obstruction, **(1) is initial imaging choice** for abdominal masses. Refer to g\_\_\_\_\_ pediatric surgeon.

Answer 137

Most common presentation is an **abdominal** (retroperitoneal or hepatic) **mass** that is **fixed, firm, and irregular and frequently crosses the midline.** The most common site is the **adrenal medulla** (sits on top of the kidneys). About half of patients present with metastatic disease. May be accompanied by weight loss; fever; subcutaneous nodules; Horner’s syndrome (miosis, ptosis, anhidrosis); periorbital ecchymoses (“racoon eyes”); bone pain; hypertension; and, rarely, opsoclonus myoclonus syndrome. Most are diagnosed in children between the ages of 1 and 4 years. Elevated urinary catecholamines help with diagnosis. After ruling out bowel obstruction, **ultrasound is initial imaging choice** for abdominal masses. Refer to general pediatric surgeon.

Question 138

Wilms’ Tumor (Nephroblastoma) **Asymptomatic ab\_\_\_\_ mass that extends from the flank toward the midline. The nontender and sm\_\_\_\_ mass _____ crosses the midline (of the abdomen).** Some patients have abdominal pain and \_\_\_\_turia. One-fourth of patients have hyper\_\_\_\_\_. Higher incidence in (1) race (1) gender children. Peak age is 2 to __ years. The most common _____ malignancy in children. While performing the abdominal exam, **palpate g\_\_\_\_** to **avoid rupturing the renal capsule (causes bleeding and seeding of abdomen with cancer cells).** Initial imaging test is an abdominal (1). Refer to (1).

Answer 138

**Asymptomatic abdominal mass** that extends from the flank toward the midline. The nontender and **smooth mass rarely crosses the midline** (of the abdomen). Some patients have abdominal pain and hematuria. One-fourth of patients have hypertension. Higher incidence in Black female children. Peak age is 2 to 3 years. The most common renal malignancy in children. While performing the abdominal exam, **palpate gently** to **avoid rupturing the renal capsule (causes bleeding and seeding of abdomen with cancer cells).** Initial imaging test is an abdominal **ultrasound**. Refer to nephrologist.

Question 139

Epiglottitis Acute and rapid onset of high fever, chills, and toxicity. Child complains of severe sore throat and **dr\_\_\_\_** saliva. Will not eat or drink; has **muffled (1) voice** and anxiety. Characteristic **\_\_\_\_\_ sitting** posture with hyperextended neck and open-mouth breathing. St\_\_\_\_\_, tachycardia, and tachypnea. Usually occurs between ages __ and __ years. Before the **(1)** vaccine was used, most cases were due to (1) (75%). Other pathogens include *St\_\_\_\_\_ aureus*, *St\_\_\_\_\_ pyogenes*, and fungi. Now rare due to the Hib conjugate vaccine. Prophylaxis with **Rx(1)** (duration is 4 days) for close \_\_\_\_\_. R\_\_\_\_\_\_ disease to the public health department. A medical \_\_\_\_\_\_. Call 911.

Answer 139

Acute and rapid onset of high fever, chills, and toxicity. Child complains of severe sore throat and **drooling** saliva. Will not eat or drink; has **muffled** (**hot potato**) **voice** and anxiety. Characteristic **tripod sitting** posture with hyperextended neck and open-mouth breathing. Stridor, tachycardia, and tachypnea. Usually occurs between ages 2 and 6 years. Before the **Hib** vaccine was used, most cases were due to *Haemophilus influenzae* type b (Hib; 75%). Other pathogens include *Staphylococcus aureus*, *Streptococcus pyogenes*, and fungi. Now rare due to the Hib conjugate vaccine. Prophylaxis with rifampin (duration is 4 days) for close contacts. Reportable disease to the public health department. A medical emergency. Call 911.

Question 140

Osteomyelitis \_\_\_\_\_ common in children. (1) gender two times more likely than (1) gender. Infections typically occur at the meta\_\_\_\_, so the area overlying the metaphysis is often exquisitely t\_\_\_\_ to the touch. Patient is f\_\_\_\_ and t\_\_\_\_ appearing. Usually will not _____ bear or move extremity due to pain. Requires em\_\_\_\_\_ hospitalization, (1) route antibiotics, and operating room (OR) de\_\_\_\_\_\_. Growth plate infection can result in gr\_\_\_\_\_ stunting of the affected limb.

Answer 140

More common in children. Boys two times more likely than girls. Infections typically occur at the metaphyses, so the area overlying the metaphysis is often exquisitely tender to the touch. Patient is febrile and toxic appearing. Usually will not weight bear or move extremity due to pain. Requires emergent hospitalization, intravenous (IV) antibiotics, and operating room (OR) debridement. Growth plate infection can result in growth stunting of the affected limb.

Question 141

Septic Arthritis Primarily disease of infants and t\_\_\_\_\_\_. Can occur if osteo\_\_\_\_\_ spreads to the joint space but is more commonly from \_\_\_\_togenous spread. *(1)* is most common organism. **\_\_\_\_\_\_ onset of \_\_\_\_lateral h\_\_\_ or k\_\_\_\_ pain is the most common presentation**. Knee may present with swelling and warmth, but hip rarely presents with palpable findings. If patient tolerates weight bearing, antalgic limp noted. At rest, patient will prefer hip \_\_\_\_\_, abduction, and external rotation or knee in partial \_\_\_\_\_. Requires emergent joint as\_\_\_\_\_\_ and empiric IV \_\_\_\_\_\_.

Answer 141

Primarily disease of infants and toddlers. Can occur if osteomyelitis spreads to the joint space but is more commonly from hematogenous spread. *S. aureus* is most common organism. **Abrupt onset of unilateral hip or knee pain is the most common presentation.** Knee may present with swelling and warmth, but hip rarely presents with palpable findings. If patient tolerates weight bearing, antalgic limp noted. At rest, patient will prefer hip flexion, abduction, and external rotation or knee in partial flexion. Requires emergent joint aspiration and empiric IV antibiotics.

Question 142

Orbital Cellulitis Young child complains of abrupt onset of d\_\_\_\_ eye pain that is aggravated by eye _____ and is accompanied by a high f\_\_\_\_ and chills. Affected eye will appear to be b\_\_\_\_\_ (proptosis or exophthalmos). **(1) movements exam will be abnormal because of ophthalmoplegia (\_\_\_\_\_ movement of eyeball)** from infection of the ocular fat pads and muscles. More common in younger children. Ethmoid sinusitis is more likely to cause orbital cellulitis compared with frontal/maxillary sinusitis. Can be \_\_\_-threatening. A serious complication of rhino\_\_\_\_\_\_, acute otitis \_\_\_\_\_, or dental infections. Refer to \_\_\_. Imaging (1) or (1) is done in the ED.

Answer 142

Young child complains of abrupt onset of deep eye pain that is aggravated by eye movements and is accompanied by a high fever and chills. Affected eye will appear to be bulging (proptosis or exophthalmos). **Extraocular eye movements (EOMs) exam will be abnormal because of ophthalmoplegia (limited movement of eyeball)** from infection of the ocular fat pads and muscles. More common in younger children. Ethmoid sinusitis is more likely to cause orbital cellulitis compared with frontal/maxillary sinusitis. Can be life-threatening. A serious complication of rhinosinusitis, acute otitis media, or dental infections. Refer to ED. CT scan or MRI is done in the ED.

Question 143

Preseptal Cellulitis (Periorbital Cellulitis) **An infection of the \_\_\_rior portion of the (1) t**hat does ___ involve the orbit/globe or the eyes. \_\_\_\_ common than orbital cellulitis. ______ causes serious complications (compared with orbital cellulitis). Younger children are most likely to be affected. Young child complains of a **new onset of r\_\_\_, sw\_\_\_\_ eye\_\_\_ and eye p\_\_\_,** sometimes none. Eye movements do ___ cause pain, and **EOM exam is \_\_\_\_** (both are abnormal with orbital cellulitis). ___ visual impairment. May be hard to distinguish from orbital cellulitis. Refer to \_\_.

Answer 143

**An infection of the anterior portion of the eyelid** that does not involve the orbit/globe or the eyes. More common than orbital cellulitis. Rarely causes serious complications (compared with orbital cellulitis). Younger children are most likely to be affected. Young child complains of a **new onset of red, swollen eyelids and eye pain,** sometimes none. Eye movements do not cause pain, and E**OM exam is normal** (both are abnormal with orbital cellulitis). No visual impairment. May be hard to distinguish from orbital cellulitis. Refer to ED.

Question 144

Nonaccidental Trauma (Child Abuse) The majority of perpetrators are _____ (82%). About 16% of the perpetrators are persons whom the child is exposed to such as \_\_\_-care staff and unmarried p\_\_\_\_\_\_. **Multiple red flags for nonaccidental trauma (NAT)** include posteriomedial r\_\_\_ fractures, \_\_\_\_physeal avulsion fractures, bruises or fractures in v\_\_\_\_\_ stages of healing, de\_\_\_ in seeking medical care, and injuries that are in\_\_\_\_\_\_ with explanation. Infants and children who are developmentally or physically dis\_\_\_\_\_ are at higher risk. Nurses, nurse practitioners, and several other professionals are required to r\_\_\_\_\_ suspected or actual child abuse to authorities.

Answer 144

The majority of perpetrators are parents (82%). About 16% of the perpetrators are persons whom the child is exposed to such as day-care staff and unmarried partners. **Multiple red flags for nonaccidental trauma (NAT)** include posteriomedial rib fractures, metaphyseal avulsion fractures, bruises or fractures in various stages of healing, delay in seeking medical care, and injuries that are inconsistent with explanation. Infants and children who are developmentally or physically disabled are at higher risk. Nurses, nurse practitioners, and several other professionals are required to report suspected or actual child abuse to authorities.

Question 145

U.S. Health Statistics: Toddlers Top Three Causes of Death: Ages 1 to 4 Years 1. Dr\_\_\_\_\_\_ 2. C\_\_\_\_\_\_ anomalies 3. (1) accidents

Answer 145

1. Drowning 2. Congenital anomalies 3. Motor vehicle accidents

Question 146

U.S. Health Statistics: Toddlers Top Three Cancers 1. L\_\_\_\_\_ (28%) 2. Br\_\_\_ and n\_\_\_\_ system tumors (26%) 3. Ly\_\_\_\_\_\_ (8%) The most common cancer in children is leukemia. The most common type of leukemia in children is **(1)** The remaining cases are due to acute myelogenous leukemia (AML). **M\_\_\_\_\_blastomas** are the most common type of childhood brain cancer (most occur before age 10 years).

Answer 146

1. Leukemia (28%) 2. Brain and nervous system tumors (26%) 3. Lymphomas (8%) The most common cancer in children is leukemia. The most common type of leukemia in children is **acute lymphocytic leukemia (ALL).** The remaining cases are due to acute myelogenous leukemia (AML). **Medulloblastomas** are the most common type of childhood brain cancer (most occur before age 10 years).

Question 147

Pincer grasp (fine motor). Plays pat-a-cake and peek-a-boo. Says “good-bye.” May be afraid of strangers (can be clingy). Can stand holding on. Crawls.

Answer 147

9 months 9 looks like a backwards P = pincer, patty cake, peek-a-boo *Abnormal: Infantile reflexes strong. Persistence of primitive reflexes (e.g., startle, fencing). Does not babble. Does not bear weight on legs with support. Unable to sit with help.*

Question 148

**Walks. Runs**. **Climbs stairs up and down** on own by holding onto handrails. Speech mostly understood by family. **Follows two- or three-step instructions**. **Copies a line.**

Answer 148

2 years *Abnormal: Unable to speak meaningful two-word “sentences.” Does not understand simple commands. Loss of speech, social skills, or previously learned behaviors and/or does not say words by 16 months (autism).*

Question 149

Smiles. Able to coo. Makes gurgling sounds. Can hold head up. Starts to recognize parents.

Answer 149

3 months *Abnormal:* *Inability to hold head up. Avoids eye contact. Floppy.*

Question 150

Supports own weight. Walks with hands held. Parallel play. Separation anxiety. Can “climb” stairs by crawling up or down. Starts to cruise (moves from one piece of furniture to the other for support).

Answer 150

1 year *Abnormal:* *Unable to support own weight. Lack of babbling. No response to smiles, poor eye contact, loss of previously learned skills (autism)*

Question 151

Can draw a person with six body parts. Counts 10 or more things. Is aware of gender. Speaks clearly.

Answer 151

5 years *Abnormal:* *Unusually withdrawn. Not active. Trouble focusing on one activity for \>5 minutes.*

Question 152

Strong reflexes. Minimum of six to eight bowel movements per day. Urinates eight times a day.

Answer 152

Neonate *Abnormal:* *Jaundice at birth (hemolysis). High-pitched cry. Irritable. “Floppy” (hypotonic). Poor reflexes.*

Question 153

Sits up without support. Rolls in both directions (front to back, back to front). Says single-syllable sounds: “ba, da, ma.” Tries to get things out of reach by “raking” (uses palms to reach).

Answer 153

6 months *Abnormal:* *Lack of babbling. Does not laugh. Inability to turn head past midline (180 degrees)*

Question 154

Copies a cross with crayon or pencil. Draws person with three body parts. Plays “Mom” and “Dad.” Hops and stands on one foot up to 2 seconds. Cooperates with other children. Names some colors and some numbers.

Answer 154

4 Years *Abnormal:* *Unable to speak in full sentences. Inability to skip, run, hop. Cannot put on clothes without help. Unable to play with other kids. Unable to follow three-part commands.*

Question 155

Speaks three- to five-word sentences; understood by strangers. Copies a circle with crayon or pencil. Rides tricycle. Builds towers of more than six blocks. Runs and climbs easily

Answer 155

3 years *Abnormal:* *Speech hard to understand or unclear speech. Unable to understand simple commands. Falls down often. Does not speak in sentences. No eye contact. Loses skills they once had.*

Question 156

2 Years Old **Language** Speaks in \_\_\_- or \_\_\_\_-word sentences (intelligible mostly by family) Follows \_\_\_-step commands Knows common p\_\_\_\_\_\_ in a book

Answer 156

Speaks in two- or three-word sentences (intelligible mostly by family) Follows two-step commands Knows common pictures in a book

Question 157

2 Years Old **Fine Motor** Stacks ___ or ___ cubes Can copy (1) shape **Gross Motor** Goes up stairs using ____ foot; uses r\_\_\_\_ for support R\_\_\_, jumps, and climbs Is very active and en\_\_\_\_\_

Answer 157

**Fine Motor** Stacks five or six cubes Can copy straight line **Gross Motor** Goes up stairs using same foot; uses railing for support Runs, jumps, and climbs Is very active and energetic

Question 158

2 Years **Behaviors** Temper _____ are common at this age. Easily frustrated and says “\_\_\_” often; def\_\_\_\_ behaviors May have a favorite stuffed toy (tr\_\_\_\_\_ object) T\_\_\_\_\_ training is now in progress. Report loss of speech, social skills, or previously learned skills; flapping hands; avoidance of social interaction (rule out \_\_\_\_\_); unsteady walking; inability to speak in \_\_\_-word sentences

Answer 158

Temper tantrums are common at this age. Easily frustrated and says “no” often; defiant behaviors May have a favorite stuffed toy (transitional object) Toilet training is now in progress. Report loss of speech, social skills, or previously learned skills; flapping hands; avoidance of social interaction (rule out autism); unsteady walking; inability to speak in two-word sentences

Question 159

3 Years Old **Language** Speaks in sentences using ___ to ____ words Most speech is understood by st\_\_\_\_\_\_. Knows first \_\_\_\_, a\_\_\_ M\_\_\_\_\_ thinking is prominent at this age (ages 3–5 years); may have an im\_\_\_\_\_ friend; a girl may think that she is a f\_\_\_\_ with special powers.

Answer 159

Speaks in sentences using three to five words Most speech is understood by strangers. Knows first name, age Magical thinking is prominent at this age (ages 3–5 years); may have an imaginary friend; a girl may think that she is a fairy with special powers.

Question 160

3 Years Old **Fine Motor** Copies (1) shape Can stack more than ___ cubes **Gross Motor** Pedals a \_\_\_\_\_ Can throw a ____ overhand Walks up and down stairs with ________ feet

Answer 160

**Fine Motor** Copies a circle Can stack more than six cubes **Gross Motor** Pedals a tricycle Can throw a ball overhand Walks up and down stairs with alternating feet

Question 161

3 Years Old **Behaviors** Freud classified this age as the “\_\_\_\_ stage” (phallic stage). The child expresses the desire to marry the ____ of the opposite sex; occurs between the ages of 3 and 5 years (preschool). Plays with other children (gr\_\_\_\_\_ play) but does not like to _____ toys or take turns. Im\_\_\_\_\_\_ is becoming more active (pretends that a broom is a “horse”). Report any regression in previously learned skills; “cl\_\_\_\_” with frequent falls; minimal vocabulary or speech difficult to understand; speech dysfluencies; no or poor ___ contact.

Answer 161

Freud classified this age as the “Oedipal stage” (phallic stage). The child expresses the desire to marry the parent of the opposite sex; occurs between the ages of 3 and 5 years (preschool). Plays with other children (group play) but does not like to share toys or take turns. Imagination is becoming more active (pretends that a broom is a “horse”). Report any regression in previously learned skills; “clumsy” with frequent falls; minimal vocabulary or speech difficult to understand; speech dysfluencies; no or poor eye contact.

Question 162

Nutrition for Toddlers Have _____ mealtimes (3 meals/day) and ____ (2–3 per day). Food jags are common = Transition from whole milk to ____ fat milk at 2 years of age. ____ fruit juice intake. Cut solid food into \_\_\_-size pieces. Avoid ___ foods, such as nuts, raw carrots, and hard candies, as well as other ch\_\_\_\_\_ hazards like gum drops, jelly beans, whole grapes (cut in quarters if offering), and whole hot dogs (cut into slices that are then quartered).

Answer 162

Have regular mealtimes (3 meals/day) and snacks (2–3 per day). Food jags are common = will only eat one food item Transition from whole milk to lower fat milk at 2 years of age. Limit fruit juice intake. Cut solid food into bite-size pieces. Avoid hard foods, such as nuts, raw carrots, and hard candies, as well as other choking hazards like gum drops, jelly beans, whole grapes (cut in quarters if offering), and whole hot dogs (cut into slices that are then quartered).

Question 163

Toilet Training Clues that a child is ready include when child is * w\_\_\_\_ * can r\_\_\_\_ potty chair * knows the difference between w\_\_ and d\_\_ * can comm\_\_\_\_\_\_ when having a bowel movement * can ____ down own pants * can stay dry for up to __ hours at a time * and shows int\_\_\_\_\_ in the toilet or potty seat. Make sure that child can understand basic instructions.

Answer 163

.Clues that a child is ready include when child is * walking * can reach potty chair * knows the difference between wet and dry * can communicate when having a bowel movement * can pull down own pants * can stay dry for up to 2 hours at a time * and shows interest in the toilet or potty seat. Make sure that child can understand basic instructions.

Question 164

Toilet Training ## Footnote Most children are ready for “potty” training at \_\_**-**\_\_ months. Some children may not be ready until 36 months of age. During toilet training, signs that a child is ready to use the potty are sq\_\_\_\_, h\_\_\_\_ genital area, and sq\_\_\_\_\_. Most children master daytime bladder and bowel control by age __ to __ years. \_\_\_\_time control of urine is usually the last toileting skill that is mastered. Complete nighttime control may not happen until child is __ to __ years of age. Children between 5 and 6 years of age with primary ______ enuresis should be evaluated and interventions started.

Answer 164

Most children are ready for “potty” training at 18 to 24 months. Some children may not be ready until 36 months of age. During toilet training, signs that a child is ready to use the potty are squirming, holding genital area, and squatting. Most children master daytime bladder and bowel control by age 3 to 4 years. Nighttime control of urine is usually the last toileting skill that is mastered. Complete nighttime control may not happen until child is 4 to 5 years of age. Children between 5 and 6 years of age with primary nocturnal enuresis should be evaluated and interventions started.

Question 165

Car Safety for Toddlers = Children younger than age ___ should be restrained in the back seat.

Answer 165

Toddlers should be placed in the back seat in a **forward-facing safety seat** with a harness system until they outgrow the height and weight limits of the seat. Make sure anchors and tethers are used correctly. Children younger than age 12 should be restrained in the back seat.

Question 166

Safety Education ## Footnote Child should be sup\_\_\_\_\_ at all times. Hold child’s ___ when crossing the street or when shopping. Use ____ burners on stove. Turn pot h\_\_\_\_\_ away from reach. Keep tools and sh\_\_\_\_\_ objects out of reach. Inspect toys for l\_\_\_\_ parts or breakage. Water safety education needed. Put _____ around pools. Never leave child alone in the pool.

Answer 166

Child should be supervised at all times. Hold child’s hand when crossing the street or when shopping. Use rear burners on stove. Turn pot handles away from reach. Keep tools and sharp objects out of reach. Inspect toys for loose parts or breakage. Water safety education needed. Put fences around pools. Never leave child alone in the pool.

Question 167

Autism Signs of autism spectrum disorder may appear in early childhood. Screening starts at age 18 months. Five behaviors to look for: Does not p\_\_\_/w\_\_\_/gr\_\_\_/reach (by 12 months) No ba\_\_\_\_\_\_ (by 12 months) Does not say ____ words (by 16 months) Does not say \_\_\_-word phrases on their own (by 24 months) \_\_\_\_\_ of language or social skills (at any age)

Answer 167

Signs of autism spectrum disorder may appear in early childhood. Screening starts at age 18 months. Five behaviors to look for: ## Footnote Does not point/wave/grasp/reach (by 12 months) No babbling (by 12 months) Does not say single words (by 16 months) Does not say two-word phrases on their own (by 24 months) Loss of language or social skills (at any age)

Question 168

Classic Case of Autism An autistic 3-year-old boy is enrolled in a preschool program. The mother goes inside the school to drop the child off at the classroom. After she gives him a hug, she leaves the room. How would the child react after his mother leaves?

Answer 168

At this age, a 3-year-old boy (who is not autistic) would most likely cry, protest, and cling to his mother’s legs when she tries to leave. An autistic child may not protest, cling, or cry when his mother leaves (as would be expected in a child who does not have autism). If the mother hugs him, an autistic 3-year-old child may hold his body stiffly and not return the hug. Some may push the mother away because they do not like to be touched.

Question 169

Autism Diagnosis and Treatment ## Footnote Typically diagnosed by a dev\_\_\_\_\_\_\_ pediatrician using highly specialized ______ tools. M\_\_\_\_modal interventions are used to ameliorate some of the cognitive and behavioral issues.

Answer 169

Typically diagnosed by a developmental pediatrician using highly specialized diagnostic tools. Multimodal interventions are used to ameliorate some of the cognitive and behavioral issues.

Question 170

Exam Tips ## Footnote Wilms’ tumor is a congenital tumor of the (1). More common in (1) race (1) gender. *Epiglottitis presentation:* S\_\_\_\_\_ posture with ______ neck and open-\_\_\_\_breathing. Speech of a 2-year-old includes \_\_\_\_-word phrases mostly understood by \_\_\_\_members. Speech of a 3-year-old includes \_\_\_- to-\_\_\_\_-word sentences that can be mostly understood by \_\_\_\_\_\_.

Answer 170

Wilms’ tumor is a congenital tumor of the kidneys. More common in African American girls. *Epiglottitis presentation:* Sitting posture with hyperextended neck and open-mouth breathing. Speech of a 2-year-old includes two-word phrases mostly understood by family members. Speech of a 3-year-old includes three- to-five-word sentences that can be mostly understood by strangers.

Question 171

Exam Tips ## Footnote \_\_\_\_-year-old can ride a tricycle. Can ride a bicycle at the age of __ to __ years. Three-year-old can copy a \_\_\_\_\_. (An easy way to memorize this fact is that when you take the “3” and join the two halves, it forms a circle.) Four-year-old can copy a _____ (the number “4” resembles a cross at the center) and draw a “\_\_\_ person” with ____ body parts. Five-year-old can draw a person with at least ___ body parts.

Answer 171

Three-year-old can ride a tricycle. Can ride a bicycle at the age of 6 to 7 years. Three-year-old can copy a circle. (An easy way to memorize this fact is that when you take the “3” and join the two halves, it forms a circle.) Four-year-old can copy a cross (the number “4” resembles a cross at the center) and draw a “stick person” with three body parts. Five-year-old can draw a person with at least six body parts.

Question 172

Exam Tips ## Footnote Oedipal stage is when the child (age \_\_–\_\_ years) expresses the desire to? Red flags for autistic behavior are ____ of skills at any age; no p\_\_\_\_, r\_\_\_\_, or b\_\_\_\_\_ by 1 year; no w\_\_\_\_ by 16 months; and no \_\_\_\_-word phrases by 2 years.

Answer 172

Oedipal stage is when the child (age 3–6 years) expresses the desire to marry the parent of the opposite sex. Red flags for autistic behavior are loss of skills at any age; no pointing, reaching, or babbling by 1 year; no words by 16 months; and no two-word phrases by 2 years.