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ABP Pediatric Hospital Medicine study materials
ABP Pediatric Hospital Medicine study resources

ABP Pediatric Hospital Medicine practice questions

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Question 1Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 4-year-old with acute asthma exacerbation has received three albuterol nebulizer treatments and systemic corticosteroids. On reassessment, respiratory rate is 44/min, there is suprasternal retraction, accessory muscle use, and oxygen saturation is 89% on room air. What is the most appropriate next step in management?

  1. Obtain a chest radiograph before any further respiratory therapy
  2. Begin continuous inhaled beta-agonist therapy and supplemental oxygen Correct answer.
  3. Administer a dose of oral montelukast and reassess in one hour
  4. Discharge home with an oral corticosteroid course and albuterol inhaler

Explanation

Persistent hypoxemia with marked retractions after initial beta-agonist and steroid therapy indicates a severe exacerbation requiring continuous inhaled bronchodilators and oxygen while preparing for possible escalation. Chest imaging is reserved for suspected complications such as pneumonia or pneumothorax and should not delay bronchodilator therapy.

Question 2Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

Which finding is most characteristic of a simple febrile seizure in a child aged 6 months to 5 years?

  1. Focal clonic activity confined to one limb
  2. Generalized tonic-clonic activity lasting less than 15 minutes Correct answer.
  3. Persistent postictal hemiparesis lasting several hours
  4. Seizure recurrence within 24 hours of the first event

Explanation

A simple febrile seizure is generalized, lasts under 15 minutes, and occurs once in a 24-hour period in a neurologically normal child. Focal features, prolonged duration, recurrence within 24 hours, or postictal focal deficits define complex febrile seizures.

Question 3Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 3-week-old infant presents with projectile nonbilious emesis after feeds, a palpable olive-shaped mass in the right upper abdomen, and hypochloremic hypokalemic metabolic alkalosis. Which diagnosis is most likely?

  1. Hypertrophic pyloric stenosis Correct answer.
  2. Malrotation with midgut volvulus
  3. Congenital adrenal hyperplasia
  4. Gastroesophageal reflux disease

Explanation

Projectile nonbilious vomiting in a 3- to 6-week-old with a palpable olive and hypochloremic hypokalemic metabolic alkalosis is the classic presentation of hypertrophic pyloric stenosis. Bilious emesis would raise concern for malrotation and volvulus.

Question 4Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 10-month-old is admitted with acute gastroenteritis and moderate dehydration. After initial fluid resuscitation, which maintenance fluid composition is most appropriate for a child with normal electrolytes?

  1. 0.225% sodium chloride with dextrose
  2. Isotonic crystalloid with added potassium chloride Correct answer.
  3. 5% dextrose in water alone
  4. Ringer's lactate without dextrose

Explanation

Maintenance intravenous fluids for children should be isotonic with appropriate potassium supplementation once urine output is established, avoiding hypotonic fluids that risk hyponatremia. Dextrose-containing isotonic fluid is commonly used to prevent ketosis and hypoglycemia.

Question 5Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 6-year-old with nephrotic syndrome is admitted with periorbital and lower extremity edema. Which laboratory finding is most consistent with minimal change disease?

  1. Elevated creatinine with red blood cell casts
  2. Low C3 with elevated antistreptolysin O titer
  3. Selective proteinuria with normal complement levels Correct answer.
  4. Positive antinuclear antibody with low C4

Explanation

Minimal change disease, the most common cause of childhood nephrotic syndrome, produces selective proteinuria with normal complement levels. Low complement suggests postinfectious glomerulonephritis or a complement-mediated process, and red cell casts suggest nephritic syndrome.

Question 6Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

Which pathogen is the most common cause of bacterial meningitis in a fully immunized 18-month-old child in the United States?

  1. Haemophilus influenzae type b
  2. Streptococcus pneumoniae Correct answer.
  3. Listeria monocytogenes
  4. Neisseria meningitidis

Explanation

With widespread conjugate vaccination, Streptococcus pneumoniae remains the leading cause of bacterial meningitis beyond the neonatal period. Listeria is a neonatal and immunocompromised pathogen, and Haemophilus influenzae type b is now rare due to vaccination.

Question 7Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 5-year-old presents with fever, sore throat, and a diffuse sandpaper-like rash with circumoral pallor. Throat culture confirms group A Streptococcus. Which finding most increases the risk of acute rheumatic fever?

  1. Age younger than 3 years
  2. Presence of a scarlatiniform rash
  3. Untreated pharyngitis lasting more than a week Correct answer.
  4. Concurrent viral upper respiratory infection

Explanation

Acute rheumatic fever follows untreated or inadequately treated group A streptococcal pharyngitis, and prompt antibiotic therapy within about 9 days prevents it. The rash of scarlet fever does not itself increase rheumatic fever risk, and children under 3 rarely develop rheumatic fever.

Question 8Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 2-year-old is admitted with a barking cough, inspiratory stridor at rest, and mild subcostal retractions. Which intervention is the most appropriate initial treatment?

  1. Nebulized albuterol
  2. Racemic epinephrine alone
  3. Dexamethasone with nebulized epinephrine Correct answer.
  4. Oral antibiotics and cool mist

Explanation

Croup with stridor at rest and retractions is moderate disease, treated with systemic corticosteroids plus nebulized epinephrine for rapid symptom relief. Antibiotics are not indicated for viral croup, and albuterol does not treat upper airway edema.

Question 9Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 7-year-old with sickle cell disease presents with fever of 39.0°C. Which action is most appropriate?

  1. Give acetaminophen and reassess in 4 hours
  2. Obtain blood cultures and begin empiric intravenous antibiotics promptly Correct answer.
  3. Discharge home with oral antibiotics after a single dose
  4. Obtain a chest radiograph and await results before antibiotics

Explanation

Children with sickle cell disease and fever are at high risk for overwhelming bacterial sepsis, particularly from encapsulated organisms, and require prompt cultures and empiric parenteral antibiotics. Antibiotics should not be delayed for imaging or observation.

Question 10Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

Which clinical feature most reliably distinguishes bronchiolitis from asthma in a 6-month-old infant?

  1. Personal history of atopy with recurrent wheeze
  2. Sudden onset of symptoms after allergen exposure
  3. Diffuse wheezing preceded by several days of rhinorrhea and low-grade fever Correct answer.
  4. Marked improvement after bronchodilator therapy

Explanation

Bronchiolitis in infants typically presents with a prodrome of coryza and low-grade fever followed by wheezing and crackles, and it does not respond reliably to bronchodilators. Asthma is less common in early infancy and often shows bronchodilator responsiveness and atopic history.

Question 11Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 3-day-old term newborn is jaundiced with a total serum bilirubin of 18 mg/dL and is breastfeeding poorly. Which is the most important immediate step?

  1. Obtain a liver biopsy
  2. Initiate phototherapy and evaluate for hemolysis Correct answer.
  3. Reassure the family that jaundice is normal at this age
  4. Discontinue breastfeeding and switch to formula

Explanation

A bilirubin of 18 mg/dL at 72 hours exceeds typical thresholds and requires treatment with phototherapy plus evaluation for hemolytic causes. Breastfeeding should generally be supported rather than stopped, and liver biopsy is not indicated acutely.

Question 12Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 12-year-old with type 1 diabetes presents with vomiting, abdominal pain, and Kussmaul respirations. Blood glucose is 480 mg/dL, pH is 7.12, and bicarbonate is 10 mEq/L. After initial isotonic fluid resuscitation, what is the next priority?

  1. Restrict fluids until the glucose normalizes
  2. Give a bolus of sodium bicarbonate
  3. Begin an insulin infusion with frequent electrolyte monitoring Correct answer.
  4. Administer subcutaneous long-acting insulin alone

Explanation

Diabetic ketoacidosis is treated with isotonic fluid resuscitation followed by a continuous insulin infusion and careful monitoring of potassium, glucose, and acid-base status. Bicarbonate is rarely indicated and can worsen outcomes, and fluid restriction is harmful.

Question 13Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

Which finding is most consistent with a diagnosis of Kawasaki disease in a 3-year-old with 5 days of fever?

  1. Bilateral nonexudative conjunctival injection with cracked lips Correct answer.
  2. Petechiae on the lower extremities with thrombocytopenia
  3. Purulent pharyngeal exudate with tender cervical adenopathy
  4. Vesicular rash in a dermatomal distribution

Explanation

Kawasaki disease is a clinical diagnosis requiring fever plus characteristic mucocutaneous findings, including bilateral nonexudative conjunctivitis, oral mucosal changes, rash, extremity changes, and cervical lymphadenopathy. Purulent exudates suggest streptococcal infection, and petechiae suggest another process.

Question 14Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 9-year-old is admitted with a first episode of acute hematogenous osteomyelitis of the tibia. Which organism is most likely?

  1. Staphylococcus aureus Correct answer.
  2. Salmonella species
  3. Mycoplasma pneumoniae
  4. Neisseria gonorrhoeae

Explanation

Staphylococcus aureus is the most common cause of acute hematogenous osteomyelitis in children beyond the neonatal period. Salmonella is associated with sickle cell disease, and gonococcus causes septic arthritis in sexually active adolescents.

Question 15Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

An 8-year-old is admitted with new-onset generalized edema, hypertension, and cola-colored urine two weeks after a sore throat. Which laboratory pattern is expected?

  1. Normal C3 with massive proteinuria
  2. Low C3 with elevated antistreptolysin O titer Correct answer.
  3. Elevated C3 with low antistreptolysin O titer
  4. Low C4 with positive antinuclear antibody

Explanation

Poststreptococcal glomerulonephritis presents with nephritic syndrome after a streptococcal infection and shows low C3 that normalizes over weeks, along with elevated streptococcal antibodies. Low C4 with positive ANA suggests lupus nephritis.

Question 16Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 15-year-old with anorexia nervosa is admitted with a body mass index of 14 kg/m² and bradycardia. Which complication is most important to monitor for during nutritional rehabilitation?

  1. Refeeding syndrome with hypophosphatemia Correct answer.
  2. Diabetic ketoacidosis
  3. Hypernatremic dehydration
  4. Hyperthyroidism

Explanation

Refeeding syndrome occurs when nutrition is reintroduced too rapidly in severely malnourished patients, causing hypophosphatemia, hypokalemia, and hypomagnesemia. Careful caloric advancement and electrolyte monitoring are essential.

Question 17Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

Which of the following best describes the appropriate use of a sepsis screening tool in a hospitalized child with a suspected infection?

  1. It is used solely to determine intensive care admission
  2. It confirms sepsis only when lactate is elevated
  3. It triggers prompt evaluation and early antibiotics when positive Correct answer.
  4. It replaces clinical judgment in diagnosing sepsis

Explanation

Sepsis screening tools are designed to prompt timely evaluation and initiation of antibiotics when positive, but they do not replace clinical assessment. Lactate supports but is not required to diagnose sepsis, and screening is not limited to ICU triage decisions.

Question 18Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 2-year-old is admitted after a witnessed ingestion of an unknown amount of acetaminophen. Four hours after ingestion, which test is most appropriate to assess hepatotoxicity risk?

  1. Urine drug screen
  2. Abdominal ultrasound
  3. Serum acetaminophen level plotted on the Rumack-Matthew nomogram Correct answer.
  4. Serum amylase and lipase

Explanation

A serum acetaminophen level obtained at least 4 hours after ingestion is plotted on the Rumack-Matthew nomogram to guide N-acetylcysteine therapy. Urine drug screens and imaging do not assess acetaminophen hepatotoxicity risk.

Question 19Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 4-year-old with a ventriculoperitoneal shunt presents with headache, vomiting, and lethargy. Which initial evaluation is most appropriate?

  1. Lumbar puncture before imaging
  2. Reassurance and outpatient follow-up
  3. Oral antibiotics for presumed otitis media
  4. Urgent neuroimaging and shunt evaluation Correct answer.

Explanation

Shunt malfunction or infection must be evaluated urgently with neuroimaging and shunt assessment, often including cerebrospinal fluid sampling from the shunt. Lumbar puncture before imaging risks herniation if there is elevated intracranial pressure.

Question 20Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 6-week-old presents with poor feeding, irritability, and a temperature of 38.3°C. Which management approach is most appropriate?

  1. Full sepsis evaluation with empiric intravenous antibiotics and admission Correct answer.
  2. Antipyretic therapy with reassessment in the emergency department in 6 hours
  3. Observation at home with a scheduled recheck in 24 hours
  4. Urinalysis alone with discharge if negative

Explanation

Febrile infants younger than 2 to 3 months require a comprehensive sepsis evaluation, including blood, urine, and cerebrospinal fluid studies, with empiric antibiotics and admission. Outpatient observation is not appropriate at this age.

Question 21Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

Which statement about the management of acute severe bronchiolitis in a previously healthy infant is most accurate?

  1. Supportive care with oxygen and hydration is the mainstay Correct answer.
  2. Chest physiotherapy reduces length of stay
  3. Routine systemic corticosteroids shorten hospitalization
  4. Nebulized hypertonic saline is recommended for all infants

Explanation

Bronchiolitis management is primarily supportive, with oxygen and hydration as needed. Corticosteroids, routine hypertonic saline, and chest physiotherapy have not been shown to improve outcomes in uncomplicated cases.

Question 22Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 13-year-old is admitted with community-acquired pneumonia and a parapneumonic effusion. Which finding most suggests the effusion requires drainage?

  1. Presence of a mild cough
  2. Small free-flowing fluid with a depth of 5 mm
  3. Loculated fluid with septations on imaging Correct answer.
  4. Clear fluid with few white blood cells

Explanation

Loculated or septated pleural fluid suggests complicated parapneumonic effusion or empyema and typically requires drainage, often with fibrinolytics. Small simple effusions without evidence of infection may be managed with antibiotics alone.

Question 23Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 5-year-old with acute lymphoblastic leukemia in remission is admitted with fever and neutropenia. Which principle best guides initial antibiotic selection?

  1. Withhold antibiotics until cultures are positive
  2. Narrow-spectrum oral antibiotics alone
  3. Empiric broad-spectrum coverage including antipseudomonal activity Correct answer.
  4. Antifungal monotherapy as initial therapy

Explanation

Febrile neutropenia requires prompt empiric broad-spectrum intravenous antibiotics with antipseudomonal coverage because of the high risk of rapid deterioration from bacterial sepsis. Therapy is narrowed once cultures identify an organism.

Question 24Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 10-year-old is admitted with a severe asthma exacerbation and requires intravenous magnesium sulfate. What is the mechanism of action of magnesium in this setting?

  1. Direct inhibition of mast cell histamine release
  2. Smooth muscle relaxation of the airways Correct answer.
  3. Beta-2 receptor agonism
  4. Reduction of airway mucus viscosity

Explanation

Magnesium sulfate promotes bronchial smooth muscle relaxation and is used as an adjunct in severe asthma exacerbations. It does not act as a beta-agonist or primarily reduce mucus viscosity.

Question 25Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

Which electrolyte abnormality is most likely in a child with severe acute malnutrition admitted for rehabilitation?

  1. Hyperphosphatemia and hyperkalemia
  2. Hypokalemia and hypomagnesemia Correct answer.
  3. Hypernatremia and hypercalcemia
  4. Hyperkalemia and hypermagnesemia

Explanation

Severe malnutrition depletes total body potassium and magnesium, and refeeding can further lower serum levels. Monitoring and supplementation are essential to prevent refeeding syndrome complications.

Question 26Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 4-year-old is admitted with dehydration from acute gastroenteritis. Which intravenous fluid bolus is most appropriate for initial resuscitation of a child with shock from hypovolemia?

  1. 10 mL/kg of 5% dextrose in water given over 10 minutes
  2. 5 mL/kg of isotonic crystalloid given over 1 hour
  3. 20 mL/kg of isotonic crystalloid given over 5 to 20 minutes Correct answer.
  4. 50 mL/kg of hypotonic saline given over 30 minutes

Explanation

Pediatric hypovolemic shock is initially treated with an isotonic crystalloid bolus of 20 mL/kg, repeated as needed based on reassessment. Hypotonic and dextrose-containing fluids do not expand the intravascular volume effectively and can worsen hyponatremia.

Question 27Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 6-year-old is admitted with a 3-day history of profuse watery diarrhea and is estimated to be 8% dehydrated but remains alert with normal blood pressure. Which rehydration strategy is most appropriate?

  1. Enteral rehydration with frequent small volumes of oral rehydration solution Correct answer.
  2. Withholding all fluids until stool output stops
  3. Rapid 60 mL/kg bolus of isotonic fluid before any oral intake
  4. Immediate total parenteral nutrition until diarrhea resolves

Explanation

For mild to moderate dehydration in an alert child, enteral rehydration with oral rehydration solution is first-line and as effective as intravenous therapy. Intravenous fluids are reserved for severe dehydration, shock, or inability to tolerate enteral intake.

Question 28Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 10-month-old is admitted with acute bronchiolitis and requires supplemental oxygen. Which parameter is the most appropriate target for oxygen saturation monitoring in this infant?

  1. Maintain SpO2 above 99%
  2. Maintain SpO2 above 90% Correct answer.
  3. Maintain SpO2 above 85%
  4. Maintain SpO2 above 97%

Explanation

Current guidance supports a target oxygen saturation above 90% in infants with bronchiolitis, since higher targets confer no benefit and prolong hospitalization. Weaning oxygen once saturations are consistently above 90% is standard practice.

Question 29Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 7-year-old is admitted with an acute asthma exacerbation. Which finding on reassessment best indicates that the exacerbation is severe rather than mild?

  1. Pulsus paradoxus with silent chest and accessory muscle use Correct answer.
  2. Mild end-expiratory wheeze with good air entry
  3. Speaks in full sentences and has a normal respiratory rate
  4. Oxygen saturation of 96% on room air

Explanation

Severe asthma exacerbations are marked by inability to speak normally, accessory muscle use, pulsus paradoxus, and diminished air entry up to a silent chest. A silent chest reflects critically low airflow and is an ominous sign.

Question 30Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 3-year-old is admitted with suspected bacterial pneumonia. Which finding on physical examination is most suggestive of a consolidated lobar pneumonia?

  1. Tympanitic percussion with absent breath sounds
  2. Bilateral high-pitched expiratory wheezing
  3. Dullness to percussion with increased tactile fremitus and bronchial breath sounds Correct answer.
  4. Hyperresonance to percussion with decreased tactile fremitus

Explanation

Consolidation transmits sound better through the lung, producing dullness to percussion, increased tactile fremitus, and bronchial breath sounds over the affected lobe. Air trapping and effusion produce the opposite findings.

Question 31Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 2-year-old admitted with pneumonia develops increasing respiratory distress and a new oxygen requirement on day 3. Which next step is most appropriate when a parapneumonic effusion is suspected?

  1. Start high-dose inhaled corticosteroids
  2. Obtain a chest radiograph or lung ultrasound and consider thoracentesis Correct answer.
  3. Discontinue antibiotics and observe for 24 hours
  4. Begin a trial of nebulized albuterol every 2 hours

Explanation

A new or worsening effusion in a child with pneumonia should be confirmed with imaging, and diagnostic thoracentesis is indicated when the effusion is large or the child is toxic. Fluid analysis guides drainage and duration of therapy.

Question 32Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 5-year-old is admitted with acute bacterial sinusitis that has failed two courses of appropriate oral antibiotics. Which factor most strongly supports the decision to obtain imaging before escalation of therapy?

  1. Household exposure to a sibling with a cold
  2. Low-grade fever at the time of presentation
  3. Presence of purulent nasal discharge for 12 days
  4. Worsening symptoms despite adequate antibiotic therapy Correct answer.

Explanation

Uncomplicated acute bacterial sinusitis is a clinical diagnosis and does not require imaging. Imaging is reserved for severe or complicated disease, treatment failure, or suspected extension such as orbital or intracranial involvement.

Question 33Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 4-year-old is admitted with acute otitis media complicated by mastoiditis. Which finding most strongly suggests that the infection has extended beyond the mastoid?

  1. Bulging, erythematous tympanic membrane
  2. Serous middle ear effusion
  3. Ear pain relieved by acetaminophen
  4. Protruding auricle with postauricular swelling and fluctuance Correct answer.

Explanation

Mastoiditis is suggested by postauricular swelling, erythema, tenderness, and protrusion of the auricle. Fluctuance or abscess formation indicates subperiosteal extension and often requires surgical drainage in addition to antibiotics.

Question 34Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 12-year-old is admitted with acute pyelonephritis. Which clinical feature is most consistent with upper rather than lower urinary tract infection?

  1. High fever with flank pain and costovertebral angle tenderness Correct answer.
  2. Dysuria with urinary frequency
  3. Malodorous urine without systemic symptoms
  4. Suprapubic discomfort relieved by voiding

Explanation

Upper urinary tract infection is characterized by systemic signs such as fever, chills, flank pain, and costovertebral angle tenderness. Lower tract infection produces dysuria, frequency, and suprapubic discomfort without fever.

Question 35Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 6-year-old is admitted with acute glomerulonephritis and hypertension. Which additional finding would most increase concern for a hypertensive emergency requiring urgent treatment?

  1. Trace pedal edema
  2. Mild periorbital puffiness on awakening
  3. Headache with altered mental status and seizures Correct answer.
  4. Blood pressure at the 90th percentile for age

Explanation

Hypertensive emergency is defined by severe blood pressure elevation with evidence of end-organ injury such as encephalopathy, seizures, or heart failure. These findings require controlled blood pressure reduction in a monitored setting.

Question 36Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 9-year-old is admitted with acute rheumatic fever following a recent streptococcal pharyngitis. Which finding is a major Jones criterion for the diagnosis?

  1. Fever of 38.5°C
  2. Elevated antistreptolysin O titer
  3. Erythema marginatum Correct answer.
  4. First-degree heart block

Explanation

Major Jones criteria include carditis, polyarthritis, chorea, erythema marginatum, and subcutaneous nodules. Fever, elevated streptococcal titers, and first-degree heart block are supporting or minor findings.

Question 37Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 14-year-old is admitted with syncope during exercise. Which finding most strongly suggests a cardiac cause rather than a benign vasovagal mechanism?

  1. Syncope while standing in a hot shower with nausea beforehand
  2. Syncope after prolonged standing with pallor and sweating
  3. Syncope occurring during exertion with no prodrome Correct answer.
  4. Syncope while fasting with a preceding feeling of warmth

Explanation

Syncope during exertion or without prodrome raises concern for a cardiac arrhythmia or structural heart disease and warrants cardiac evaluation. Vasovagal syncope typically has a prodrome and occurs with provoking situations such as heat or prolonged standing.

Question 38Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 3-year-old is admitted for a febrile seizure that lasted 3 minutes and resolved spontaneously. Which feature would classify the event as a complex febrile seizure?

  1. Lasted 3 minutes
  2. Focal onset with postictal weakness Correct answer.
  3. Occurred at an age of 3 years
  4. Associated with a temperature of 39°C

Explanation

Complex febrile seizures are defined by focal features, duration longer than 15 minutes, or recurrence within 24 hours. Age, brief duration, and fever magnitude are typical of simple febrile seizures.

Question 39Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 10-year-old with new-onset seizures is admitted for evaluation. Which finding on history most suggests a structural or space-occupying cause that would require urgent neuroimaging?

  1. A sibling with a history of febrile seizures
  2. A seizure occurring with a mild febrile illness
  3. A single generalized seizure with full recovery
  4. A focal seizure with new focal neurologic deficit Correct answer.

Explanation

Focal seizure activity with a new focal neurologic deficit suggests a structural lesion, stroke, or mass and warrants urgent imaging. Uncomplicated generalized seizures with full recovery generally do not require emergent imaging.

Question 40Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 5-year-old is admitted with bacterial meningitis and is being treated with dexamethasone. What is the primary rationale for adjunctive dexamethasone in this setting?

  1. To eradicate the causative organism more rapidly
  2. To reduce meningeal inflammation and hearing loss Correct answer.
  3. To reduce the risk of syndrome of inappropriate antidiuretic hormone
  4. To prevent seizures during the first 24 hours

Explanation

Adjunctive dexamethasone reduces meningeal inflammation and has been shown to decrease hearing loss and neurologic sequelae, particularly with pneumococcal disease. It is given with or just before the first antibiotic dose and does not sterilize the cerebrospinal fluid.

Question 41Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 2-day-old term newborn is admitted with jaundice. Which finding would most strongly suggest pathologic rather than physiologic jaundice?

  1. Jaundice present within the first 24 hours of life Correct answer.
  2. Total bilirubin rising less than 5 mg/dL per day
  3. Jaundice appearing on day 3 of life
  4. Peak bilirubin of 10 mg/dL at 72 hours

Explanation

Jaundice present within the first 24 hours of life is always pathologic and requires urgent evaluation for hemolysis, infection, or metabolic disease. Physiologic jaundice appears after 24 hours and peaks around days 3 to 5.

Question 42Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 3-week-old is admitted with projectile nonbilious vomiting and a palpable olive-shaped mass. Which metabolic abnormality is most likely to be found on laboratory evaluation?

  1. Hyperkalemia with metabolic acidosis
  2. Hyperglycemia with ketosis
  3. Hypernatremia with metabolic acidosis
  4. Hypochloremic hypokalemic metabolic alkalosis Correct answer.

Explanation

Pyloric stenosis causes recurrent vomiting of gastric contents, leading to loss of hydrogen and chloride and a hypochloremic, hypokalemic metabolic alkalosis. Volume repletion and electrolyte correction precede surgical pyloromyotomy.

Question 43Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 4-year-old is admitted with acute appendicitis. Which finding on presentation most suggests that the appendix has already perforated?

  1. Periumbilical pain that migrates to the right lower quadrant
  2. Fever with localized right lower quadrant tenderness
  3. Anorexia with low-grade fever
  4. Sudden relief of pain followed by diffuse abdominal pain and rigidity Correct answer.

Explanation

Perforation is suggested by a transient relief of pain followed by generalized peritonitis with diffuse tenderness and rigidity. This change reflects spillage of purulent contents into the peritoneal cavity.

Question 44Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 6-month-old is admitted with severe acute malnutrition. Which complication should be monitored for during the initial stabilization phase of management?

  1. Hypernatremic dehydration from overfeeding
  2. Hypercalcemia from vitamin D supplementation
  3. Refeeding syndrome with hypophosphatemia Correct answer.
  4. Hyperglycemia from high-calorie feeds

Explanation

Refeeding syndrome occurs when nutrition is reintroduced too rapidly, causing shifts of phosphate, potassium, and magnesium into cells. Monitoring electrolytes and advancing calories cautiously prevents this complication.

Question 45Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 12-year-old is admitted with diabetic ketoacidosis. Which principle best guides intravenous fluid and insulin management in the first hours of therapy?

  1. Withhold insulin until the glucose normalizes
  2. Give bicarbonate routinely to correct acidosis
  3. Give a large insulin bolus immediately and restrict fluids
  4. Begin fluid resuscitation first and start an insulin infusion after initial volume repletion Correct answer.

Explanation

Fluid resuscitation precedes insulin therapy in pediatric diabetic ketoacidosis to restore perfusion and reduce the risk of cerebral edema. Insulin infusion is started after initial volume repletion and continued until ketoacidosis resolves.

Question 46Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 15-year-old is admitted with anorexia nervosa and severe malnutrition. Which finding indicates that the patient requires continuous cardiac monitoring?

  1. Sinus bradycardia with a heart rate of 48 beats per minute Correct answer.
  2. Heart rate of 90 beats per minute
  3. Blood pressure of 110/70 mm Hg
  4. Temperature of 36.8°C

Explanation

Severe bradycardia in anorexia nervosa reflects increased vagal tone and reduced myocardial mass and is associated with arrhythmia risk. Continuous monitoring is indicated for marked bradycardia, hypotension, or electrolyte abnormalities.

Question 47Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 7-year-old is admitted with a suspected central line-associated bloodstream infection. Which action is most appropriate when obtaining blood cultures from a central venous catheter?

  1. Draw cultures only after antibiotics are started
  2. Draw cultures from the central line only
  3. Draw paired cultures from the central line and a peripheral site Correct answer.
  4. Draw a single culture from a peripheral site

Explanation

Paired central and peripheral cultures allow calculation of differential time to positivity, which helps distinguish catheter-related infection from contamination or another source. Cultures should be obtained before antibiotics whenever possible.

Question 48Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 9-year-old is admitted with a fever and a new petechial rash. Which laboratory finding most strongly suggests a consumptive coagulopathy rather than isolated thrombocytopenia?

  1. Elevated erythrocyte sedimentation rate
  2. Prolonged prothrombin time, elevated D-dimer, and low fibrinogen Correct answer.
  3. Isolated anemia with normal platelets
  4. Platelet count of 40,000/µL with normal coagulation studies

Explanation

Disseminated intravascular coagulation produces prolonged clotting times, elevated fibrin degradation products such as D-dimer, and low fibrinogen due to consumption. Isolated thrombocytopenia with normal coagulation studies suggests immune thrombocytopenia instead.

Question 49Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 5-year-old with sickle cell disease is admitted with acute chest syndrome. Which intervention is most important in the initial management?

  1. Immediate exchange transfusion for all patients
  2. Aggressive hydration with hypotonic fluids
  3. Strict bed rest with no incentive spirometry
  4. Supplemental oxygen with incentive spirometry and prompt antibiotics Correct answer.

Explanation

Initial management of acute chest syndrome includes oxygen, incentive spirometry to prevent atelectasis, antibiotics, and pain control. Simple or exchange transfusion is reserved for severe or worsening cases.

Question 50Pediatric Hospital Medicine Content (official subspecialty content outline domains not enumerated in source)

A 13-year-old is admitted with a suspected opioid overdose and has a depressed respiratory rate. Which medication is the appropriate first-line antidote?

  1. Flumazenil
  2. Naloxone Correct answer.
  3. N-acetylcysteine
  4. Glucagon

Explanation

Naloxone is a competitive opioid receptor antagonist that rapidly reverses opioid-induced respiratory depression. It should be given promptly while supporting airway and ventilation.