RDA

Question 1

What is the most important use of ultrasound?

a) Provides an accurate determination of gestational age
b) Assess overall fetal well-being
C) Measure fetal abdominal circumference accurately
D) Measurement of fetal head circumference accurately

Answer 1

b) Assess overall fetal well-being

The MOST IMPORTANT outcome is the overall assessment of the fetus and well-being, rather than any one measurement.
Measurements can be made with accuracy, but ultrasound cannot determine gestational age.

Question 2

Low Birth Weight (LBW) refers to infants that are:

a) Below the 10th centile
b) Below the 3rd centile
c) Less than 1500 grams
d) Less than 2500 grams

Answer 2

d) Less than 2500 grams

LBW is a measure of size only; does not consider centile information at all, so of limited use. VLBW less than 1,500g.
Also does not take account of gestational age.

Question 3

Which of the following are most important for fetal weight gain?

a) Amino acids
b) Glucose
c) Minerals
d) Vitamins

Answer 3

b) Glucose

All of the above are needed for infant development, but glucose provides the most energy of those listed. Lipids may be of importance, but not in the list!

Question 4

Centile charts are useful because:

a) They automatically compensate for genetic variability
b) The normality of fetal size can be confirmed
c) Serial measurements can be plotted
d) The impact of pathologies is included

Answer 4

c) Serial measurements can be plotted

Centile charts cannot do any of the others, as they are based on the overall population, and cannot address the other aspects. Genetic contribution is not compensated.

Question 5

Which of the following mainly affects fetal growth?

a) Maternal drug use
b) Maternal pathogens
c) Maternal alcohol consumption
d) Maternal malnutrition

Answer 5

d) Maternal malnutrition

Point here is fetal growth; fetal development more likely to be affected by the others listed.

Question 6

A study includes 200 normal babies. How many of these babies would be expected to have weights below the tenth centile?

a) 20
b) 50
c) 10
d) none

Answer 6

a) 20

10% of any normal population will be below the 10th centile, and 10% of 200 is 20.

Question 7

Comparing first and second pregnancies with the same parents:

a) The second baby is likely to be lighter
b) The second baby is likely to be heavier
c) There is usually no difference in size
d) The second baby is likely to be shorter

Answer 7

b) The second baby is likely to be heavier

This is the data observed in large population studies; individual differences may be greater than this, so all may be observed in a family.

Question 8

Fetal growth velocity is greatest at which gestational age?

a) Late first trimester
b) Mid second trimester
c) Mid third trimester
d) Just before delivery

Answer 8

c) Mid third trimester

The rate of growth (velocity) tends to fall towards the end of pregnancy. Fetal weight may increase rapidly in early pregnancy, but actual velocity (e.g. grams/week) is greater in the 3rd trimester.

Question 9

Which of the following are included in the generally accepted definition of pre-eclampsia?

a) Maternal oedema
b) Maternal seizures
c) Fetal distress
d) Maternal proteinuria

Answer 9

d) Maternal proteinuria

Only D is part of the general definition. A is observed, but not now part of the definition; seizures define Eclampsia, and fetal distress may be observed in late pregnancy. The accepted definition is new-onset hypertension with proteinuria during pregnancy

Question 10

What is the preferred method for measuring fetal growth, if ultrasound is not available?

a) Determine symphysis-fundal height
b) Measurement of maternal weight gain
c) Palpation of the uterus
d) Determination of the maternal abdominal circumference

Answer 10

a) Determine symphysis-fundal height

There are no accurate methods for this – A is simple and has been used before ultrasound, but will only detect gross changes. Palpation is the method to be used, not the actual measurement. The others do not give enough information.

Question 11

What is the significance of ‘limit’ ages in child development?

a) Has no signifiance to child development
b) Average age a developmental milestone is achieved
c) Upper age by which a developmental milestone should be achieved
d) Minimum age at which a developmental milestone should be achieved

Answer 11

c) Upper age by which a developmental milestone should be achieved

Limit ages are the age by which a developmental milestone should have been achieved = 2 standard deviations from the mean. They indicate cause of major concern. Examples of Red flags that require urgent onwards referral to paediatrics is a child who is not able to sit unsupported by 12 months or any child that has no speech by 18 months (urgent hearing test also).

Question 12

How is obesity defined in children?

a) Obesity is assessed on the BMI centile position
b) Obesity is defined differently depending on the culture the child is from
c) Same as adults - BMI of over 25 kg/m2 is overweight and over 30 kg/m2 is obese.
d) There is no universally accepted definition for obesity in children

Answer 12

a) Obesity is assessed on the BMI centile position

Children have lower BMI than adults.
This changes with age so these figures do not apply.
Obesity is assessed on the BMI centile position.
Some nations have a much higher rate of obesity than others.
In some cultures being overweight is seen as a desirable feature indicating wealth and high status.

Question 13

When a child is 2 years old, what key milestone would a child be expected to reach?

a) Copy a circle
b) Stand briefly on one foot
c) Join 2-3 words when talking
d) Use 6-12 words

Answer 13

c) Join 2-3 words when talking

By 2 years old, a child would be expected to join 2-3 words when talking, know some body parts and identify objects in pictures regarding their speech and language development. In addition, they would be expected to possibly kick a ball, climb stairs 2 feet per step regarding gross motor. With respect of fine motor, they would be able to build a tower 6-7 cubes and do circular scribbles. With social development they should be able to remove some clothes.

Question 14

Is there any difference between height velocity and cumulative growth?

a) Cumulative growth is the height velocity at one age minus the height velocity at another age
b) There is no difference between height velocity and cumulative growth
c) Height velocity is the total growth at any given point and cumulative growth is how fast a child is growing in cm per year
d) Height velocity is how fast a child is growing in cm per year. Cumulative growth is the total growth at any given point

Answer 14

d) Height velocity is how fast a child is growing in cm per year. Cumulative growth is the total growth at any given point

Centile charts we use are for cumulative height- how tall the child is now.
Height velocity is how fast a child is growing in cm per year, usually this is calculated over a whole year.
Most short children are growing at a completely normal speed.
Other useful information when assessing growth is the height of family members- parents and siblings.
Ideally measure them yourself because people can be very inaccurate in assessing their own height.

Question 15

Growth hormone is released by the pituitary. Which hormones are directly involved in stimulation and suppression?

a) Somatostatin stimulates secretion and growth hormone releasing hormone suppresses secretion
b) Growth hormone releasing hormone stimulates secretion and somatostatin suppresses secretion
c) Insulin like growth factor stimulates and suppresses directly
d) No hormones are directly are directly involved in the stimulation and secretion of growth hormone

Answer 15

b) Growth hormone releasing hormone stimulates secretion and somatostatin suppresses secretion

Growth hormone (GH) is the most important hormonal factor in growth.
Hypothalamus secretes growth hormone releasing hormone (GHRH) which stimulates secretion of growth hormone from pituitary. Somatostatin is produced by the hypothalamus and inhibits secretion of growth hormone from hypothalamus.
GH is released by the pituitary as pulses most of which occur overnight.
GH has some growth effect itself and also stimulates the release of IGF1 (insulin like growth factor 1).
IGF 1 circulates bound to a number of binding proteins and stimulates growth in all the tissues of the body.

Question 16

At 12 months what gross motor milestone would you expect most children to reach?

a) Independent walking alone
b) Kicks a ball
c) Runs
d) Pulls to stand

Answer 16

d) Pulls to stand

At 12 months, we would expect most children to pull to stand. Some may stand alone, or possibly cruise or possibly even walk alone briefly. With fine motor skills, we would expect children to put blocks in a cup. Language skills that would be emerging are saying 1-2 words and imitating adult sounds. Social milestone expected would be to drink from a cup and have object permanence (understanding objects are there even when out of sight). At 18 months, we would expect a child to run and by 2 to kick a ball.

Question 17

What is the initial clinical approach to an 18 month child whose parent is concerned about their child’s development?

a) Physical examination
b) Thorough history
c) Metabolic blood tests
d) Paediatric referral

Answer 17

b) Thorough history

It is paramount a history is taken from the parent, and any collateral history they may also have i.e. nursery. It is important to understand what aspect of development they are concerned with or if the concern is global developmental delay. In addition, an understanding of their vision and hearing is also important. Of course A, C, D may also happen after.

Question 18

Which of the options is a cause of abnormal growth resulting in short stature?

a) Marfan syndrome
b) Obesity
c) Chronic disease e.g. Coeliac disease
d) Hyperthyroidism

Answer 18

c) Chronic disease e.g. Coeliac disease

Commonest concern about growth is short stature.
Majority of short children have a normal growth pattern, and do not have anything wrong with them.
If a child grows slower than normal over a significant period of time they will fall in their centile position. This is abnormal and a cause should be looked for:
• Poor nutrition • Chronic disease • Endocrine causes- GH deficiency, thyroid hormone deficiency • Genetic disorders affecting bone growth (e.g achondroplasia, Turner syndrome, Down syndrome). • Psychological distress and neglect.

Question 19

In precocious puberty, growth spurt occurs very early, how do these children usually present?

a) Tall stature with early physical signs of puberty
b) Short stature with physical signs of puberty
c) Tall stature with no physical signs of puberty
d) Average stature with physical signs of puberty

Answer 19

a) Tall stature with early physical signs of puberty

Tall stature is a very unusual concern.
Most tall children have a normal growth pattern and do not have anything wrong with them.
Causes to consider are:
• Syndromes of overgrowth including Marfan syndrome and Soto syndrome.
• GH excess from a pituitary tumour. This is very rare indeed, most of the “tallest men and women in the world” have had this diagnosis.
In precocious puberty the pubertal growth spurt occurs very early and so children with this can present with tall stature.
However growth stops early as well so they can then be short as adults.

Question 20

Mother, brings in her 5 year old daughter to the GP, who is having trouble at school. Speech appears to be normal but mother complains she doesn’t always do what she is asked to do. Child was born at 32 weeks, and mother had a traumatic birth. What cause of action would you take?

a) Obtain more knowledge of the cause of the prematurity
b) Establish an up to date developmental history
c) Hearing test
d) Better understanding of what trouble at school means

Answer 20

d) Better understanding of what trouble at school means

All of these stems could potentially be correct. However, with all aspects of clinical medicine it is important to start with the parents Ideas, concerns and expectations. Possibly trouble at school might be inattention or possibly that she does not appear to have any friends or possibly another issue such as enuresis.

Question 21

How do you plot height on a centile chart?

a) Plot the height ( x axis) against age ( y axis)
b) Plot the age ( x axis) against height ( y axis)
c) Plot the age ( x axis) against height velocity ( y axis)
d) Plot the height velocity ( x axis) against age ( y axis)

Answer 21

b) Plot the age ( x axis) against height ( y axis)

To use a centile chart you plot the age (x axis) against height (y axis).
Centile charts are used for a range of growth measurements- height, weight, head circumference and BMI are the commonest.
Based on surveys of large numbers of children- in the UK we use both UK population based charts and ones from the WHO which look at an international population.

Question 22

When measuring children’s height, which option is important for an accurate measurement?

a) Parents’ median height
b) Child is measured in the morning
c) Weight is measured at the same time
d) The child’s shoes are removed

Answer 22

d) The child’s shoes are removed

Getting an accurate height and weight is important in assessing growth.
Equipment should be accurate and maintained properly.
Position the child properly to get an accurate height (read the instructions on the growth chart).
Make sure you get rid of things which interfere with measuring- shoes off, hair out of the way and clothes off for weight.

Question 23

Mum is worried as her daughter is following the 25th centile on the growth chart in her red book, what does this mean?

a) 75% of children are taller than this patient
b) 75% of children are growing faster than this patient
c) 25% of children are growing faster than this patient
d) 25% of children are taller than this patient

Answer 23

a) 75% of children are taller than this patient

75% of children will be taller than the 25th centile.
25% shorter than the 25th centile, and so on.
Centile charts are not a “normal range”, they are just a way of looking at where height is compared to others
There are different centile charts for girls and boys.

Question 24

Which of the following statements concerning endometrial organisation during the menstrual cycle is most accurate?

a) Most layers of the endometrium are sloughed during the proliferative phase
b) The endometrium decreases in thickness during the first half of the cycle
c) After ovulation the endometrium becomes more highly vascularised
d) The endometrium is supplied by 4 types of arteries
e) Vascular necrosis factor is expressed after ovulation

Answer 24

c) After ovulation the endometrium becomes more highly vascularised

Progesterone is released from the corpus luteum after ovulation, and acts on the endometrium to prepare it for implantation of an egg. One of these adaptations is vascularisation of the endometrium to prepare it to deliver nutrients to the developing fetus.

Question 25

Which of the following directs formation of the neural tube?

a) Neural plate
b) Notochord
c) Mesoderm
d) Primitive streak
e) Primitive node

Answer 25

b) Notochord

The notochord forms during gastrulation (formation of the three-layer disc) and gives rise to the neural tube

Question 26

Which sequence of embryonic tissue differentiation is correct?

a) Inner cell mass – trophectoderm - epiblast
b) Epiblast – hypoblast – mesoderm
c) Inner cell mass - hypoblast – trophectoderm
d) Inner cell mass – epiblast – mesoderm
e) Epiblast – endoderm – mesoderm

Answer 26

d) Inner cell mass – epiblast – mesoderm

It is worth having an idea of the progression of the developing embryo during the first 1 or 2 weeks. The progression is as follows:
Fertilised egg - zygote - morula - blastocyst - bilaminar disc - 3-layer disc (via gastrulation)
The inner cell mass is a small group of cells in the blastocyst, the outside of which is comprised of the trophectoderm cells (these are the same thing as trophoblast cells). The epiblast and hypoblast are the two layers of the bilaminar disc, which is surrounded by a trophectoderm layer. The endoderm, ectoderm, and mesoderm are the components of the three-layer disc post-gastrulation. This is best learned with the aid of lots of diagrams.

Question 27

What is the most important factor in deciding if a child’s growth pattern is normal:

a) Parental height
b) Position on the centile chart
c) Speed of growth over time
d) Whether parents are satisfied with height
e) Bone age

Answer 27

c) Speed of growth over time

Whilst the position of a child on a centile chart may seem important, it isn’t particularly; a child may be in the 10th centile and as long as it grows at a normal rate, this is not concerning. A sudden change in speed of growth however, is concerning because it implies something has suddenly begun to stunt or accelerate the child’s growth, which is more indicative of pathology.

Question 28

A common feature of Turner syndrome is:

a) Tall stature
b) Early puberty
c) Food-seeking behavior
d) Short limbs
e) Failure to progress in puberty

Answer 28

e) Failure to progress in puberty

Turner syndrome is caused by partial or complete loss of an X chromosome in a female, resulting in a 45X genotype. Turner syndrome patients undergo rapid depletion of their eggs, so that their supply is often gone before they reach the age of puberty, and so they commonly fail to go through puberty.

Short stature is also a key feature of Turner syndrome, as is a webbed neck, swelling in the hands and feet at birth, and low-set ears. There are no particular abnormalities in limb proportion associated with Turner syndrome, and option ‘b’ (food-seeking behaviour) is seen not in Turner syndrome, but in Prader-Willi syndrome.

Question 29

Which of the following fetal hormones are considered to have major direct effects on fetal growth?

a) Follicle stimulating hormone
b) Insulin
c) Luteinizing hormone
d) Prolactin
e) Somatotrophin

Answer 29

b) Insulin

Insulin is known to be key in regulating fetal growth. This is why mothers with insulin resistance or full-blown diabetes tend to give birth to larger children - the fetus is exposed to more insulin than normal, and so grows faster than it should.

Question 30

Which factor is associated with IUGR (intra-uterine growth restriction)?

a) High birth weight
b) Single intrauterine pregnancy
c) Placenta praevia
d) Maternal age 16-35

Answer 30

c) Placenta praevia

Placenta praevia is when the placenta latches on to the endometrium too far down in the uterus, near to, or over, the cervical opening. This can lead to a whole host of maternal and fetal complications during gestation and labour. As a general rule, anything that can cause complications during pregnancy will cause IUGR and/or premature birth

Question 31

At what gestation do we define a stillbirth?

a) 12 weeks
b) 14 weeks
c) 24 weeks
d) 32 weeks

Answer 31

c) 24 weeks

23/24 week is the limit of viability - the minimum gestational age at which a child can be delivered and survive. As a result, fetal death after this time is defined as stillbirth, as the child could theoretically have survived birth.

Question 32

How long is a MOCA assessment supposed to take?

a) <10 minutes
b) 10-15 minutes
c) 30 minutes
d) 30-60 minutes

Answer 32

b) 10-15 minutes

The Montreal Cognitive Assessment is a screening tool for cognitive impairment. The test should take 10-15 minutes and consists of a sheet with various types of questions, and a maximum score of 30.

Question 33

What are the physical changes associated with an ageing brain?

a) Volume of CSF around the brain decreases
b) Ventricles enlarge
c) Brain weight increases
d) Gaps between the major gyri narrow

Answer 33

b) Ventricles enlarge

As the brain ages, it tends to shrink, so the ventricles enlarge, the weight decreases, and the gaps between the gyri increase as the brain atrophies.

Question 34

At what stage of development is exposure to teratogens most likely to lead to birth defects?

a) Implantation
b) Before conception
c) 1st trimester
d) 2nd Trimester
e) 3rd Trimester

Answer 34

c) 1st trimester

Teratogens are substances or pathogens which can cause malformations in the foetus resulting in birth defects. The foetus is not invulnerable to teratogens for the first 2 weeks post-fertilisation, but exposure results in miscarriage, hence exposure at this time won’t actually lead to birth defects. After the initial two-week period, exposure will result in birth defects. These malformations will be more severe and present in more organs the earlier the foetus is exposed.

Question 35

During the first trimester, where is main production of oestrogen & progesterone?

a) Corpus luteum
b) Placenta
c) Fallopian tube
d) Ovary
e) Embryo

Answer 35

a) Corpus luteum

For the first 8 weeks, the corpus luteum is the main synthesiser of steroid hormones (oestradiol and progesterone) for the developing foetus, until the placenta is sufficiently mature to take over hormone production, which occurs between weeks 8 - 9.

Question 36

Which of the options would a 20-week ultrasound scan of a foetus be most useful for?

a) Assess risk of pre-eclampsia
b) Assess for serious heart defects
c) Estimate fetal weight
d) Determine body measurements (e.g. femur length)
e) Investigate for multiple foetuses

Answer 36

b) Assess for serious heart defects

The 20-week scan is used to assess for major fetal defects e.g. major spina bifida, anencephaly, and serious cardiac abnormalities.

Question 37

What milestone should be reached by 2 years of age?

a) Build 6 block high tower
b) Use phrases when speaking
c) Smiles
d) Fears strangers
e) Symbolic play

Answer 37

e) Symbolic play

There is a long list of milestones which should be reached by specific ages, but there are a few key ones. Symbolic play refers to using one object to represent another (e.g. picking up a wooden block and pretending it is a telephone). It is worth briefly familiarising yourself with some of the developmental milestones.

Question 38

Which of the following is a normal maternal change that occurs in pregnancy?

a) Increase in joint stiffness
b) Increased resistance to viral infection
c) Decreased blood pressure
d) Decreased kidney function
e) Reduced blood coagulability

Answer 38

c) Decreased blood pressure

Maternal joints loosen during pregnancy, supposedly to allow the pelvis to widen sufficiently to allow the baby to pass through it. Immunological changes also take place in order to induce tolerance of the fetus by the maternal immune system, but these changes make the mother more susceptible to viral infections, rather than less (if you want to look this up for context, google the Th1-Th2 shift during pregnancy).

Maternal blood pressure consistently decreases during pregnancy, but a decrease in kidney function is not normal. Blood coagulability in pregnancy tends to increase.

Question 39

Which option is true regarding the initiation of labour?

a) CRH (corticotrophin-releasing hormone) and PAF (platelet activating factor) are thought to be involved in the initiation
b) Nf-kB expression decreases
c) Maternal infection results in delayed labour
d) Oxytocin release stimulates milk production in the breast
e) A spike in progesterone leads to expression or pro-labour genes

Answer 39

a) CRH (corticotrophin-releasing hormone) and PAF (platelet activating factor) are thought to be involved in the initiation

The exact mechanism of labour initiation is not known, but CRH and PAF are both thought to be important in initiation. They lead to expression of the Nf-kB transcription factor, which is the crucial influencer of labour, and actuates a slew of pro-inflammatory genes which regulate labour.

Infection generally leads to premature labour because it stimulates an inflammatory response. Maintaining pregnancy is dependent on an anti-inflammatory environment, hence infection can lead to premature delivery. Progesterone is crucial in maintaining the anti-inflammatory environment within the uterus, but the level of progesterone does not decrease to trigger labour, although some sort of ‘functional withdrawal’ has been hypothesised (e.g. receptor antagonism).

Oxytocin is an important hormone released during labour which stimulates myometrial contraction of the uterus. It also stimulates ejection of milk from the breast, but does not stimulate milk synthesis, that is prolactin.

Question 40

List 3 advantages and 3 disadvantages of a MOCA (Montreal Cognitive Assessment)

Answer 40

Advantages:
• Covers a variety of domains of cognitive
function
• Brief to administer (10 mins)
• Validated in a range of populations
• Available in translated versions
• Widely used

Disadvantages:
• Education level will affect results
• Language level will affect results
• Floor and ceiling effects (i.e. lower and upper limits that the test is able to detect)
• Can be poorly administered
• Possibly practice/coaching effects

Question 41

List 4 things to consider when doing a cognitive assessment on the elderly

Answer 41

• Hearing and visual impairment may limit testing
• Physical problems may limit testing
• Most assume numeracy and literacy
• Most assume some basic cultural knowledge (e.g. dates of WW1)
• Depression can masquerade as dementia
• Not valid in acute illness
• Normal cognitive changes (slower processing
speed, slower reaction times) may affect
administration

Question 42

Give two symptoms of pre-eclampsia

Answer 42

Peripheral oedema (swelling)
Headache
Epigastric pain
Nausea or vomiting

In general, the symptoms of pre-eclampsia are vague and unhelpful, but regular blood pressure checks and urinanalysis are useful in detecting the characteristic hypertension and proteinuria.