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CPEN practice questions

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Question 1Cardiovascular

Which condition is the most common cause of bradycardia in a pediatric emergency patient?

  1. Hyperkalemia
  2. Increased intracranial pressure
  3. Hypoxia Correct answer.
  4. Hypothermia

Explanation

In children, bradycardia is usually a consequence of hypoxia and respiratory failure rather than a primary conduction problem. Airway and ventilation take priority, and the heart rate typically improves once oxygenation and ventilation are restored. A primary cardiac cause should be considered only after hypoxia is corrected.

Question 2Cardiovascular

What is the recommended intravenous dose of epinephrine for a child in cardiac arrest?

  1. 0.01 mg/kg of 1:10,000 Correct answer.
  2. 0.1 mg/kg of 1:10,000
  3. 0.05 mg/kg of 1:10,000
  4. 0.01 mg/kg of 1:1,000

Explanation

The cardiac arrest dose is 0.01 mg/kg (0.1 mL/kg) of the 1:10,000 concentration, repeated every 3 to 5 minutes. Giving the more concentrated 1:1,000 solution at the same volume would deliver a tenfold overdose.

Question 3Cardiovascular

What is the initial defibrillation energy dose for a child in ventricular fibrillation?

  1. 4 J/kg
  2. 2 J/kg Correct answer.
  3. 0.5 J/kg
  4. 1 J/kg

Explanation

The first shock is delivered at 2 J/kg and subsequent shocks at 4 J/kg, with escalation up to 10 J/kg or the adult dose. An inadequate first energy dose lowers the chance of terminating ventricular fibrillation.

Question 4Cardiovascular

Which treatment most reduces the risk of coronary artery aneurysms in a child with Kawasaki disease?

  1. Prophylactic broad-spectrum antibiotics until afebrile
  2. Subcutaneous low-molecular-weight heparin for six weeks
  3. Oral corticosteroids as single-drug therapy with aspirin
  4. Intravenous immune globulin plus high-dose aspirin Correct answer.

Explanation

Intravenous immune globulin given within the first 10 days of illness, together with high-dose aspirin, reduces the incidence of coronary artery abnormalities. Once the child is afebrile, aspirin is usually decreased to low-dose antiplatelet therapy.

Question 5Cardiovascular

Which position should be used first for an infant experiencing a hypercyanotic spell?

  1. Knee-chest position Correct answer.
  2. Supine with legs extended
  3. Left lateral decubitus position
  4. Trendelenburg position

Explanation

Knee-chest positioning raises systemic vascular resistance, which decreases the right-to-left shunt and improves pulmonary blood flow. Calm handling, supplemental oxygen, and morphine are added if the spell does not resolve.

Question 6Cardiovascular

Which finding is the earliest and most common sign of heart failure in an infant?

  1. Sinus bradycardia at rest
  2. Poor feeding and tachypnea Correct answer.
  3. Jugular venous distension
  4. Bilateral peripheral edema

Explanation

Infants rarely develop dependent edema or visible neck vein distension; they instead show tachypnea, poor feeding, and poor weight gain. Feeding is the equivalent of exercise for an infant, so prolonged feeds with respiratory distress are a key early sign.

Question 7Cardiovascular

A 6-year-old with supraventricular tachycardia at 240 beats/min remains alert with adequate perfusion after vagal maneuvers fail, and an IV is in place. Which medication order is correct?

  1. Amiodarone 5 mg/kg IV infused over 20 minutes
  2. Adenosine 0.1 mg/kg given as a slow IV push over 2 minutes
  3. Adenosine 0.1 mg/kg rapid IV push with immediate flush Correct answer.
  4. Synchronized cardioversion at 2 J/kg

Explanation

Adenosine must be pushed rapidly and followed immediately by a saline flush because its half-life is only seconds; a slow push allows metabolism before the drug reaches the AV node. The initial dose is 0.1 mg/kg (maximum 6 mg), with a second dose of 0.2 mg/kg (maximum 12 mg).

Question 8Cardiovascular

A 3-day-old has profound cyanosis and is suspected of having a ductal-dependent congenital heart lesion. Which order should the nurse anticipate?

  1. Administering 100% oxygen as the primary treatment
  2. Beginning a high-dose epinephrine infusion
  3. Starting a prostaglandin E1 infusion Correct answer.
  4. Withholding all feedings and giving a fluid bolus

Explanation

Prostaglandin E1 keeps the ductus arteriosus open so blood can reach the lungs or the systemic circulation in ductal-dependent lesions. Because apnea is a common adverse effect, the infant needs close monitoring with airway equipment available.

Question 9Cardiovascular

A newborn's critical congenital heart disease screen shows an SpO2 of 92% in the right hand and 88% in the right foot. What is the appropriate interpretation?

  1. Document the result as normal because both values exceed 85%
  2. It is a positive screen requiring further evaluation Correct answer.
  3. Discharge home with follow-up in one week
  4. Repeat the screening test in 24 hours

Explanation

A saturation below 90% in either the right hand or the foot is an immediate positive screen, and the infant needs prompt clinical assessment and echocardiography. Repeating the screen or discharging the infant delays diagnosis of a critical lesion.

Question 10Cardiovascular

Which laboratory value is most important to monitor in a child with suspected digoxin toxicity?

  1. Serum potassium Correct answer.
  2. Serum chloride
  3. Serum calcium
  4. Serum magnesium

Explanation

Hyperkalemia reflects the degree of sodium-potassium pump blockade and correlates with the severity of digoxin toxicity. A serum digoxin level and renal function are also obtained, but the potassium value drives immediate management decisions.

Question 11Cardiovascular

An adolescent has a blood pressure of 150/90 mmHg in the right arm and 100/60 mmHg in the right leg. Which diagnosis best explains this difference?

  1. Coarctation of the aorta Correct answer.
  2. Tricuspid atresia
  3. Patent ductus arteriosus
  4. Aortic valve regurgitation

Explanation

Coarctation narrows the aortic arch distal to the vessels supplying the head and arms, producing upper extremity hypertension and lower extremity hypotension with weak femoral pulses. Four-limb blood pressures and pulse comparison are essential screening steps.

Question 12Cardiovascular

Five days after cardiac surgery, a child has muffled heart sounds, hypotension, and distended neck veins. What is the priority action?

  1. Obtain a chest radiograph before intervening
  2. Place the child in the Trendelenburg position
  3. Administer a 20 mL/kg normal saline bolus
  4. Prepare for emergent pericardiocentesis Correct answer.

Explanation

These findings indicate cardiac tamponade, which is a clinical diagnosis requiring urgent drainage of pericardial fluid. Fluid boluses are only a temporizing measure and must not delay pericardiocentesis in a decompensating child.

Question 13Cardiovascular

Which finding counts as a major Jones criteria manifestation of acute rheumatic fever?

  1. Erythema marginatum Correct answer.
  2. Arthralgia without arthritis
  3. Elevated erythrocyte sedimentation rate
  4. Fever

Explanation

The major manifestations are carditis, polyarthritis, chorea, erythema marginatum, and subcutaneous nodules. Fever, arthralgia, elevated inflammatory markers, and a prolonged PR interval are minor manifestations used only in combination with evidence of streptococcal infection.

Question 14Cardiovascular

A 15-year-old collapsed during a basketball game. The ECG shows left ventricular hypertrophy with strain, and an uncle died suddenly at age 20. What is the most appropriate recommendation?

  1. Clear the athlete for play once the ECG normalizes
  2. Encourage aggressive hydration before each game
  3. Restrict from competitive sports pending evaluation Correct answer.
  4. Prescribe a stimulant for presumed vasovagal syncope

Explanation

Exertional syncope with left ventricular hypertrophy and a family history of sudden death suggests hypertrophic cardiomyopathy, and restriction from competitive athletics reduces the risk of sudden cardiac death. Evaluation includes echocardiography, ECG screening of family members, and cardiology consultation.

Question 15Cardiovascular

Which finding most suggests supraventricular tachycardia rather than sinus tachycardia in an infant?

  1. Rate of 190 beats/min in a febrile infant
  2. Presence of a P wave before every QRS complex
  3. Heart rate that varies with handling and feeding
  4. Abrupt onset of a fixed rate of 260 beats/min Correct answer.

Explanation

Supraventricular tachycardia typically starts and stops abruptly and holds a fixed rate above the expected maximum for age, often above 220 beats/min in infants. Sinus tachycardia varies with activity, usually stays below 220 minus age, and has an identifiable cause such as fever or dehydration.

Question 16Cardiovascular

Which child most clearly needs antibiotic prophylaxis before a dental procedure?

  1. A child with a repaired atrial septal defect and no residual defect
  2. A child with a prosthetic mitral valve Correct answer.
  3. A child with mitral valve prolapse and no regurgitation
  4. A child with an innocent murmur

Explanation

Prophylaxis is recommended for the highest-risk groups, including children with prosthetic valves or prosthetic material used for valve repair, a history of infective endocarditis, certain unrepaired cyanotic lesions, and repaired lesions with residual defects. Innocent murmurs and fully repaired lesions without residual defects do not require prophylaxis.

Question 17Cardiovascular

Which assessment finding best indicates that a modified Blalock-Taussig shunt is providing adequate pulmonary blood flow in an infant?

  1. A continuous shunt murmur Correct answer.
  2. Absence of any cardiac murmur
  3. Oxygen saturation of 100% on room air
  4. Bounding peripheral pulses

Explanation

A continuous murmur over the shunt reflects flow throughout the cardiac cycle and is the most reliable bedside sign of shunt patency. A disappearing murmur in a cyanotic infant suggests shunt obstruction and requires immediate escalation.

Question 18Cardiovascular

A 10-year-old had syncope while swimming, and the ECG shows a QTc of 520 ms. Which statement is most accurate?

  1. Sports restriction and avoidance of QT-prolonging drugs are recommended Correct answer.
  2. Beta-blockers are contraindicated in congenital long QT syndrome
  3. The QT interval must be corrected for heart rate using Bazett's formula before interpretation
  4. Syncope while swimming in a child is usually benign and needs no workup

Explanation

A QTc above 460 to 480 ms combined with exertional or swimming syncope supports congenital long QT syndrome, and management includes beta-blockers, avoidance of QT-prolonging medications, and restriction from competitive sports. Family screening and cardiology referral are also indicated.

Question 19Cardiovascular

A 12-year-old has three days of fever and vomiting, chest pain, a troponin of 8 ng/mL, diffuse ST elevation, and normal coronary arteries with reduced ventricular function on echocardiography. Which diagnosis is most likely?

  1. Hypertrophic cardiomyopathy
  2. Acute myocardial infarction from Kawasaki disease
  3. Pericarditis with cardiac tamponade
  4. Acute viral myocarditis Correct answer.

Explanation

Fever, gastrointestinal symptoms, markedly elevated troponin, and diffuse ST changes with globally reduced function and normal coronary arteries point to myocarditis. Children with myocarditis are at risk for arrhythmias and cardiogenic shock and need continuous monitoring.

Question 20Cardiovascular

A child with myocarditis is in cardiogenic shock with a blood pressure of 78/50 mmHg, cool extremities, and hepatomegaly. Which management approach is most appropriate?

  1. Immediate synchronized cardioversion at 2 J/kg
  2. Two rapid 20 mL/kg normal saline boluses
  3. Inotropic support with cautious fluid administration Correct answer.
  4. Placement in the Trendelenburg position

Explanation

In cardiogenic shock the ventricle is failing, so large fluid boluses can precipitate pulmonary edema; treatment centers on inotropes or inodilators such as milrinone or epinephrine with small, carefully titrated fluid volumes. Early cardiology involvement and mechanical circulatory support may be needed.

Question 21Respiratory

Which virus is the most common cause of bronchiolitis in infants?

  1. Human rhinovirus
  2. Adenovirus
  3. Respiratory syncytial virus Correct answer.
  4. Parainfluenza virus type 1

Explanation

RSV infects nearly all children by age 2 and causes the large majority of bronchiolitis cases seen in emergency care. Rhinovirus and adenovirus usually produce upper respiratory symptoms, and parainfluenza type 1 is the classic cause of croup rather than bronchiolitis.

Question 22Respiratory

Which medication is first-line pharmacologic therapy for a child with croup?

  1. Nebulized hypertonic saline
  2. Oral dexamethasone Correct answer.
  3. Oral amoxicillin
  4. Nebulized albuterol

Explanation

A single dose of dexamethasone reduces subglottic edema and the need for further interventions in croup. Bronchodilators such as albuterol act on the lower airways and do not relieve laryngeal edema, and antibiotics have no role in this viral illness.

Question 23Respiratory

Which finding in a child with respiratory distress is most concerning for impending respiratory failure?

  1. Falling respiratory rate with lethargy Correct answer.
  2. Nasal flaring with mild tachypnea
  3. Audible expiratory wheezing on auscultation
  4. Moderate subcostal retractions

Explanation

A declining respiratory rate in a child who is becoming lethargic signals exhaustion and inadequate minute ventilation, which precedes arrest. Flaring, retractions, and wheezing are compensatory signs of increased work of breathing that can persist while the child is still moving air.

Question 24Respiratory

A 4-year-old has high fever, drooling, a muffled voice, and sits tripod with the neck extended. Which action is the priority?

  1. Place the child supine to start an IV
  2. Keep the child calm and prepare for airway control Correct answer.
  3. Obtain a throat swab for culture
  4. Inspect the posterior pharynx with a tongue blade

Explanation

Suspected epiglottitis can progress to complete obstruction at any moment, so the child is kept in a position of comfort and the airway is secured in a controlled setting with anesthesia and ENT available. Instrumenting the pharynx can precipitate laryngospasm and total obstruction.

Question 25Respiratory

A 2-year-old had a sudden coughing fit while eating peanuts and now has a unilateral wheeze. Which diagnosis is most likely?

  1. Foreign body aspiration Correct answer.
  2. Exercise-induced asthma
  3. Bacterial pneumonia
  4. Viral bronchiolitis

Explanation

An abrupt choking episode in a toddler followed by a persistent unilateral wheeze is the classic presentation of an aspirated foreign body lodged in a mainstem bronchus. Bronchiolitis, asthma, and pneumonia produce diffuse or bilateral findings and lack the sudden choking onset.

Question 26Respiratory

Which medication is used as a rapid reliever for acute asthma symptoms in children?

  1. Inhaled fluticasone
  2. Nebulized albuterol Correct answer.
  3. Inhaled salmeterol
  4. Oral montelukast

Explanation

Short-acting beta-2 agonists such as albuterol relax bronchial smooth muscle within minutes and are the cornerstone of rescue therapy for acute asthma. Inhaled corticosteroids, montelukast, and salmeterol are controller medications that do not relieve acute bronchospasm.

Question 27Respiratory

For a previously healthy 5-month-old with RSV bronchiolitis, which intervention improves outcomes?

  1. Systemic corticosteroids for 5 days
  2. Chest physiotherapy twice daily
  3. Oxygen for hypoxemia plus hydration support Correct answer.
  4. Nebulized albuterol every 4 hours

Explanation

Bronchiolitis is a self-limited viral illness, and management is supportive: oxygen for hypoxemia and maintenance of hydration. Bronchodilators, corticosteroids, chest physiotherapy, and antibiotics have not been shown to shorten the course in previously healthy infants.

Question 28Respiratory

Which infant is the best candidate for palivizumab prophylaxis during RSV season?

  1. A 3-year-old with a repaired atrial septal defect
  2. A 4-month-old born at 28 weeks' gestation Correct answer.
  3. An 18-month-old with mild intermittent asthma
  4. A full-term 4-month-old with a mild cold

Explanation

Palivizumab is recommended as RSV prophylaxis for infants born before 29 weeks' gestation during their first RSV season, along with certain other high-risk infants. Term infants, older children, and children with repaired acyanotic lesions do not meet criteria.

Question 29Respiratory

A 5-year-old with two days of croup-like symptoms now has a high fever, toxic appearance, and thick purulent tracheal secretions; nebulized epinephrine gives only brief relief. Which diagnosis fits best?

  1. Epiglottitis
  2. Spasmodic croup
  3. Retropharyngeal abscess
  4. Bacterial tracheitis Correct answer.

Explanation

Bacterial tracheitis produces a croup-like illness that becomes toxic and febrile with thick purulent secretions, and it responds poorly to nebulized epinephrine because obstruction comes from secretions and mucosal swelling in the trachea. Croup is viral and low-grade, epiglottitis causes drooling and dysphagia without a croupy cough, and a retropharyngeal abscess causes neck stiffness and dysphagia.

Question 30Respiratory

A child with asthma suddenly develops severe distress, absent right-sided breath sounds, tracheal deviation to the left, and hypotension. What is the immediate action?

  1. Perform needle decompression of the right chest Correct answer.
  2. Give a second dose of nebulized albuterol
  3. Perform pericardiocentesis
  4. Obtain a portable chest radiograph

Explanation

Tension pneumothorax is a clinical diagnosis: sudden deterioration, absent breath sounds on the affected side, tracheal deviation away from that side, and hypotension. Immediate needle decompression followed by tube thoracostomy is required, and waiting for imaging risks cardiac arrest.

Question 31Respiratory

A child with a tracheostomy has increasing respiratory distress and no air movement through the tube; suctioning does not help. What is the next action?

  1. Insert an oropharyngeal airway and begin bag-mask ventilation
  2. Give nebulized racemic epinephrine
  3. Remove the tube and ventilate through the stoma Correct answer.
  4. Perform chest compressions immediately

Explanation

When suctioning does not restore airflow, the tube is assumed to be obstructed or dislodged and must be removed so the child can be ventilated through the stoma or by bag-mask. Chest compressions and nebulized medications do not relieve a mechanical obstruction of the tube.

Question 32Respiratory

A 9-year-old with severe asthma has received repeated albuterol, ipratropium, and IV corticosteroids but remains in distress with a peak flow of 40% predicted. Which adjunct is most appropriate?

  1. Nebulized normal saline
  2. Oral montelukast
  3. IV furosemide
  4. IV magnesium sulfate Correct answer.

Explanation

Intravenous magnesium sulfate is recommended as an adjunct for children with severe asthma who fail to respond to inhaled beta-agonists, ipratropium, and systemic corticosteroids. Montelukast, saline, and diuretics do not produce bronchodilation in acute severe asthma.

Question 33Respiratory

Which oxygen delivery device provides a precise, set FiO2 regardless of the child's inspiratory effort?

  1. Venturi mask Correct answer.
  2. Nasal cannula
  3. Simple face mask
  4. Nonrebreather mask

Explanation

An air-entrainment (Venturi) mask mixes oxygen with room air at a fixed ratio, delivering a precise FiO2 even when the child's inspiratory flow varies. Simple masks, nasal cannulas, and nonrebreather masks deliver a variable FiO2 that depends on the patient's breathing pattern.

Question 34Respiratory

Which presentation is most characteristic of pertussis in a 3-month-old infant?

  1. Barking cough with inspiratory stridor at rest
  2. Paroxysms of cough followed by vomiting Correct answer.
  3. Sudden onset of unilateral wheezing
  4. High fever with drooling and tripoding

Explanation

Pertussis in young infants classically causes paroxysms of cough ending in a whoop or post-tussive emesis, and infants under 6 months may have no whoop and instead present with apnea. A barking cough suggests croup, unilateral wheezing suggests a foreign body, and drooling with high fever suggests epiglottitis.

Question 35Respiratory

Which organism is the most common bacterial cause of community-acquired pneumonia in children beyond the newborn period?

  1. Streptococcus pneumoniae Correct answer.
  2. Staphylococcus aureus
  3. Group A Streptococcus
  4. Mycoplasma pneumoniae

Explanation

Streptococcus pneumoniae remains the most common bacterial pathogen of community-acquired pneumonia in children. Mycoplasma is common in school-aged children but is classified as an atypical pathogen, and staphylococcal and group A streptococcal pneumonias are less frequent.

Question 36Respiratory

Which technique reduces the risk of hypoxia when suctioning a child with an artificial airway?

  1. Instilling 2 mL of saline before each pass
  2. Applying suction while inserting the catheter
  3. Preoxygenate and limit each pass to 10 seconds Correct answer.
  4. Suctioning continuously for 15 to 20 seconds per pass

Explanation

Preoxygenating with 100% oxygen and limiting each suction pass to about 10 seconds minimizes the hypoxemia and vagally mediated bradycardia that suctioning can cause. Prolonged suction, saline instillation, and suctioning during insertion all increase mucosal trauma and hypoxia.

Question 37Respiratory

A child rescued from a house fire is confused but has an SpO2 of 99% on room air. Which statement best explains this finding?

  1. Methemoglobinemia falsely elevates the oximeter reading
  2. Anemia causes pulse oximetry to read falsely high
  3. Carboxyhemoglobin is read as oxyhemoglobin Correct answer.
  4. Oximetry measures dissolved oxygen rather than saturation

Explanation

Standard two-wavelength pulse oximeters cannot distinguish carboxyhemoglobin from oxyhemoglobin, so the displayed saturation appears normal despite severely impaired oxygen delivery. Diagnosis requires co-oximetry, and treatment is 100% oxygen with consideration of hyperbaric therapy.

Question 38Respiratory

A 7-year-old in severe asthma distress has a PaCO2 of 40 mmHg with a pH of 7.35. How should this be interpreted?

  1. Concerning for impending respiratory failure Correct answer.
  2. Reassuring; ventilation is normal
  3. Expected response to albuterol therapy
  4. Evidence of a metabolic alkalosis

Explanation

A child with acute severe asthma hyperventilates, so the PaCO2 should be low; a normal or rising value means the child can no longer sustain the increased work of breathing and is tiring toward respiratory failure. Such a value is not reassuring and is not produced by albuterol or by a metabolic alkalosis.

Question 39Respiratory

Which infant with bronchiolitis is at greatest risk of apnea?

  1. A 14-month-old with a febrile seizure history
  2. A 10-month-old born at term
  3. An 8-month-old with eczema
  4. A 6-week-old born at 34 weeks' gestation Correct answer.

Explanation

Apnea is the presenting symptom of bronchiolitis mainly in infants younger than 2 months and in those born prematurely, whose respiratory control is immature. Older term infants typically present with rhinorrhea, cough, wheeze, and increased work of breathing rather than apnea.

Question 40Respiratory

Which intervention is most important to prevent acute chest syndrome in a hospitalized child with sickle cell disease and chest pain?

  1. Routine supplemental oxygen for all children
  2. Restricting intravenous fluids to half maintenance
  3. Hourly incentive spirometry while awake Correct answer.
  4. Strict bed rest until the fever resolves

Explanation

Incentive spirometry performed at least hourly while awake, along with adequate analgesia, hydration, and prompt antibiotics, reduces atelectasis and progression to acute chest syndrome. Bed rest, routine oxygen in the absence of hypoxemia, and fluid restriction do not prevent atelectasis and may worsen outcomes.

Question 41Neurological

Which medication class should be given first to a child who is in status epilepticus?

  1. A barbiturate such as phenobarbital
  2. A benzodiazepine such as lorazepam Correct answer.
  3. A hydantoin such as fosphenytoin
  4. A pyrrolidine such as levetiracetam

Explanation

Benzodiazepines work rapidly by enhancing GABA-mediated inhibition and are the first-line therapy for status epilepticus; lorazepam 0.1 mg/kg IV (max 4 mg) or midazolam 0.2 mg/kg IM when there is no IV access is standard. Second-line agents are added only if seizures persist.

Question 42Neurological

Which transmission-based precautions are required for a child admitted with suspected meningococcal meningitis?

  1. Contact precautions
  2. Standard precautions only
  3. Droplet precautions Correct answer.
  4. Airborne precautions

Explanation

Neisseria meningitidis spreads through large respiratory droplets, so droplet precautions are required until at least 24 hours of effective antibiotic therapy have been completed. Standard precautions alone are not sufficient during that window.

Question 43Neurological

Which finding in an infant most suggests raised intracranial pressure?

  1. A sunken fontanel accompanied by dry mucous membranes and tachycardia
  2. Mild hair loss over the temporal region with normal tone
  3. Increased urine output with normal developmental milestones
  4. A bulging fontanel with downward deviation of the eyes Correct answer.

Explanation

In an infant with an open fontanel, raised intracranial pressure produces a tense, bulging fontanel and 'sunset' eyes from downward gaze deviation; irritability, vomiting, and rapid head growth are other clues. Dehydration produces the opposite fontanel finding.

Question 44Neurological

Febrile seizures are defined as seizures with fever occurring within which age range?

  1. Birth to 6 months
  2. 3 years to 12 years
  3. 6 months to 3 years
  4. 6 months to 5 years Correct answer.

Explanation

A febrile seizure occurs between 6 months and 5 years of age in a child with fever but without central nervous system infection or a prior afebrile seizure. Seizures with fever outside this window warrant evaluation for other causes.

Question 45Neurological

A child arrives actively convulsing. Which action should the nurse take first?

  1. Obtain a full set of vital signs before intervening
  2. Restrain the arms and legs to stop the movements
  3. Turn the child to the side and protect the head Correct answer.
  4. Insert an oral airway between the teeth

Explanation

During a convulsion the priorities are airway protection and injury prevention: turn the child to the side, clear the area, pad the head, and time the event. Nothing should be placed in the mouth, and restraint does not stop seizure activity.

Question 46Neurological

Which description is characteristic of a simple febrile seizure?

  1. Focal onset with postictal hemiparesis
  2. Generalized, lasting under 15 minutes, once in 24 hours Correct answer.
  3. Duration of 20 minutes with two events in 24 hours
  4. Occurs only in a child with a known seizure disorder

Explanation

A simple febrile seizure is generalized, lasts less than 15 minutes, and occurs only once in 24 hours in a neurologically normal child. Focal features, a duration over 15 minutes, or recurrence within 24 hours define a complex febrile seizure.

Question 47Neurological

A 20-kg child with an IV in place is in status epilepticus. Which lorazepam order is correct?

  1. Lorazepam 20 mg IV (1 mg/kg)
  2. Lorazepam 2 mg IV (0.1 mg/kg) Correct answer.
  3. Lorazepam 10 mg IV (0.5 mg/kg)
  4. Lorazepam 0.2 mg IV (0.01 mg/kg)

Explanation

The standard first benzodiazepine dose is lorazepam 0.1 mg/kg IV, with a maximum of 4 mg per dose, so a 20-kg child receives 2 mg; the dose may be repeated once. When IV access is unavailable, midazolam 0.2 mg/kg intramuscularly is used.

Question 48Neurological

Which finding is a contraindication to immediate lumbar puncture in a child with suspected bacterial meningitis?

  1. A new focal neurologic deficit with unequal pupils Correct answer.
  2. A positive Brudzinski sign elicited during the examination
  3. An age of 4 years with no other medical problems
  4. A temperature of 39.2°C (102.6°F) recorded in the emergency department

Explanation

Lumbar puncture is deferred when there are signs of raised intracranial pressure or impending herniation, such as a focal deficit, unequal pupils, or a deteriorating level of consciousness, because of the risk of herniation. Blood cultures and empiric antibiotics are started without delay.

Question 49Neurological

The parent of a child with confirmed meningococcal meningitis asks how household members can be protected. Which statement is correct?

  1. Household contacts should receive chemoprophylaxis with rifampin or ciprofloxacin Correct answer.
  2. Only children younger than 5 years in the household need prophylaxis
  3. All visitors should receive the meningococcal conjugate vaccine before contact
  4. Prophylaxis is not needed if the child has received antibiotics for 12 hours

Explanation

Close contacts, including all household members, should receive chemoprophylaxis with rifampin, ciprofloxacin, or ceftriaxone as soon as possible, ideally within 24 hours of the diagnosis. Prophylaxis eradicates nasopharyngeal carriage and prevents secondary cases.

Question 50Neurological

An 8-year-old struck his head, was briefly unconscious, awoke and spoke normally, then within an hour became drowsy with a dilated right pupil. Which injury does this pattern suggest?

  1. Simple concussion
  2. Subdural hematoma
  3. Diffuse axonal injury
  4. Epidural hematoma Correct answer.

Explanation

A brief loss of consciousness followed by a lucid interval and then rapid decline with an ipsilateral dilated pupil is characteristic of an epidural hematoma, usually from a middle meningeal artery tear. It is a neurosurgical emergency requiring urgent decompression.