Pediatrics

Question 1

Which of the following statements regarding physiologic jaundice is correct?

A. It appears when bilirubin levels reach 3mg/dL.
B. It first appears on the feet and progresses upward on the body.
C. It generally clears within 2-3 weeks with adequate feedings.
D. It begins within the first 24 hours of life.

Answer 1

C. It generally clears within 2-3 weeks with adequate feedings.

-This is a normal transitional state that resolves once the infant’s liver can keep up with the demand for bilirubin conjugation.
- It starts after the first 24 hours of life when the bilirubin level reaches 5mg/dL or higher.
- Starts on the infant’s face, then progresses down the body.

Question 2

A neonate is noted to have shortened palpebral fissures and microcephaly with a small jaw. This infant MOST LIKELY has which diagnosis?
A. Down syndrom
B. Fetal alcohol syndrome
C. Growth delay
D. Hydrocephalus

Answer 2

B. Fetal alcohol syndrome

-Down syndrome = upward deviation of palperbral fissures, macroglossia, and hypotonia
- Hydrocephalus = unusually large head size and downward deviation of the eyes.

Question 3

A new parent reports that their 6-month-old infant has a cold and a fever of 99.8F. The infant is not irritable and is feeding well without problems. The parent wants to know whether it is okay for the infant to immunized at this time. Which of the following statements is TRUE?

A. The infant should not be immunized until they are afebrile.
B. An infant with a cold can be immunized at any time.
C. An infant with a cold can be immunized as long as their temperature is not higher than 100.4F.
D. Because immunization is so important, it should be given to the infant as scheduled.

Answer 3

C. An infant with a cold can be immunized as long as their temperature is not higher than 100.4F.

-A child can be vaccinated even if they have a low-grade fever, cold, runny nose, cough, otitis media, or mild diarrhea. The vaccine will not make these symptoms worse.

Question 4

An infant is noted to have a strawberry hemangioma. The NP knows that further education is needed when the pt’s parent states:

A. “It will most likely disappear by the age of 1-5 yrs”.
B. “We will watch the hemangioma to see what happens”.
C. “It will be treated with laser therapy if it has not resolved in 12 months”.
D. “Strawberry hemangiomas are benign”.

Answer 4

C. “It will be treated with laser therapy if it has not resolved in 12 months”.

• True strawberry hemangiomas will eventually resolve by the time the child goes to kindergarten. Most will reduce or disappear in the first 2 years without intervention, so watchful waiting of this benign skin lesion is the most useful strategy.
• Laser tx is rarely used.

Question 5

Which of the following is considered an abnormal finding?

A. A “clunk” sound heard while performing the Ortolani maneuver.
B. A 6-month-old infant starting to babble.
C. Flat, pink patches on the forehead of a 12-month-old infant.
D. A 12-month-old who is “cruising”.

Answer 5

A. A “clunk” sound heard while performing the Ortolani maneuver.

• This is a positive finding and indicated a possible hip abnormality (hip dysplasia) in infants.
  -Refer to a pediatric orthopedist.
• Infants do begin to babble at 6 months.
• At 12 months, babies learn to “cruise” or hold onto furniture while walking.
• Flat pink patches found on the forehead, eyelids, and nape of the neck are salmon patches, which typically fade by 18 months.

Question 6

An infant is being seen for a well-child exam. The infant is able to use a pincer grasp, says “Dada”, and balances well on the feet with support. This childe is likely what age in months?

A. 6
B. 9
C. 12
D. 15

Answer 6

B. 9

• May also be able to string similar sounds together, and may be able to pull themselves into a standing position with support.
• 6 months = babbling, rolling in both directions, and sitting without support.
• 12 months = cruising or walking, have 1-2 words other than Mama/Dada, and can use a sippy cup with dexterity.
• 15 months = walking independently, using a spoon, and having more than 6 words in their vocabulary.

Question 7

A newborn infant is seen at a 2-week well-child visit and is noted to have a watery discharge from both eyes. The parent noted some blood in the discharge yesterday. The infant is otherwise well with no respiratory symptoms. Which of the following is the NEXT BEST management step?

A. Treat empirically with ceftriaxone IM (Rocephin)
B. Treat with ophthalmic erythromycin ointment (ilotycin)
C. Collect a swab of the inner eyelid
D. Order a chest x-ray

Answer 7

C. Collect a swab of the inner eyelid

• This is to gather a sample of the discharge and also of the epithelium.
• Child is presenting with possible chlamydial infection of the eye.

Question 8

A child is seen for a well visit. Which of the following findings would require a consult or referral for further evaluation?

A. A 3-day-old with multiple 1-2 mm white papules on the forehead and nose.
B. A 4-month-old with thick yellow scale behind the ears and on the eyebrows.
C. A 6-month-old with a round, orange-red glow from each eye on fundoscopic exam.
D. A 9-month-old with a Moro reflex

Answer 8

D. A 9-month-old with a Moro reflex

• Persistence of a Moro reflex after age 4-5 months is concerning for underlying brain pathology.
• A 3-day-old may present with the normal finding of milia (white papules on the forehead and nose).
• Seborrheic dermatitis is common in infants aged 2-4 months.
• A 6-month-old should have a bilateral red reflex- failure of this would be concerning.

Question 9

Which of the following in a newborn would be MOST CONCERNING for an associated neurologic disorder?

A. Erythema toxicum found on the face
B. Congenital dermal melanocytosis on the sacral area
C. Cafe au lait spots (more than 5 lesions) on the chest
D. Nevus flammeus on the shoulders and upper chest area.

Answer 9

C. Cafe au lait spots (more than 5 lesions) on the chest

• This is associated with neurofibromatosis.
• Nevus flammeus (port-wine stains) can be associated with the neurologic involvement of cranial nerves V1 and V2 if located on the eyelind and with Sturge-Weber disease if found unilaterally over the face. Found on other areas of the body are rarely associated with neurologic issues.
• Erythema toxicum can be a normal finding on the face of a newborn.
• Congenital dermal melanocytosis is most commonly found on the sacral and medial gluteal area and has no association with neurological issues.

Question 10

Which of the following is TRUE regarding a caput seccedaneum?

A. it is commonly associated with assisted deliveries.
B. It can be associated with jaundice.
C. It is described as diffuse edema that crosses the suture lines.
D. It is swelling that is localized to one area of the skull.

Answer 10

C. It is described as diffuse edema that crosses the suture lines.

• Occurs d/t a prolonged delivery or pressure on the head as the infant moves through the vaginal canal.
  -The pressure causes fluid to build up under the scalp.

-Cephalohematoma = periosteal blood vessel rupture over a particular skull bone, usually secondary to an assisted delivery. As the blood is contained in the subperiosteal space, it is localized to one area of the skull and does not spread diffusely. A large collection of blood can increase the bilirubin levels in the infant’s bloodstream, placing them at increased risk for jaundice.

Question 11

A 12-month-old is seen for a routine wellness exam. The pt is found to have weak femoral pulses and has a BP greater than the 90th percentile for his height. Which of the following would be the NEXT BEST step to determine the diagnosis?

A. Check BP in the right arm compared with the left.
B. Compare BPs in the upper and lower extremities.
C. Order a chest x-ray.
D. Perform an EKG

Answer 11

B. Compare BPs in the upper and lower extremities.

• A brachiofemoral delay is diagnostic for coarctation of the aorta (CoA).
• If present, the BP will be > 20mmHg higher in the arms than in the lower extremities.
• If BPs are abnormal, order a chest x-ray, Echo and EKG.

Question 12

An infant is being seen for a 4-month well-child check. The pt is up to date on immunizations at this point. Which of the following is the correct set of immunizations to order?

A. Hep B, Hib, PCV, IPV, rotavirus, DTaP, influenza.
B. Hep B, Hib, PCV, IPV, rotavirus, DTaP.
C. Hib, PCV, IPV, rotavirus, DTaP
D. MMR, varicella, Hep A.

Answer 12

C. Hib, PCV, IPV, rotavirus, DTaP.

• If the child is up to date, the next set of vaccines will include the following: Rotavirus #2, DTaP #2, Hib #2, PCV #2, and IPV #2.
• This pt is too young for the influenza vaccine.
• Hep B #2 should have been given at 1-2 months (1st vaccine is at birth, given in hospital).
• MMR and Varicella are live vaccines, cannot give until 12 months.
  -Hep A is given between 12-23 months.

Question 13

Which of the following would increase the risk that a child’s Barlow or Ortolani test would be positive?

A. 6-month-old who rolls from front to back and back to front.
B. Male newborn with hx of vacuum-assisted delivery.
C. Newborn female with a hx of breech delivery
D. 2- month-old with a negative Galeazzi sign.

Answer 13

C. Newborn female with a hx of breech delivery.

-Risk factors of hip dysplasia = firstborn, female, breech presentation, oligohydramnios, and family hx of DDH.

-A negative Galeazzi sign is a normal finding and indicates equal leg lengths.
- Rolling back and forth is a normal finding.

Question 14

Separation anxiety begins for infants at what age in months?

A. 6
B. 9
C. 12
D. 15

Answer 14

C. 12.

• The fear that the parent will leave and not return.
• Starts at 12 months and can last until 2-3 years.

Question 14

An infant is noted to have upward deviation of palpebral fissures, macroglossia, and hypotonia. Which of the following is MOST LIKELY the infant’s underlying issue?

A. Amblyopia
B. Down syndrome
C. Esotropia
D. Fetal alcohol spectrum disorder

Answer 14

B. Down syndrome

• Fetal alcohol spectrum disorder = microcephaly with a flat nasal bridge and a thin lip with a smooth philtrum.
• Esotropia = the upward deviation of the eye.
• Amblyopia = a visual disturbance characterized by decreased vision d/t abnormal visual development.