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CPNP-AC practice questions

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Question 1Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

Which resting heart rate is most consistent with a normal, awake 6-month-old infant?

  1. 130 beats/min Correct answer.
  2. 50 beats/min
  3. 190 beats/min
  4. 70 beats/min

Explanation

Expected awake heart rate in infancy is roughly 100 to 160 beats/min, so 130 beats/min falls within the normal range. Rates well below 100 suggest bradycardia and rates above 180 to 200 suggest a tachyarrhythmia or high-output state. Interpretation always requires correlating with temperature, activity, and perfusion.

Question 2Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

An infant with bronchiolitis has an expiratory grunt. What does this finding most likely represent?

  1. Mild inflammation of the upper airway
  2. A normal finding in a sleeping infant
  3. Retained secretions in the oropharynx
  4. Effort to keep alveoli open Correct answer.

Explanation

Grunting is generated by partial glottic closure at end-expiration, which creates positive end-expiratory pressure and helps preserve functional residual capacity and alveolar recruitment. It is a sign of increased work of breathing and small-airway or alveolar disease, not a benign finding.

Question 3Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

Which finding best supports a diagnosis of moderate dehydration in a 2-year-old with gastroenteritis?

  1. Serum bicarbonate level of 24 mEq/L
  2. Capillary refill of 3 seconds Correct answer.
  3. Moist mucous membranes
  4. Urine output of 2 mL/kg/hr

Explanation

Capillary refill normally occurs within 2 seconds; a delay to 3 seconds indicates reduced peripheral perfusion consistent with moderate dehydration. Moist membranes and normal urine output argue against significant volume depletion. Bicarbonate of 24 mEq/L is normal and does not reflect dehydration.

Question 4Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 20-kg child is being treated for anaphylaxis. What is the appropriate intramuscular epinephrine dose?

  1. 0.02 mg/kg of 1:10,000 intravenously
  2. 0.1 mg/kg of 1:1000 subcutaneously
  3. 0.2 mg of 1:1000 intramuscularly Correct answer.
  4. 0.5 mg of 1:10,000 intravenously

Explanation

Intramuscular epinephrine for anaphylaxis is dosed at 0.01 mg/kg of the 1:1000 concentration, giving 0.2 mg for a 20-kg child with a maximum of 0.5 mg. The anterolateral thigh is the preferred site because absorption is most reliable there. Intravenous dosing uses a dilute concentration and is reserved for refractory cases with monitoring.

Question 5Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

Which set of vital signs is most consistent with Cushing triad in a child with rising intracranial pressure?

  1. Hypotension with bradycardia and hypothermia
  2. Hypertension with tachycardia and unexplained hyperthermia
  3. Hypotension with tachycardia and shallow tachypnea
  4. Hypertension, bradycardia, irregular respirations Correct answer.

Explanation

Cushing triad consists of systolic hypertension with widened pulse pressure, bradycardia, and irregular respirations resulting from brainstem compression. It is a late and ominous sign of raised intracranial pressure. Hypotension or tachycardia points instead toward shock.

Question 6Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 13-year-old presents 2 hours after sudden onset of severe left scrotal pain with a high-riding testis and an absent cremasteric reflex. What is the most appropriate next step?

  1. Prescribe antibiotics for epididymitis and recheck in 24 hours
  2. Emergent urology consultation for surgical exploration Correct answer.
  3. Obtain a scrotal ultrasound before any intervention
  4. Apply ice and arrange outpatient follow-up in 1 week

Explanation

Sudden severe pain with a high-riding testis and absent cremasteric reflex is torsion until proven otherwise, and salvage depends on detorsion within roughly 6 hours. Imaging must not delay surgery when the clinical picture is convincing. Emergent surgical exploration allows detorsion and orchiopexy.

Question 7Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 3-year-old treated for acute otitis media for 5 days now has postauricular swelling, tenderness, and protrusion of the pinna. What is the most likely diagnosis?

  1. Simple persistent otitis media
  2. Peritonsillar abscess
  3. Otitis externa
  4. Acute mastoiditis Correct answer.

Explanation

Postauricular erythema, swelling, and pinna protrusion in a child with recent otitis media indicate acute mastoiditis, a suppurative complication of the middle ear. Evaluation typically includes imaging and intravenous antibiotics, with possible drainage. Otitis externa affects the canal and produces pain with pinna traction rather than postauricular swelling.

Question 8Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 7-year-old in status asthmaticus continues to wheeze despite three albuterol nebulizers. Which combination is the most appropriate first-line escalation?

  1. Inhaled ipratropium with systemic corticosteroids Correct answer.
  2. Intravenous furosemide and fluid restriction
  3. Subcutaneous epinephrine plus oral prednisolone therapy
  4. Oral amoxicillin and a chest radiograph

Explanation

For severe exacerbations not responding to repeated beta-agonists, guidelines recommend adding inhaled ipratropium and giving systemic corticosteroids early while continuing albuterol. This combination reduces hospitalization and improves airflow. Antibiotics and diuretics have no role in bronchospasm.

Question 9Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 4-year-old has fever, neck stiffness, and a petechial rash. Which finding should most strongly delay lumbar puncture?

  1. Temperature of 39.5 degrees Celsius
  2. Vomiting twice in the emergency department
  3. New-onset focal seizure with papilledema Correct answer.
  4. Heart rate of 130 beats/min

Explanation

Focal neurologic deficits, papilledema, or seizures at presentation raise concern for raised intracranial pressure and herniation with lumbar puncture. In that situation blood cultures and empiric antibiotics are given first, and imaging is considered before cerebrospinal fluid sampling. Fever, tachycardia, and vomiting alone do not contraindicate the procedure.

Question 10Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 25-kg child has a generalized tonic-clonic seizure that has lasted 7 minutes, and intravenous access is available. What is the most appropriate initial medication?

  1. Fosphenytoin 20 mg PE/kg IV
  2. Levetiracetam 60 mg/kg IV
  3. Lorazepam 0.1 mg/kg IV Correct answer.
  4. Phenytoin 20 mg/kg IV

Explanation

A seizure lasting beyond 5 minutes meets the definition of status epilepticus, and a benzodiazepine is the first-line agent. Lorazepam at 0.1 mg/kg IV (2.5 mg for this child) is standard. Second-line agents are given only after adequate benzodiazepine dosing.

Question 11Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 10-kg child in septic shock shows no signs of fluid overload. What is the most appropriate initial fluid resuscitation?

  1. 5 mL/kg of packed red blood cells over 1 hour
  2. 200 mL of 5% dextrose in water as a bolus
  3. Maintenance fluids only, with no bolus
  4. 200 mL of 0.9% sodium chloride as a bolus Correct answer.

Explanation

Initial resuscitation of pediatric septic shock uses isotonic crystalloid at 20 mL/kg, which equals 200 mL for a 10-kg child, given rapidly and reassessed after each bolus. Dextrose-containing solutions are not resuscitation fluids because they distribute quickly and can cause hyponatremia. Blood products are reserved for hemorrhage or specific indications.

Question 12Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 10-month-old has episodic inconsolable crying with drawing up of the legs, and a sausage-shaped abdominal mass is palpated. What is the most appropriate next step?

  1. Barium swallow study
  2. Ultrasound then air enema reduction Correct answer.
  3. Exploratory laparotomy
  4. Abdominal computed tomography with intravenous contrast

Explanation

The presentation is classic for ileocolic intussusception, and ultrasound confirms the target or pseudokidney sign before fluoroscopically or air-guided enema reduction, which is both diagnostic and therapeutic. Surgery is reserved for perforation, peritonitis, or failed reduction. Radiation-sparing ultrasound is preferred in a stable infant.

Question 13Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 3-day-old has cyanosis, a single second heart sound, and an oxygen saturation of 70% that does not improve with supplemental oxygen. Which intervention is most appropriate while awaiting echocardiography?

  1. Intravenous ceftriaxone
  2. Intravenous prostaglandin E1 infusion Correct answer.
  3. Oral furosemide
  4. High-flow nasal cannula oxygen at 2 L/kg/min

Explanation

Cyanosis with a single second heart sound and oxygen-unresponsive hypoxemia suggests a ductal-dependent cyanotic congenital heart lesion. Prostaglandin E1 maintains ductal patency and preserves pulmonary or systemic blood flow until definitive imaging and intervention. Supplemental oxygen does not correct the intracardiac right-to-left shunt.

Question 14Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

Which feature most strongly favors epiglottitis over viral croup?

  1. Barking cough
  2. Drooling and a muffled voice Correct answer.
  3. Gradual onset over 2 to 3 days
  4. Hoarse voice with inspiratory stridor

Explanation

Epiglottitis produces a toxic-appearing child with drooling, a muffled or hot-potato voice, and rapidly progressive airway obstruction. Croup is characterized by a barking cough, hoarseness, and a more gradual prodrome. The airway should not be instrumented until personnel and equipment for emergency intubation are available.

Question 15Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 4-year-old opens his eyes to pain, withdraws from pain, and speaks inappropriate words. What is his Glasgow Coma Scale score?

  1. 6
  2. 11
  3. 9 Correct answer.
  4. 7

Explanation

Eye opening to pain scores 2, withdrawal from pain scores 4 on the motor scale, and inappropriate words score 3 on the verbal scale, totaling 9. Scores are assigned using the pediatric verbal scale appropriate for age. A total of 8 or less generally prompts airway protection considerations.

Question 16Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 3-year-old meets clinical criteria for Kawasaki disease on day 6 of fever. Which treatment most reduces the risk of coronary artery aneurysms?

  1. Oral amoxicillin for 10 days
  2. Intravenous immune globulin with aspirin Correct answer.
  3. Intravenous methylprednisolone as the only therapy
  4. High-dose aspirin alone

Explanation

Intravenous immune globulin given within the first 10 days of illness, together with aspirin, reduces the incidence of coronary artery aneurysms. Corticosteroids may be added for refractory disease but are not first-line monotherapy. Antibiotics have no role because the process is a vasculitis.

Question 17Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

Which combination of findings best distinguishes minimal change nephrotic syndrome from acute glomerulonephritis in a 5-year-old?

  1. Elevated antistreptolysin O titer
  2. Hypertension with periorbital edema
  3. Hematuria with red blood cell casts
  4. Hypoalbuminemia with heavy proteinuria Correct answer.

Explanation

Nephrotic syndrome is defined by heavy proteinuria and hypoalbuminemia, producing edema and often hyperlipidemia without significant hematuria. Glomerulonephritis presents with hematuria, red cell casts, hypertension, and evidence of recent streptococcal infection. The two syndromes can overlap but are distinguished by the degree of protein loss.

Question 18Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 3-month-old who cannot yet roll over has a spiral femur fracture without a plausible reported mechanism. Which action is most appropriate?

  1. Report to child protective services and complete a skeletal survey Correct answer.
  2. Apply a spica cast and arrange an orthopedic visit in one week
  3. Discharge with routine pediatric follow-up
  4. Obtain genetic testing for osteogenesis imperfecta as the sole workup

Explanation

A femur fracture in a non-ambulatory infant without a credible mechanism is a classic marker of inflicted injury and requires a report to child protective services plus a skeletal survey to identify occult fractures. Medical evaluation and treatment of the fracture continue concurrently. Discharge without evaluation places the infant at risk for further harm.

Question 19Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

Which finding best identifies compensated rather than decompensated shock in a 6-year-old?

  1. Altered mental status with anuria lasting more than 6 hours
  2. Bradycardia with absent peripheral pulses and mottled skin
  3. Systolic blood pressure below the fifth percentile for age
  4. Tachycardia with delayed refill but normal blood pressure Correct answer.

Explanation

Children maintain blood pressure through tachycardia and vasoconstriction, so compensated shock shows delayed capillary refill with a normal blood pressure. Hypotension is a late finding that signals decompensation. Mental status change and anuria indicate end-organ hypoperfusion.

Question 20Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 2-year-old has sudden-onset cough and unilateral wheezing after eating peanuts. He is alert and moving air well. What is the most appropriate next step?

  1. Arrange urgent rigid bronchoscopy Correct answer.
  2. Begin abdominal thrusts immediately
  3. Obtain a chest radiograph before any airway evaluation
  4. Perform blind finger sweeps of the oropharynx

Explanation

A witnessed choking event with unilateral wheezing indicates an aspirated foreign body in a stable child, and prompt bronchoscopic removal is indicated to prevent obstruction and inflammation. Blind finger sweeps and thrusts are reserved for complete obstruction or visible objects in the mouth. Imaging does not replace a convincing history.

Question 21Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 6-day-old has repeated bilious vomiting and a mildly distended abdomen. Which diagnostic study is most definitive for the suspected diagnosis?

  1. Upper gastrointestinal contrast series Correct answer.
  2. Serum electrolytes and a blood gas
  3. Plain abdominal radiograph
  4. Abdominal ultrasonography with Doppler of the mesenteric vessels

Explanation

Bilious vomiting in a neonate raises concern for malrotation with midgut volvulus, and an upper gastrointestinal contrast series is the definitive study, showing an abnormally positioned duodenojejunal junction or a corkscrew duodenum. Surgery should be consulted urgently because volvulus can cause bowel necrosis. Laboratory studies assess severity but do not establish the diagnosis.

Question 22Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 4-year-old with acute kidney injury has a potassium of 7.2 mEq/L. Which electrocardiographic finding is of most immediate concern?

  1. Prominent U waves
  2. Widened QRS complex Correct answer.
  3. Prolonged QT interval
  4. Sinus tachycardia at 130 beats/min

Explanation

Hyperkalemia progresses from peaked T waves to QRS widening, which indicates slowing of ventricular conduction and impending sine-wave arrest. QRS widening warrants immediate calcium administration to stabilize the myocardium along with potassium-lowering therapy. QT prolongation and U waves suggest hypokalemia or hypocalcemia.

Question 23Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 3-year-old presents 5 hours after a single acetaminophen ingestion, and the serum concentration falls above the treatment line on the Rumack-Matthew nomogram. What is the most appropriate action?

  1. Begin N-acetylcysteine now Correct answer.
  2. Give activated charcoal and observe
  3. Repeat the level in 4 hours before treating
  4. Observe for 24 hours with serial liver enzymes

Explanation

A timed acetaminophen concentration at or above the treatment line indicates risk of hepatotoxicity, and N-acetylcysteine should be started promptly, ideally within 8 hours of ingestion. Waiting for a repeat level or for symptoms allows glutathione depletion to progress. Activated charcoal is most effective within 1 to 2 hours and does not substitute for the antidote.

Question 24Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 9-year-old with new-onset type 1 diabetes in diabetic ketoacidosis becomes lethargic 6 hours into treatment with headache and bradycardia. What is the most appropriate immediate management?

  1. Obtain a CT scan before any treatment
  2. Slow the fluids and give mannitol or 3% saline Correct answer.
  3. Administer a subcutaneous insulin bolus
  4. Give a 20 mL/kg bolus of 0.9% sodium chloride

Explanation

Lethargy, headache, and bradycardia during DKA treatment suggest cerebral edema, which is a clinical diagnosis requiring immediate reduction of the fluid rate and hyperosmolar therapy with mannitol or hypertonic saline. Additional isotonic boluses worsen cerebral edema. Imaging must not delay treatment.

Question 25Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 20-kg child has partial-thickness burns over 30% of total body surface area. Using the Parkland formula, what volume should be given in the first 8 hours from the time of injury?

  1. 4800 mL
  2. 600 mL
  3. 1200 mL Correct answer.
  4. 2400 mL

Explanation

The Parkland formula calculates 4 mL/kg per percent total body surface area over 24 hours, which is 2400 mL for this child, with half given in the first 8 hours from the time of injury, or 1200 mL. The clock starts at the moment of injury, so prehospital time is subtracted. Children also require maintenance fluids in addition to resuscitation.

Question 26Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 2-year-old is breathing comfortably at rest during a well-child visit. Which respiratory rate is most appropriate to document as normal for age?

  1. 12 breaths/min
  2. 20 breaths/min Correct answer.
  3. 44 breaths/min
  4. 16 breaths/min

Explanation

Normal resting respiratory rate for a 2-year-old is approximately 20 to 28 breaths/min. Rates below 20 suggest hypoventilation, and 44 indicates significant tachypnea.

Question 27Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 6-year-old develops urticaria, wheezing, and hypotension minutes after eating peanuts. Which medication should be administered first?

  1. Oral diphenhydramine
  2. Intramuscular epinephrine Correct answer.
  3. Nebulized albuterol
  4. Intravenous methylprednisolone

Explanation

Intramuscular epinephrine is first-line therapy for anaphylaxis because it rapidly reverses vasodilation, mucosal edema, and bronchospasm. Antihistamines, bronchodilators, and corticosteroids are adjuncts and do not treat the acute airway and vascular compromise.

Question 28Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

Which finding in a 1-year-old with acute gastroenteritis best indicates severe dehydration?

  1. Capillary refill of 4 seconds Correct answer.
  2. Tears with crying
  3. Urine output of 1 mL/kg per hour
  4. Moist mucous membranes

Explanation

Severe dehydration is indicated by delayed capillary refill, lethargy, weak pulses, and markedly decreased urine output. Moist mucous membranes, tears, and normal urine output suggest mild or no dehydration.

Question 29Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

Which timing of jaundice in a newborn is considered pathologic and requires prompt evaluation?

  1. Within the first 24 hours of life Correct answer.
  2. At 4 days of life
  3. At 7 days of life
  4. At 36 hours of life

Explanation

Jaundice appearing within the first 24 hours of life is always pathologic and may reflect hemolysis, infection, or a metabolic disorder. Physiologic jaundice typically appears after 24 hours and peaks around days 3 to 5.

Question 30Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

Which medication is recommended for all children with croup, including those with mild disease?

  1. Dexamethasone Correct answer.
  2. Racemic epinephrine
  3. Amoxicillin
  4. Albuterol

Explanation

A single dose of dexamethasone reduces airway edema and the need for return visits in all children with croup, including mild cases. Racemic epinephrine is reserved for moderate to severe stridor, and antibiotics and albuterol are not routine treatment.

Question 31Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

Which finding is most characteristic of bronchiolitis in a 4-month-old infant?

  1. Inspiratory stridor with a barking cough
  2. Diffuse wheezing and fine crackles Correct answer.
  3. Focal lobar consolidation
  4. Unilateral decreased breath sounds

Explanation

Bronchiolitis typically produces diffuse wheezing and fine crackles from small-airway inflammation. Stridor and barking cough suggest croup, while focal or unilateral findings suggest pneumonia or a foreign body.

Question 32Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

Which febrile infant requires a full sepsis evaluation regardless of general appearance?

  1. A 2-year-old with a temperature of 38.5°C
  2. A 2-week-old with a temperature of 38.2°C Correct answer.
  3. A 2-month-old with a temperature of 38.0°C
  4. A 5-year-old with a temperature of 39.0°C

Explanation

Infants younger than 28 days with fever require a full sepsis evaluation, including blood, urine, and cerebrospinal fluid studies, regardless of how well they appear. Older infants and children may be risk-stratified based on age, appearance, and laboratory results.

Question 33Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 7-year-old falls from a swing and has a brief loss of consciousness. Which finding most strongly indicates the need for emergent head CT?

  1. A focal neurologic deficit on examination Correct answer.
  2. One episode of vomiting
  3. A scalp hematoma at the impact site
  4. A headache that improves with acetaminophen

Explanation

A focal neurologic deficit after head trauma is a high-risk feature that warrants emergent neuroimaging. A single vomiting episode, a responsive headache, or a scalp hematoma alone are lower-risk findings.

Question 34Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 6-week-old has projectile nonbilious vomiting and a palpable olive-shaped mass. Which laboratory pattern is most expected?

  1. Hypochloremic hypokalemic metabolic alkalosis Correct answer.
  2. High anion gap metabolic acidosis
  3. Respiratory alkalosis with hypochloremia
  4. Metabolic acidosis with hyperkalemia

Explanation

Pyloric stenosis causes loss of gastric hydrochloric acid and potassium, producing a hypochloremic, hypokalemic metabolic alkalosis. The vomiting is nonbilious because the obstruction is proximal to the ampulla of Vater.

Question 35Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 9-year-old with sickle cell disease has fever, chest pain, and a new pulmonary infiltrate. In addition to oxygen and analgesia, which management is most appropriate?

  1. Incentive spirometry alone
  2. Immediate exchange transfusion for all patients
  3. Broad-spectrum antibiotics and close monitoring Correct answer.
  4. Observation without antibiotics

Explanation

Acute chest syndrome is treated with oxygen, analgesia, incentive spirometry, and broad-spectrum antibiotics because infection and infarction often coexist. Transfusion is added for severe hypoxemia or clinical deterioration, not routinely for every patient.

Question 36Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 2-month-old has a heart rate of 260 beats/min, narrow QRS complexes, and poor feeding. Vagal maneuvers are unsuccessful. Which medication is most appropriate next?

  1. Adenosine Correct answer.
  2. Amiodarone
  3. Digoxin
  4. Synchronized cardioversion

Explanation

Adenosine is the first-line pharmacologic treatment for stable supraventricular tachycardia after failed vagal maneuvers. Synchronized cardioversion is used if the infant is unstable or adenosine fails.

Question 37Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

Which finding most strongly suggests a retropharyngeal abscess rather than a peritonsillar abscess in a child?

  1. Neck stiffness and reluctance to extend the neck Correct answer.
  2. Uvular deviation to one side
  3. Enlarged tonsils with exudate
  4. Trismus and a hot-potato voice

Explanation

Retropharyngeal abscess typically causes neck stiffness, pain on neck extension, and systemic toxicity, whereas peritonsillar abscess causes trismus, uvular deviation, and a hot-potato voice. Both can cause fever and sore throat.

Question 38Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

Which newborn is at highest risk for hypoglycemia?

  1. A breastfed infant at 6 hours of life
  2. A post-term infant with a birth weight of 3.5 kg
  3. A term appropriate-for-gestational-age infant
  4. An infant of a diabetic mother who is large for gestational age Correct answer.

Explanation

Infants of diabetic mothers have fetal hyperinsulinism, and those who are large for gestational age are at especially high risk for postnatal hypoglycemia. Appropriate-for-gestational-age term infants have lower risk.

Question 39Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 4-month-old with tetralogy of Fallot becomes deeply cyanotic and agitated. Which initial intervention is most appropriate?

  1. Start a prostaglandin E1 infusion
  2. Administer intravenous furosemide
  3. Place in knee-chest position and give oxygen Correct answer.
  4. Perform immediate synchronized cardioversion

Explanation

Hypercyanotic spells are managed initially with knee-chest positioning, oxygen, and calming measures to increase systemic vascular resistance and reduce right-to-left shunting. Fluid boluses and morphine may be added if needed.

Question 40Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

Which set of vital signs is most consistent with Cushing triad from raised intracranial pressure?

  1. Hypotension, tachycardia, and tachypnea
  2. Hypertension, tachycardia, and hyperthermia
  3. Hypertension, bradycardia, and irregular respirations Correct answer.
  4. Hypotension, bradycardia, and apnea

Explanation

Cushing triad consists of hypertension, bradycardia, and irregular respirations and indicates elevated intracranial pressure with brainstem compression. It is a late and ominous finding.

Question 41Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 15-year-old presents after a deliberate overdose of amitriptyline. The ECG shows a QRS duration of 120 ms. Which treatment is most appropriate?

  1. Intravenous sodium bicarbonate Correct answer.
  2. Intravenous flumazenil
  3. Oral activated charcoal
  4. Intravenous calcium gluconate

Explanation

A widened QRS after tricyclic antidepressant overdose reflects sodium channel blockade, and intravenous sodium bicarbonate is the treatment. It provides a sodium load and alkalinizes the serum to reverse cardiotoxicity.

Question 42Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 10-year-old has periumbilical pain that migrates to the right lower quadrant, anorexia, and low-grade fever. Which finding most supports acute appendicitis?

  1. Diffuse abdominal tenderness with hyperactive bowel sounds
  2. Bilious emesis with abdominal distention
  3. Pain relief after vomiting
  4. Pain migration with rebound tenderness at McBurney point Correct answer.

Explanation

Appendicitis classically begins with periumbilical visceral pain that migrates to the right lower quadrant as parietal peritoneal irritation develops, with rebound tenderness at McBurney point. Diffuse tenderness and bilious emesis suggest other processes such as gastroenteritis or obstruction.

Question 43Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 2-month-old has paroxysmal coughing spells followed by apnea and a whoop. Which diagnosis is most likely?

  1. Pertussis Correct answer.
  2. Croup
  3. Foreign body aspiration
  4. Bronchiolitis

Explanation

Pertussis in young infants causes paroxysmal cough, apnea, and a post-tussive whoop, and infants may not have fever. Bronchiolitis and croup produce different patterns of airway symptoms.

Question 44Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 4-year-old with gastroenteritis has a seizure and a serum sodium of 118 mEq/L. Which treatment is most appropriate initially?

  1. Oral rehydration with free water
  2. Rapid correction with 0.9% saline
  3. Fluid restriction alone
  4. 3% hypertonic saline to raise sodium by 4 to 6 mEq/L Correct answer.

Explanation

Symptomatic hyponatremia with seizures requires prompt correction with 3% hypertonic saline, typically raising serum sodium by 4 to 6 mEq/L to control symptoms. Correction should then proceed slowly to avoid osmotic demyelination.

Question 45Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 14-year-old has sudden severe unilateral pelvic pain, nausea, and vomiting. Which study is most appropriate to evaluate for ovarian torsion?

  1. Urinalysis and observation
  2. Pelvic ultrasound with Doppler Correct answer.
  3. Abdominal radiograph
  4. CT of the abdomen without contrast

Explanation

Pelvic ultrasound with Doppler is the preferred initial imaging study for suspected ovarian torsion because it assesses ovarian size, perfusion, and associated masses. Prompt surgical consultation is needed if torsion is suspected.

Question 46Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 3-week-old boy has poor feeding, vomiting, weight loss, hyponatremia, hyperkalemia, and hypotension. Which diagnosis is most likely?

  1. Urea cycle disorder
  2. Pyloric stenosis
  3. Congenital adrenal hyperplasia with salt wasting Correct answer.
  4. Diabetes insipidus

Explanation

Salt-wasting congenital adrenal hyperplasia presents in the first weeks of life with hyponatremia, hyperkalemia, hypotension, vomiting, and poor feeding, often in a male infant without ambiguous genitalia. The combined sodium and potassium abnormalities point to adrenal insufficiency.

Question 47Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 2-day-old breastfed infant develops lethargy, tachypnea, and vomiting. Ammonia is 450 µmol/L, with respiratory alkalosis and normal glucose. Which diagnosis is most likely?

  1. Urea cycle disorder Correct answer.
  2. Fatty acid oxidation defect
  3. Congenital lactic acidosis
  4. Organic acidemia

Explanation

A markedly elevated ammonia with respiratory alkalosis and normal glucose in a newborn suggests a urea cycle disorder. Organic acidemias and fatty acid oxidation defects more often produce metabolic acidosis and hypoglycemia.

Question 48Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 6-year-old with bacterial meningitis has hyponatremia, high urine sodium, and worsening neurologic status. Which finding best distinguishes cerebral salt wasting from SIADH?

  1. High urine specific gravity
  2. Signs of hypovolemia with high urine output Correct answer.
  3. Low serum osmolality
  4. Elevated antidiuretic hormone levels

Explanation

Cerebral salt wasting causes hypovolemia and high urine output, whereas SIADH causes euvolemia or hypervolemia with low urine output. Both can produce hyponatremia, high urine sodium, and concentrated urine.

Question 49Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 5-year-old with severe traumatic brain injury has increased intracranial pressure. Which osmotic therapy is most appropriate for acute reduction of ICP?

  1. 5% dextrose in water
  2. 3% hypertonic saline Correct answer.
  3. 0.9% saline bolus
  4. Lactated Ringer solution

Explanation

Hypertonic saline is an osmotic agent used to reduce cerebral edema and lower intracranial pressure in severe traumatic brain injury. Isotonic fluids and hypotonic fluids do not provide the same osmotic effect.

Question 50Advanced assessment, diagnosis, and clinical decision-making for acute and complex pediatric conditions

A 7-year-old in septic shock remains hypotensive despite 40 mL/kg of crystalloid and has cold extremities. Which vasoactive agent is most appropriate to add?

  1. Dobutamine
  2. Epinephrine Correct answer.
  3. Norepinephrine
  4. Dopamine at low dose

Explanation

Cold septic shock with persistent hypotension is treated with epinephrine, which increases contractility and systemic vascular resistance. Norepinephrine is preferred for warm shock with vasodilation.