NP Cert Exam - Pediatrics

70. A diet low in the following nutrients encourages lead absorption. (Choose all that apply.) A. protein B. carbohydrates C. zinc D. magnesium

70. Correct: C. zinc, and D. magnesium Increased lead absorption can occur with a diet low in calcium, iron, zinc (C), magnesium (D), and copper, as well as high-fat diets. Incorrect: Diets that are low in protein (A) or carbohydrates (B) do not impact lead absorption.

1. Which of the following is appropriate advice to give to a mother who is breastfeeding her 10-day-old infant? A. "Your milk will come in today. B. "To minimize breast tenderness, the baby should not be kept on either breast for more than 5 to 10 minutes.?" C. "A clicking sound made by the baby during feedings signifies a good latch and suck" D. "The baby's urine should be light or colorless."

1. Correct: D. "The baby's urine should be light or colorless. Urine that is light and colorless is a good indication that the baby is well hydrated and feeding sufficiently (D). Incorrect: The transition from colostrum to mature milk typically occurs between days 2 to 5 after childbirth and not 10 days after birth (A). Proper breastfeeding of the newborn should have a minimum of 10 minutes on each breast every 1.5 to 3 hours (B). A clicking sound made during nursing would indicate an improper latch (C).

10. The anticipated average daily weight gain during the first 3 months of life is approximately: A. 15 g or 0.53 oz. B. 20 g or 0.7 oz. C. 25 g or 0.88 oz. D. 30 g or 1 oz.

10. Correct: D. 30 g or 1 oz. During the first 3 months of life, the average daily weight gain is approximately 26 to 31 g (D). The anticipated daily weight gain will then decrease to 17 to 18 g during months 3 to 6, and 12 to 13 g daily during months 6 to 9. Incorrect: In a newborn up to 3 months of age, the average daily weight gain should exceed 25 g and range near 30 g (A, B, C).

100. When evaluating a child who has aseptic or viral meningitis, the NP expects to find CF results of: A. low protein. B. predominance of lymphocytes. C. glucose at about 30% of serum levels. D. low opening pressure.

100. Correct: B. predominance of lymphocytes. An elevation in lymphocytes is an indication of viral infection and would be expected in the child with viral meningitis (B). Incorrect: The typical CF response in viral meningitis includes normal glucose level (C), normal to slightly elevated protein level (A), and an elevated CSF opening pressure, which is a near universal finding in meningitis (D).

101. Gina is 2 years old and presents with a 3-day history of fever, crankiness, and congested cough. Her respiratory rate is more than 50% of the ULN for age. Tubular breath sounds are noted at the right lung base. Skin turgor is normal, and she is wearing a wet diaper. She is alert, is resisting the examina- tion as age appropriate, and engages in eye contact. Temperature is 38.3°C (101°F). Ginas diagnostic evaluation should include: A. chest x-ray. B. urine culture and susceptibility. C. lumbar puncture. D. sputum culture.

101. Correct: A. chest x-ray. For this patient with respiratory symptoms of a con- gested cough and elevated respiratory rate, a chest ×-ray is warranted to rule in or out pneumonia as the source of infection (A). Incorrect: With the presence of respiratory tract symptoms, a chest x-ray should be given priority over the other diagnostic measures to check for the presence of pneu- monia. A sputum culture is not routinely needed as it can take days for the results and will not likely impact the initial management decisions (D). A sputum cul- ture can be considered in cases of complication or treatment failure. Urine culture and susceptibility will likely not provide any useful information regarding the nature of the infection and also will require 2 to 3 days for results (B). Other tests can more rapidly detect the presence of a UTI, such as checking for the presence of urinary nitrite. The child has a number of reassuring signs and no neurological findings that would indicate meningitis, so a lumbar puncture is not warranted (C).

102. An early indicator of hypoperfusion in an acutely ill younger child is: A. an elevation in total WBC count. B. dehydration. C. capillary refill of more than 2 seconds. D. a nonresponsive child.

102. Correct: C. capillary refill of more than 2 seconds. Hypoperfusion can be assessed by capillary refill, which is normally 2 seconds or less, and would be longer during a hypoperfusion state (C). Decreased perfusion of the skin is associated with an increase in systemic vascular resistance, which can occur early in an infant with hypovolemia. Incorrect: Hypoperfusion is related to blood flow and not related to the level of WBCs (A). Dehydration can be a con- tributor to hypoperfusion but is not an indicator for the condition (B). Nonresponsiveness in a child may be a late, rather than early, indicator of concerning find- ings in a seriously ill child (D).

103. As part of the evaluation in a febrile 3-year-old boy, the following WBC count with differential is obtained: WBCs = 22,100/mm? Neutrophils = 75% (normal 40% to 70%) with toxic granulation Bands = 15% (normal 0% to 4%) Lymphocytes = 4% (normal 30% to 40%) Which of the following best describes this child's results? A. leukocytosis with neutrophilia B. leukopenia with lymphocytosis C. lymphopenia with neutropenia D. leukopenia with neutropenia

103. Correct: A. leukocytosis with neutrophilia An elevation in WBCs (typically greater than 11,000/ mm') with elevated levels of neutrophils best describes leukocytosis with neutropenia (A). This is also known as a left shift and is typically observed during bacterial infection. Incorrect: Leukopenia is characterized by low levels of WBCs (i.e., less than 3,500/mm') and can place the individual at increased risk of infection or can occasionally be seen as a normal limit variant or as a result of the viral ill- ness (D). Lymphocytosis describes an elevation in lym- phocytes and typically occurs with viral infection (B). Lymphopenia and neutropenia describe the findings of low lymphocytes and low neutrophils, respectively (C).

104. These results in question 103 increase the likelihood that the cause of the above-mentioned child's infection is: A. viral. B. parasitic. C. fungal. D. bacterial.

104. Correct: D. bacterial. A finding of leukocytosis with neutropenia is the characteristic finding in a child with a bacterial infec tion, as neutrophils are activated to fight these kinds of infection (D). Incorrect: Viral infections are more commonly associated with lymphocytosis rather than neutrophilia (A). Parasitic infections can result in eosinophilia, or elevated levels of eosinophils (B). Fungal infections result in elevated levels of monocytes (C).

105. Potential adverse events with acetaminophen use in a child with fever and mild dehydration include: A. seizure. B. hepatotoxicity. C. petechial rash. D. gastric ulcer.

105. Correct: B. hepatotoxicity. Acetaminophen is generally safe to use in children when given in appropriate doses. However, excessive doses of this medication can result in hepatotoxicity (B). Incorrect: Acetaminophen is not associated with the development of seizure (A) or petechial rash (C). Risk for gastric ulcer is more likely observed with long-term use of ibuprofen rather than acetaminophen (D).

106. For a child with fever, a cool bath is not recommended due to: A. higher risk of febrile seizure. B. risk for development of generalized rash. C. an increase in body temperature resulting from shivering. D. increased risk of bacteremia.

106. Correct: C. an increase in body temperature result- ing from shivering. Though caregivers may be tempted to give a cooling bath for their febrile infant or young child, the practice is not recommended as this can lead to an eventual increase in body temperature due to the child shivering as a result of the cool bath (C). Incorrect: Though a cooling bath is not recommended for a febrile child, it is not associated with an increased risk of febrile seizure (A), development of rash (B), or an increased risk of bacteremia (D).

115. The main risk factor for AOM in infants is: A. undiagnosed dairy allergy. B. eustachian tube dysfunction. C. cigarette smoke exposure. D. use of soy-based infant formula.

115. Correct: B. eustachian tube dysfunction. Knowledge of the pathophysiology of disease is critical in ensuring proper management of the disease and recognition of risk factors. Conditions that cause eusta- chian tube dysfunction or eustachian tube obstruction will block secretions and allow aspiration of pathogens into the middle ear, causing AOM (B). Incorrect: Cigarette smoke exposure is a risk factor for AOM but is not as strong a risk factor as eustachian tube dysfunction (C). A dairy allergy (A) or the use of soy- based infant formula (D) are not risk factors for AOM. However, bottle-fed babies tend to be at higher risk compared to breastfed babies.

107. The practice of alternating between ibuprofen and acetaminophen for a child with fever: A. will result in an additive effect in fever reduction. B. should only be performed when also giving cough-and-cold medication. C. is only recommended for high-grade fevers. D. is not recommended due to a higher potential for adverse effects.

107. Correct: D. is not recommended due to a higher potential for adverse effects. In general, alternating between acetaminophen and ibuprofen is not recommended as there is a lack of evi- dence supporting this practice, and it can increase the risk of dosing errors and adverse effects in the infant and child (D). Incorrect: There is little clinical evidence supporting the practice of alternating between acetaminophen and ibuprofen for fever reduction (A), including those with high-grade fever (C). The use of cough-and- cold medications is also not recommended for young children as there is little evidence showing any benefit of these products, which can also contain acetaminophen or ibuprofen and lead to overdosing of the child who is also receiving antipyretic therapy (B).

108. The development of Reyes syndrome is associated with the administration of which of the following in children with fever? A. acetaminophen B. aspirin C. vitamin C supplement D. ibuprofen

108. Correct: B. aspirin Aspirin use is associated with the development of Reyes syndrome when given to children with fever (B). Reyes syndrome is a rapidly progressing encephalopa- thy that can include symptoms of vomiting, confusion, seizures, and loss of consciousness. Incorrect: Reye's syndrome is not associated with the use of acet- aminophen (A), ibuprofen (D), or vitamin C supple- ments (C) in children with fever.

109. The use of ibuprofen should be avoided in the child with varicella infection due to an increased risk of: A. seizure. B. Reyes syndrome. C. aseptic meningitis. D. necrotizing fasciitis.

109. Correct: D. necrotizing fasciitis. Ibuprofen use in the child with varicella infection can increase the risk of necrotizing fasciitis (D). The anti- inflammatory effects of ibuprofen can mask the signs of a serious secondary bacterial infection. Early signs of necrotizing fasciitis include redness, swelling, and severe pain followed by sores or blisters that ooze. Incorrect: The use of ibuprofen is not associated with seizure (A) or aseptic Merinets(One childrenwith watcellesult from the use of aspirin in children with fever (B).

11. The average required caloric intake in an infant from age 0 to 3 months is usually: A. 40 to 60 kcal/kg/day. B. 60 to 80 kcal/kg/day. C. 80 to 100 kcal/kg/day. D. 100 to 120 kcal/kg/day.

11. Correct: D. 100 to 120 kcal/kg/day. The required caloric intake for an infant between O and 3 months of age is approximately 100 to 120 kcal/kg/day (D). This amount does not change substantially as the child grows, with a requirement of 105 to 115 kcal/kg/ day for those 3 to 6 months of age and 100 to 105 kcal/ kg/day for those 6 to 9 months of age. Incorrect: During the first 3 months of life, the average required caloric intake ranges from 100 to 120 kcal/kg/day (A, B, C).

110. Which of the following is the most prudent first-line treatment choice for an otherwise well toddler without known allergies who now has AM and requires antimicrobial therapy? A. oral cefdinir B. oral amoxicillin C. oral cefuroxime D. oral azithromycin

110. Correct: B. oral amoxicillin When antimicrobial therapy is deemed necessary for AOM, an agent with activity against S pneumo- niae is needed. According to guidelines, first-line therapy would include oral amoxicillin (B) or oral amoxicillin-clavulanate. Incorrect: The macrolides such as azithromycin are not rec- ommended for AOM due to elevated rates of resis- tance by S pneumoniae (D). Cephalosporins such as cefuroxime (C) or cefdinir (A) can be considered in children with a penicillin allergy and who would not be able to take amoxicillin.

111. Most AOM is caused by: A. certain gram-positive and gram-negative bacteria and select respiratory viruses. B. atypical bacteria and pathogenic fungi. C. rhinovirus and methicillin-resistant Staphylococcus aureus (MRSA). D. predominately beta-lactamase-producing organisms.

111. Correct: A. certain gram-positive and gram-negative bacteria and select respiratory viruses. The most common pathogens that cause AOM include the gram-positive S pneumonia as well as gram- negative pathogens H influenza and M catarrhalis (A). Certain respiratory viruses, such as RV, human rhino- virus, and coronavirus, can also be involved. Incorrect: Atypical pathogens, such as M pneumoniae and C pneu- moniae, and fungi are rarely implicated in AOM and are more likely to be found in lower respiratory tract infections such as pneumonia (B). Though rhinovirus has been implicated in AOM, the presence of MRSA is not a common finding (C). Though H influenza and M catarrhalis commonly produce beta-lactamase, the predominant pathogen is S pneumonia (D).

112. The incidence of AOM in children has decreased in the past decade in part because of: A. earlier detection and treatment. B. more effective treatment options. C. an increase in select vaccination use. D. lower rates of viral infections.

112. Correct: C. an increase in select vaccination use. As a greater number of children are receiving the pneu- mococcal and Hib vaccines, this has brought down the incidence of AOM over the years (C). Incorrect: Earlier detection and treatment of AOM will not affect the incidence of the disease (A) and neither will the availability of more effective treatment options (B). There has been no indication of lower rates of viral infections associated with AOM (D).

113. Which of the following represents the best choice of clinical agents for a child with AOM who has had a history of penicillin allergy, with parental report of a flat, pink, slightly itchy rash without diffi- culty breathing during the reaction, who requires antimicrobial therapy? A. oral azithromycin B. oral cefdinir C. oral amoxicillin D. oral trimethoprim-sulfamethoxazole (TMP-SMX)

113. Correct: B. oral cefdinir When antimicrobial therapy is deemed necessary for the treatment of AOM in a child with penicillin allergy, an appropriate choice would include a cephalosporin. Oral cefdinir would be the most appropriate choice for this child (B). Incorrect: Amoxicillin should be avoided due to the presence of a penicillin allergy (C). Azithromycin is not recom- mended for AM due to the elevated rates of resistance by S pneumoniae against the macrolides (A). TMP- SMX is not recommended for the treatment of AOM but is more commonly used to treat UTIs (D).

114. Which of the following does not represent a risk factor for recurrent AOM in younger children? A. pacifier use after age 10 months B. history of first episode of AOM before age 3 months C. exposure to secondhand smoke D. beta-lactam allergy

114. Correct: D. beta-lactam allergy AOM is one of the most common diagnoses in young children, and about one-third will have three or more episodes by the age of 2 years. Certain risk factors for recurrent AOM have been identified, though beta- lactam allergy, where a systemic allergic reaction is noted with the use of cephalosporins and/or penicil- lins, is not among them (D). Incorrect: Risk factors for recurrent AOM in young children include exposure to secondhand smoke (C), feeding in a supine position, pacifier use beyond 10 months of age (A), and history of a first AOM episode before 3 months of age (B).

12. Regarding physiological jaundice in the newborn, select all that are correct: A. It occurs between the first 12 and 24 hours of life. B. It progresses from the abdomen toward the head of the infant. C. Unconjugated bilirubin is elevated. D. Risk of development of hyperbilirubinemia can be reduced in a breastfed infant with frequent breastfeeding every 2 to 3 hours per 24 hours. E. It can be avoided by supplemental water and dextrose feedings between breastfeeding in the first 3 to 4 days of life to increase infant hydration while awaiting mother's milk to come in.

12. Correct: C. Unconjugated bilirubin is elevated, and D. Risk of development of hyperbilirubinemia can be reduced in a breastfed infant with frequent breast- feeding every 2 to 3 hours per 24 hours. Physiological jaundice occurs as a result of elevated levels of unconjugated bilirubin (C). The condition can be prevented by keeping the newborn well hydrated by breastfeeding at least 8 to 12 times per day, or every 2 to 3 hours (D). Incorrect: Physiological jaundice typically occurs between days 3 to 5 (A) and usually starts at the head and then spreads to the body (B). Supplemental water and dextrose should be avoided as this will interfere with the infant's hunger drive to breastfeed and will delay and reduce breast milk production (E).

13. The most likely consequence of inadequate feeding during the first few weeks of a newborn is: A. hypercalcemia. B. hypernatremia. C. hypokalemia. D. hyperkalemia

13. Correct: B. hypernatremia. Consequences of inadequate feeding during the first few weeks of life can lead to dehydration, hypernatremia (B), and hypoglycemia. Hypoglycemia is often characterized by a protracted high-pitched cry, jitteriness, and poten- tial seizures. Incorrect: Inadequate feeding of a newborn is not typically associated with hypercalcemia (A), while hypernatre- mia is more likely than hypokalemia (C) or hyperkale- mia (D).

14. Which of the following would be a concern regarding weight change in a newborn? A. weight loss of 2% by day 2 of life B. no weight gain after 3 days of life C. weight gain of less than 3% after 1 week of life D. weight loss of greater than 7% at any time after the first week of life

14. Correct: D. weight loss of greater than 7% at any time after the first week of life A key criterion to assess for adequate feeding is slow growth or weight loss during the first few weeks of life. A weight loss of greater than 7% at any time, particularly after the first week of life, is particularly concerning as it increases the likelihood of neonatal jaundice and hyper- natremia (D). Incorrect: Weight loss of greater than 7% at any time in a newborn is a major concern. Some weight loss can be expected during the first few days of life (A, B) before the new- born begins to gain weight (C).

15. A mother who has been breastfeeding her newborn is planning on returning to work and asks about the use of breast pumps. The nurse practitioner (NP) counsels on all of the following except: A. Some insurance companies will cover the costs of breast pumps. B. Breast pumps can allow flexibility in allowing mothers to return to work or school. C. Double pumps are not recommended as they express about half the amount of milk as single pumps. D. Federal law requires the employer to provide adequate breaks and a location for breast pumping.

15. Correct: C. Double pumps are not recommended as they express about half the amount of milk as single pumps. Breast pumps can provide breastfeeding mothers with flexibility with feedings. Double pumps are particularly helpful as they reduce the time needed to pump by one-half by expressing milk from both breasts at the same time. These pumps do not differ in the amount of milk expressed compared to single pumps (C). Incorrect: Breast pumps can be helpful in allowing nursing mothers to return to work or school (B). Some insurance compa- nies as well as state Medicaid will cover the costs of breast pumps (A). The FLSA requires employers to provide a reasonable amount of break time to express milk as well as a functional space in which to pump milk (D).

16 to 19. Indicate (yes or no) whether each of the following is expected with a good latch by a newborn. 16. Areola easily visible 17. Dimpling of the baby's cheeks 18. Clicking noise made by baby 19. Baby's mouth is widely open with lips flanged outward

16. Correct: No 17. Correct: No 18. Correct: No 19. Correct: Yes A correct latch is critical for proper breastfeeding of the newborn. With adequate latch, the baby's chin and stomach should be able to comfortably rest against the mother's body, the baby's mouth is widely open, with lips flanged outward (19), and the areola is minimally visible (16). Observations with poor latch include dim- pling of the baby's cheeks (17) and/or a clicking noise with attempts at suck and swallow (18).

2. Which of the following is appropriate advice to give to a mother who is breastfeeding her 12-hour-old infant? A. "You will likely have enough milk to feed the baby within a few hours of birth." B. "The baby might need to be awakened to be fed." "Supplemental feeding is needed unless the baby has at least four wet diapers in the first day of life? D. "The baby will likely have a seedy, yellow bowel movement today.?"

2. Correct: B. "The baby might need to be awakened to be fed.?' A newborn who is breastfed should feed every 1.5 to 3 hours (about 8 to 12 times per day), which may require waking the baby to ensure adequate feeding (B). Incorrect: The transition from colostrum to mature milk typically occurs between days 2 and 5 after childbirth (A). How- ever, supplemental feeding with formula or dextrose and water should be avoided as this will interfere with the baby's hunger drive to breastfeed and can delay or reduce production of breast milk (C). The first bowel movements of the newborn consist of meconium, which is a thick, black or dark green substance that eventually transitions to a yellow-green stool (D).

84. Screening cholesterol levels in children with one or more risk factors begins at what age? A. birth B. 2 years C. 5 years D. 10 years

84. Correct: B. 2 years Current guidelines recommend screening for lipid abnormalities among children with certain risk factors or whose family history is not known after 2 years of age and no later than 10 years of age (B). Lipid screening should not be performed prior to age 2 years.

20. Expected stool findings for a 2-week-old baby who is breastfeeding would most likely include: A. loose, seedy stools multiple times per day. B. black, tar-like stool about once per day. C. thick, blood-tinged stool after each feeding. D. watery stool about once every 2 to 3 days.

20. Correct: A. loose, seedy stools multiple times per day. Typical stools in a healthy breastfed baby at 2 weeks of age would most likely consist of loose, seedy stools that occur several times per day (A). As the baby matures, the frequency of stools will decrease. Increase: Initial stools in newborns consist of meconium, which is a thick black or dark green stool that passes during the first couple of days after birth (B). Normal stools in a newborn would not contain blood (C). A breastfed baby would produce loose stool, but it would not be considered watery, which could indicate a diarrheal condition (D).

21. A 26-year-old mother who is breastfeeding her 4-month-old son reports a problematic cough and intermittent wheeze. She has a history of asthma that was well controlled with a medium-potency inhaled corticosteroid (ICS) and sporadic use of a short-acting beta-2 agonist (i.e., albuterol), but she stopped taking her medications during her pregnancy. The NP advises that: A. she should return to using the ICS on a set schedule with as-needed albuterol and continue breastfeeding. B. she should continue with the ICS on a set schedule with as-needed albuterol and discontinue breastfeeding. C. a long-acting beta-2 agonist (LABA) is recommended while breastfeeding. D. theophylline should be used while breastfeeding until the baby is 6 months old, then switch to an ICS.

21. Correct: A. She should return to using the ICS on a set schedule with as-needed albuterol and continue breastfeeding. For this patient with a history of asthma, she should restart her asthma medication regimen to control symp- toms. ICSs are generally safe to use during breastfeeding, as very little is absorbed systemically and will not con- centrate in breast milk (A). Incorrect: ICS is not contraindicated in nursing mothers and so breastfeeding can continue with treatment (B). A LABA as monotherapy is not recommended for the treatment of asthma (C), and theophylline is not considered a first- line agent for asthma (D).

22. The use of homemade infant formula versus commercially prepared infant formula is discouraged due to: A. increased risk of contaminations. B. increased risk of an allergic reaction. C. excessive amount of calcium. D. higher cost.

22. Correct: A. increased risk of contaminations. Homemade infant formula is usually made from cow's or goat's milk with supplemental vitamins. However, the use of these homemade formulas should be discouraged as there can be an invariable lack of critical micronu- trients and carbohydrates needed by the developing newborn as well as a risk of contaminations in the ingre- dients used (A). Incorrect: Though homemade infant formula can cause an aller- gic reaction, there is not a necessarily higher risk when compared to commercially available products (B). The concern with homemade formula is the risk of contami- nants and possible lack of micronutrients and not exces- sive amounts of calcium (C). The cost of homemade infant formula can actually be lower than commercially produced formulas (D).

39. A healthy 6- to 7-month-old infant is able to: A. roll from back to stomach. B. confidently feed self a cracker. C. reach for an object. D. crawl on abdomen.

39. Correct: A. roll from back to stomach. The ability to roll from back to stomach and stomach to back is expected by age 6 to 8 months (A). Incorrect: Reaching for an object occurs by 3 to 4 months of age (C), while the ability to crawl on the abdomen develops by 9 to 11 months of age (D). A child will start to feed self by 15 to 20 months of age (B).

23 to 25. Indicate (ves or no) whether the following infant formulas should be discarded. 23. Reconstituted (unused) formula left at room temperature for 1 hour 24. Reconstituted (unused) formula stored in the refrigerator for 2 hours 25. Leftover formula following a feeding left at room temperature for 20 minutes

23. Correct: No 24. Correct: No 25. Correct: Yes For the safety of the baby, caregivers should recognize when reconstituted formula is safe and when it should be discarded. Once formula is reconstituted, it should not be left out at room temperature for more than 2 hours (23), while storing it in the refrigerator can extend the life of liquid formula for a bit longer (24). If the entire amount of formula is not used during a feed- ing, the remainder, now a mixture of formula and the baby's saliva, should be discarded, as this combination will support bacterial growth (25).

26 to 29. Indicate (ves or no) whether each would support a decision to start solid foods in an infant. 26. At least 3 months old 27. Is able to sit upright without any support 28. Has more than doubled the birth weight 29. Consumes more than 32 oz of formula each day

26. Correct: No 27. Correct: Yes 28. Correct: Yes 29. Correct: Yes Certain criteria can be used to help determine whether an infant can start solid foods. Typically, solid foods should not be introduced prior to age 4 to 6 months (26), and the baby should have at least doubled the birth weight (28). Other signs include the ability to sit upright without any support (27) and have good head control. Infants that consume more than 32 oz of formula each day or have more than 8 to 10 feedings (breast or bottle) per day can also be considered for solid foods (29).

3. Compared with the use of infant formula, advantages for the breastfed baby include all of the following except: A. lower incidence of diarrheal illness. B. greater weight gain in the first few weeks of life. C. reduced risk of allergic disorders. D. lower occurrence of constipation.

3. Correct: B. greater weight gain in the first few weeks of life. Newborns that are formula-fed typically have greater weight gain during the first few weeks of life when com- pared to breastfed babies (B). However, the overall benefits of breastfeeding far outweigh this small difference in weight gain, and this likely represents excessive weight gain. Incorrect: Breastfeeding offers several benefits to the newborn as it provides the ideal form of nutrition and transfers the mother's antibodies to the infant to help prevent disease. Breastfed infants have been shown to have a lower inci dence of diarrheal illness (A), a lower risk of allergic dis- orders (C), and a lower occurrence of constipation (D).

30. Which of the following is most accurate regarding fluoride supplementation in infants? A. Supplementation is not needed for any infant younger than 12 months of age. B. Supplementation is advised in infants 6 months and older who are exclusively breastfed. C. Supplementation is not needed for any formula-fed infant. D. All infants should receive supplementation at 4 months of age until they begin solid foods.

30. Correct: B. Supplementation is advised in infants 6 months and older who are exclusively breastfed. Fluoride is an important part of preventing tooth decay in children. Fluoride supplements can be considered for children 6 months and older who are at high risk of tooth decay and who are not consuming fluorinated drinking water. This would include infants who are exclusively breastfed (B). Incorrect: Fluoride supplements are advised for children 6 months and older who do not drink fluorinated water (A). This includes infants who are exclusively breastfed as well as formula-fed infants who use nonfluorinated water (C). Fluoride supplements are not needed for all infants at 4 months of age but would start at 6 months of age when needed (D).

31. Which of the following infants would most likely require iron supplementation? A. a 5-month-old who is formula-fed B. a 2-month-old who is exclusively breastfed C. a 7-month-old who is exclusively breastfed D. an 8-month-old who is breastfed and eats a variety of solid foods

31. Correct: C. a 7-month-old who is exclusively breastfed A newborn's iron reserves typically last until 4 months of age. Breast milk contains very little iron, and so those who are exclusively breastfed should receive iron supplements beginning around 4 months and should continue until the baby begins to consume other foods that contain iron (C). Incorrect: Formula contains sufficient amounts of iron that will not require additional supplementation (A). A 2-month-old would not need iron supplementation since iron stores last until 4 months of life (B). For a child who eats a vari- ety of solid foods, it is likely that the child is getting ade- quate amounts of iron from the food and will not require supplementation (D).

32. Which of the following is most consistent with a normal developmental examination for a 3-month-old infant born at 40 weeks' gestation? A. sitting briefly with support B. experimenting with sound C. rolling over D. having a social smile

32. Correct: B. experimenting with sound A 3-month-old infant born at full term will most likely begin experimenting with sound, usually by making raspberry sounds (B). Incorrect: Sitting briefly with support is likely seen at 5 months of age (A). Rolling back to stomach and stomach to back typically occurs by 6 to 8 months of age (C). A social smile is observed by 1 to 2 months of age (D).

33. Which of the following is most consistent with a normal developmental examination for a thriving 5-month-old infant born at 32 weeks' gestation? A. sitting briefly with support B. experimenting with sound C. rolling over D. performing hand-to-hand transfers

33. Correct: B. experimenting with sound For preterm babies, the timing of milestones needs to be adjusted for prematurity for the first 24 months. Thus, the developmental expectations of a 5-month-old born at 32 weeks' gestation will correspond with a 3-month-old born at full term. An expected milestone for this child would be experimenting with sound, such as making raspberry sounds (B). Incorrect: For a 5-month-old born at 32 weeks' gestation, sitting briefly with support will be expected to occur at 7 months of age (A), while rolling over will occur by 8 to 10 months of age (C). Hand-to-hand transfer normally occurs at 6 to 8 months in an infant born at full term but will occur at 8 to 10 months in the infant born at 32 weeks' gestation (D).

34. A healthy full-term infant at age 3 to 4 months should be able to: A. recognize parents. B. grasp a cube. C. imitate others. D. say "dada" and "mama"

34. Correct: B. grasp a cube. By 3 to 4 months of age, the infant should be able to grasp a cube (B), reach for objects, and bring objects to the mouth Incorrect: Parental recognition should be accomplished by 1 to 2 months of age (A). Imitating others is a developmental milestone reached at 5 months of age (C), while putting together syllables such as "dada" and "mama" occurs around 6 to 8 months of age (D).

35. A healthy infant at age 9 to 11 months is expected to: A. roll from back to stomach. B. imitate "bye-bye." C. play peek-a-boo. D. hand over a toy on request.

35. Correct: C. play peek-a-boo. A healthy infant born at full term will play peek-a-boo at around 9 to 11 months of age (C). Incorrect: The ability to roll from back to stomach (A) as well as imitate "bye-bye" (B) both occur around 6 to 8 months of age. The ability to hand over an object on request typi- cally occurs by 12 to 15 months of age (D).

36. A healthy 2-year-old child is able to: A. speak in phrases of two or more words. B. throw a ball at a target. C. scribble spontaneously. D. ride a tricycle.

36. Correct: A. speak in phrases of two or more words. A 2-year-old child should be able to speak in phrases of two or more words, while a 3-year-old will speak in three-word sentences (A). Incorrect: The abilities to scribble spontaneously (C) as well as throw a ball (B) will be expected to develop by 15 to 20 months of age. Riding a tricycle is expected to occur at 36 months of age (D).

37. At which age would a child likely start to imitate housework? A. 18 months B. 24 months C. 30 months D. 36 months

37. Correct: A. 18 months The ability to imitate housework is an expected milestone that occurs between 15 and 20 months of age (A). Incorrect: The ability to imitate housework would normally occur by 20 months of age (B, C, D).

38. A healthy 3-year-old child is expected to: A. give his or her first and last names. B. use pronouns. C. kick a ball. D. name a best friend.

38. Correct: A. give his or her first and last names. A healthy 3-year-old should be able to provide first and last names upon request (A). At this age, nearly all speech should be intelligible even to those not in daily contact with the child. Incorrect: The ability to use pronouns (B) as well as kick a ball (C) should be achieved around 24 months of age. Having the child identify a best friend usually happens at age 5 to 6 years (D), around the time the child starts school.

46. Which of the following do you expect to find in an examination of a 2-week-old infant? A. a visual preference for the human face B. indifferent reaction in response to sounds or movements C. indifference to the cry of other neonates D. social smile

46. Correct: A. a visual preference for the human face When examining the newborn, it is important to note a preference for the human face (A). Incorrect: A newborn will typically respond to the cries of other neonates (C) and will also respond to sudden sounds by blinking or turning the head (B). A social smile will not be apparent until about 1 to 2 months of age (D).

4. At 3 weeks of age, the average-weight, formula-fed infant should be expected to take: A. 2 to 3 oz, or 60 to 90 mL, every 2 to 3 hours. B. 2 to 3 oz, or 60 to 90 mL, every 3 to 4 hours. C. 3 to 4 oz, or 90 to 118 mL, every 2 to 3 hours. D. 3 to 4 oz, or 90 to 118 mL, every 3 to 4 hours.

4. Correct: A. 2 to 3 oz, or 60 to 90 mL, every 2 to 3 hours. During the first month of life, a formula-fed infant should be expected to consume 2 to 3 oz of formula every 2 to 3 hours (A). For breastfed infants, feeding should occur at least 10 minutes on each breast every 1.5 to 3 hours. Incorrect: A newborn infant that is formula-fed should be fed approximately every 2 to 3 hours (B, D) and would expect to take 2 to 3 oz at each feeding (C).

40. You examine a healthy 9-month-old infant from a full-term pregnancy and expect to find that the infant: A. sits without support. B. cruises. C. recognizes "no." D. imitates a razzing noise.

40. Correct: B. cruises. By 9 months of age, a healthy infant should be able to crawl and cruise (B). Incorrect: The ability to sit without support (A) as well as recognize "no" (C) develops by 6 to 8 months of age. Making a raspberry sound develops by 3 to 4 months of age (D).

41. A healthy 3-year-old child is in your office for well-child care. You expect this child to be able to: A. count to four. B. alternate feet when climbing stairs. C. speak in two-word phrases. D. tie shoelaces.

41. Correct: B. alternate feet when climbing stairs. By 3 years of age, the child should be able to alternate feet when climbing stairs (B) as well as be able to ride a tricycle. Incorrect: Speaking in two-word phrases should occur by 2 years of age (C), while speaking in three-word phrases will occur by 3 years of age. The ability to count to four should occur by 4 to 5 years of age (A), and tying shoelaces will occur by 7 to 8 years of age (D).

42 to 45. Indicate (yes or no) whether each of the following are normal findings in a newborn. 42. Best vision at a range of 8 to 12 inches 43. Palmar grasp 44. Preference for lower-pitched voices 45. Well-developed sense of smell

42. Correct: Yes 43. Correct: Yes 44. Correct: No 45. Correct: Yes Anticipated findings during the examination of a new- born include movement of all extremities and spon- taneous stepping. A number of primitive reflexes can also be observed, including the Palmar grasp (43) and Babinski response. A newborn's best vision is at the range of 8 to 12 inches (42), while the newborn prefers high-pitched voices rather than low-pitched ones (44). The newborn has a well-developed sense of smell (45) and will blink in response to sound.

47. Which of the following is the most appropriate response in a developmental examination of a healthy 5-year-old child? A. being able to name a best friend B. giving gender appropriately C. naming an intended career D. hopping on one foot

47. Correct: A. being able to name a best friend A 5-year-old, who typically has started school at t age, will be able to identify a best friend (A). Incorrect Identifying gender appropriately typically occurs by 3 to 4 years of age (B), while hopping on one foot is accomplished by 2.5 years of age (D). Naming an intended career is expected by 6 to 7 years of age (C).

48. You are examining an 18-month-old boy who is not speaking any discernible words. Mom tells you he has not said "mama" or "dada" yet or babbled or smiled responsively. You: A. encourage the mother to enroll her son in day care to increase his socialization. B. conduct further evaluation of milestone attainment. C. reassure the parent that delayed speech is common in boys. D. order audiogram and tympanometry.

48.Correct: B. conduct further evaluation of milestone attainment. Typical milestones for saying "mama" and "dada" usu- ally occur by 9 to 11 months of age, while children will begin saying a few words by 12 to 15 months of age. An 18-month-old child who is not saying any words or smil- ing responsibly is a cause for concern and would require further evaluation of milestone attainment to determine the next plan of action, including early interventions (B). Incorrect: This child is demonstrating delayed milestone attainment that requires further evaluation (C). Following a com- plete evaluation of milestone attainment, early interven- tion can be considered, which can include an audiogram and tympanometry (D). Though enrollment in day care can help develop socialization skills, the scope and cause for developmental delay should be determined first (A).

49. The following benchmarks indicate normal development by a healthy child born at term who is now 12 months of age. (Choose all that apply.) A. talking in two-word sentences B. pointing to a desired object C. handing over objects on request D. walking backward

49. Correct: B. pointing to a desired object; and C. hand- ing over objects on request Anticipated milestones for a healthy 12-month-old child include pointing to a desired object (B), having a neat pincer grasp, having the ability to place a cube in a cup, and handing over objects on request (C). Incorrect: A 12-month-old child will be expected to speak a few words, while a 2-year-old child would speak in two- word sentences (A). Walking backward can be expected by 2.5 years of age (D).

5. In infants, solid foods are best introduced no earlier than: A. 1 to 3 months. B. 3 to 5 months. C. 4 to 6 months. D. 6 to 8 months.

5. Correct: C. 4 to 6 months. Solid foods should not be introduced to infants earlier than 4 to 6 months of age (C). The infant should have at least dou- bled the birth weight and consume at least 32 oz of formula per day or more than 8 to 10 feedings (breast or bottle) per day. Other signs would include being able to sit upright with little support, having good head control, and opening the mouth and leaning forward when food is offered. Incorrect: The introduction of solid foods should wait until at least 4 to 6 months of age (A, B) as certain developmental milestones are needed to be reached. Waiting up to 6 to 8 months is not needed for most infants (D).

55. One physical sign of fragile X syndrome in males includes: A. large eyes. B. large forehead. C. small head. D. recessive jaw.

55. Correct: B. large forehead. Physical findings consistent with fragile X syndrome in males include large body habitus, large forehead (B) and ears, and prominent jaw. Incorrect: Fragile X syndrome is not associated with large eyes (A) or a small head (C) but is characterized by a prominent jaw rather than a recessive jaw (D).

50. It is considered a possible developmental "red flag" if a child does not respond to his or her name by 9 months of age. A. true B. false

50.Correct: B. false A possible developmental "red flag" can include a lack of response to his or her name by 12 months of age and not 9 months of age (B).

51. All of the following demonstrate possible "red flags" for ASD in a 2-year-old except: A. avoids eye contact. B. echolalia. C. plays pretend games while alone or with others. D. overreacts to unusual smells and sounds.

51. Correct: C. plays pretend games while alone or with others. Playing pretend games either alone or with others is a normal activity by 18 months of age. A possible red flag for ASD in a 2-year-old is not playing pretend games either alone or with others (C). Incorrect: "Red flags" for ASD include avoiding eye contact (A), having obsessive interests, having delayed speech/ language skills, and repeating words over and over (echolalia) (B). Other signs can include getting upset by minor changes as well as having unusual reactions to smells or other environmental stimuli (D).

52. When assessing early developmental milestones in children born preterm, the developmental expecta- tions should be corrected for prematurity until what age? A. 6 months B. 12 months C. 24 months D. 4 years

52. Correct: C. 24 months For preterm babies, the timing of milestones needs to be adjusted for prematurity for the first 24 months (C). Thus, the developmental expectations of a 5-month-old born at 32 weeks' gestation will correspond with a 3-month-old born at full term.

53. All of the following are consistent with a fragile X syndrome diagnosis in males except: A. microorchidism following onset of puberty. B. large body habitus. C. large ears. D. hyperactivity.

53. Correct: A. microorchidism following onset of puberty. A key sign of fragile X syndrome in males is large testi- cles (macroorchidism) rather than microorchidism after the beginning of puberty (A). Incorrect: Physical findings consistent with fragile X syndrome in males include large body habitus (B), large forehead and ears (C), and prominent jaw. Behavioral findings can include hyperactivity (D) and intellectual disability.

54. Which of the following chromosomal syndromes is a common etiology of social and verbal develop- mental delays in boys? A. Tay-Sachs disease B. cystic fibrosis C. fragile X D. trisomy 18

54. Correct: C. fragile X Fragile X syndrome is the most common cause of autism in either gender and can lead to social and verbal devel- opmental delays in boys (C). Klinefelter's disease (XXY male) is also associated with developmental issues, par- ticularly related to verbal development. Incorrect: Tay-Sachs disease is a rare genetic disease that leads to nerve cell dysfunction in the brain that often leads to death in early childhood (A). Cystic fibrosis predom- inantly affects the pulmonary and digestive systems and does not impact social or verbal development (B). Trisomy 18, or Edwards' syndrome, can lead to devel- opmental delays, though only about 12% of babies born with this condition will survive after 1 year (D).

56. Klinefelter's syndrome (XXY male) is most commonly marked by: A. language impairment in males. B. fine motor delay in males. C. hip and breast enlargement in women. D. attention-deficit disorder in males.

56. Correct: A. language impairment in males. Klinefelter's syndrome only affects males and is char- acterized by developmental issues, predominantly lan- guage impairment (A). Incorrect: Klinefelter's syndrome only affects males (C). The condi- tion is not typically associated with fine motor delay (B) or attention-deficit disorder (D).

57. Klinefelter's syndrome (XXY male) and risk for having a child with this condition can be accurately identified by which of the following? (Choose all that apply.) A. urine test B. literacy assessment C. amniocentesis D. blood testing for carrier state

57. Correct: C. amniocentesis; and D. blood testing for carrier state A blood test is available for diagnosis of Klinefelter's syn- drome or identifying the carrier state (assesses genetic risk of having a child with the syndrome) (D). Antenatal diagnosis of Klinefelter's syndrome can also be per- formed via amniocentesis (C). Incorrect: There is no urine test (A) or literacy assessment (B) available that is able to diagnose Klinefelter's syndrome or the carrier state.

58. All of the following would support a diagnosis of AD except: A. a failure to initiate or respond to a social interaction. B. exhibiting extreme distress with small changes in routines. C. the symptoms are absent until the child reaches school age. D. excessive touching of objects.

58. Correct: C. the symptoms are absent until the child reaches school age. Signs of ASD can be evident in young children, and the AAP recommends routine screening for autism between 18 and 24 months of age (C). Incorrect: Signs of AD can include persistent deficits in social communication and social interaction (A), hyperreac- tivity to sensory input or unusual interests in sensory aspects of the environment, inflexible adherence to routines (B), and repetitive use of objects or speech (D).

59. At which of the following ages in a healthy infant's life is parental anticipatory guidance about teething most helpful? A. 1 to 2 months B. 2 to 4 months C. 4 to 6 months D. 8 to 10 months

59. Correct: C. 4 to 6 months Anticipatory guidance counseling is most helpful when it is provided near the time when the child is expected to reach the developmental landmark. In this manner, the advice can help the parents cope with, adapt to, and avoid problems with the expected changes. As teething typically starts around 6 months of age, parenteral antic- ipatory guidance should be given around 4 to 6 months of age (C).

6. Nursing infants generally maximally receive about which percentage of the maternal dose of a drug? A. 1% B. 3% C. 5% D. 10%

6. Correct: A. 1% When a nursing mother takes a medication, the nursing infant typically receives 1% or less of the maternal dose of medication from breast milk (A). Generally, if a medica- tion is safe to give to a child, then it is safe to prescribe to a nursing mother. Only a few drugs are contraindicated in nursing mothers. Incorrect: Only 1% or less of a medication taken by a nursing mother will pass to the infant while nursing (B, C, D).

60. At which of the following ages in a healthy young child's life is parental anticipatory guidance about temper tantrums most helpful? A. 8 to 10 months B. 10 to 12 months C. 12 to 14 months D. 14 to 16 months

60. Correct: B. 10 to 12 months Anticipatory guidance counseling is most helpful when it is provided near the time when the child is expected to reach the developmental landmark. As temper tantrums typically start after 12 months of age, often peaking between 18 and 24 months, the appropriate time to pro- vide parenteral anticipatory guidance would be between 10 and 12 months (B).

61. At which of the following ages in a developmentally on-target young child's life is parental anticipatory guidance about using "time out" as a discipline method most helpful? A. 12 to 18 months B. 18 to 24 months C. 24 to 30 months D. 30 to 36 months

61. Correct: B. 18 to 24 months Anticipatory guidance counseling is most helpful when it is provided near the time when the child is expected to reach the developmental landmark. Discipline using the "time out" method can begin around 2 years of age. Therefore, anticipatory guidance counseling on this aspect can be provided at around 18 to 24 months (B).

62. At which of the following ages in a young child's life is parental anticipatory guidance about protection from falls most helpful? A. birth B. 2 months C. 4 months D. 6 months

62. Correct: A. birth Anticipatory guidance counseling is most helpful when it is provided near the time when the child is expected to reach the developmental landmark. However, falls can occur at any time in the child's life, and so anticipatory guidance should be provided as early as possible follow- ing birth to ensure the safety of the child (A).

63. At which of the tollowing ages in a developmentally on-target young childs life 1s parental anticipatory guidance about toilet-training readiness most helpful? A. 12 months B. 15 months C. 18 months D. 24 months

63. Correct: C. 18 months Anticipatory guidance counseling is most helpful when it is provided near the time when the child is expected to reach the developmental landmark. Though readiness for toilet training will vary for each child, the process can initially be considered around 18 months of age. Therefore, parenteral anticipatory guidance on this topic should be offered around this age (C).

64. At which of the following ages in a young child's life is parental anticipatory guidance about infant sleep position most helpful? A. birth B. 2 weeks C. 2 months D. 4 months

64. Correct: A. birth Anticipatory guidance counseling is most helpful when it is provided near the time when the child is expected to reach the developmental landmark. However, parents should be educated on appropriate sleep position for their infant at birth to ensure the safety of their child (A).

65. At which of the following ages in a developmentally on-target young child's life is parental anticipatory guidance about sexual activity most helpful? A. 6 years B. 8 years C. 11 years D. 14 years

65. Correct: C. 11 years Anticipatory guidance counseling is most helpful when it is provided near the time when the child is expected to reach the developmental landmark. Parenteral anticipatory guidance regarding sexual activity should be offered prior to the child reaching puberty. The typical range of onset of Tanner stage 2 is 8 to 13 years in females and 9 to 14 years in males. Therefore, parenteral anticipatory guidance at around 11 years of age would be appropriate in most cases (C).

66. At which of the following ages in a developmentally on-target young child's life is parental anticipatory guidance about substance abuse most helpful? A. 8 years B. 11 years C. 14 years D. 16 years

66. Correct: B. 11 years Anticipatory guidance counseling is most helpful when it is provided near the time when the child is expected to reach the developmental landmark. As substance abuse can often start as early as the middle school years, parenteral anticipatory guidance on this issue should be provided by 11 years of age (B).

67. Recommended total daily screen time (e.g, television, computer, tablet, games) for a young child is.: A. 0 to 30 minutes. B. 1 to 2 hours. C. 2 to 3 hours. D. more than 4 hours.

67. Correct: B. 1 to 2 hours. The AAP recommends limiting screen time in young children to 1 to 2 hours per day (B). Screen media (other than video chatting) should be avoided in children younger than 18 months, while children 18 to 24 months can be introduced to digital media, though parents should choose high-quality programming, and parents should watch the programs together with their children to help them understand what they are watching. For older children, there should be strict limits set on the time spent and the types of media, and parents should make sure screen time does not interfere with adequate sleep, physical activity, and other behaviors essential to healthy living.

68. Which of the following children is most likely to have lead poisoning? A. a 5-year-old child with an intellectual disability who lives in a 15-year-old house in poor repair B. an infant who lives in a 5-year-old home with copper plumbing C. a toddler who lives in an 85-year-old home D. a preschooler who lives near an electric-generating plant

68. Correct: C. a toddler who lives in an 85-year-old home The most common cause of lead poisoning is through exposure to lead-based paint that is present in older homes. Inhalation of paint dust or eating paint chips is a main source of lead in toddlers. Lead-based paint stopped being available in 1978, while heavily leaded paint was used until the 1950s, and so newer homes are not likely to contain lead-based paint as a source of lead poisoning. Therefore, the toddler living in the 85-year-old house is at greatest risk of lead poisoning (C). Incorrect: Children who live in newer houses without lead-based paint are at less risk of lead poisoning, including chil- dren with intellectual disabilities (A). Copper plumbing is not a source of lead poisoning, though lead pipes and brass fixtures can contribute to plumbism (B). There is no relationship between lead poisoning and living near an electric-generating plant (D).

69. Sources of lead that can contribute to plumbism include select traditional remedies such as azarcon and greta. A. true B. false

69. Correct: A. true In addition to lead-based paint, other household prod- ucts can contain lead hazards, including imported candy, toys, jewelry, and cosmetics. Home health remedies such as azarcon and greta, which are used to treat upset stom- ach and indigestion in certain ethnic communities, often contain lead (A).

7. Most drugs pass into breast milk through: A. active transport. B. facilitated transfer. C. simple diffusion. D. creation of a pH gradient.

7. Correct: C. simple diffusion. Most drugs pass into breast milk through simple diffu- sion, moving from areas of high concentration to low concentration (C). For this reason, the pump-and-dump approach is not effective in removing a medication from breast milk, as it creates an area of low concentration in the empty breast. Incorrect: Active transport requires the expenditure of energy to move substances or medications across membranes. Facilitated transfer utilizes transmembrane proteins to move compounds across cell membranes. Neither of these mechanisms is generally used in the movement of medication from mother's serum to breast milk (A, B). Similarly, a pH gradient is not created to facilitate move- ment of medications to breast milk (D).

71. You are devising a program to screen preschoolers for lead poisoning. The most sensitive component of this campaign is: A. environmental history. B. physical examination. C. hematocrit level. D. hemoglobin electrophoresis.

71. Correct: A. environmental history. When screening young children for lead poisoning, a thorough assessment of environmental history is essen- tial, as lead poisoning is caused by exposure to lead in the environment (A). The most obvious aspect is the presence of lead-based paint in the home, which is more commonly found in older homes. Incorrect: Though lead poisoning can lead to a microcytic, hypochromic anemia, screening children by checking hematocrit levels is an invasive and costly approach (C) and would not be specific for lead poisoning. Hemoglobin electrophoresis will not offer any useful information on lead poisoning but is more often used to check for genetic disorders, such as thalassemias (D). Signs of low levels of lead poisoning will not be evident upon physical examination (B).

72. Patients with plumbism present with which kind of anemia? A. macrocytic, normochromic B. normocytic, normochromic C. hemolytic D. microcytic, hypochromic

72. Correct: D. microcytic, hypochromic Plumbism is associated with the development of a micro- cytic, hypochromic anemia (D). Basophilic stippling is also often noted on red blood cell morphology. Incorrect: A normocytic, normochromic anemia can be found with acute blood loss or anemia of chronic disease (B). Macrocytic, normochromic anemia is most commonly caused by vitamin Bi deficiency and pernicious ane- mia (A). Hemolytic anemia can be caused by genetic conditions, such as sickle cell anemia, as well as due to infection or medication (C).

73. At which of the following ages should screening begin for a child who has significant risk oflead poisoning? A. 3 months B. 6 months C. 1 year D. 2 years

73. Correct: B. 6 months For children at significant risk of lead poisoning, screening should begin at 6 months of age (B). This can be performed through risk assessment, which can be followed by a blood test if the assessment is positive. The risk assessment should be repeated at 9, 12, 18, and 24 months and then annually up to 6 years of age.

74. Intervention for a child with a lead level of 5 to 44 mcg/dL usually includes all of the following except: A. removal from the lead source. B. iron supplementation. C. chelation therapy. D. encouraging a diet high in vitamin C.

74. Correct: C. chelation therapy. Several interventions can be taken for a child who is found to have elevated levels of lead in the blood. How- ever, chelation therapy is usually reserved for children with blood lead levels of 45 to 50 mcg/dL (C). Incorrect: Children with elevated levels of lead in the range of 5 to 44 mcg/dL are initially treated with iron therapy (B) and improved nutrition (D), as well as removal of the child from the source of lead (A).

75. Intervention for a child with a lead level of 45 to 50 mcg/dL or greater usually includes: A. chelation therapy. B. calcium supplementation. C. exchange transfusion. D. iron depletion therapy.

75. Correct: A. chelation therapy. Chelation therapy is usually reserved for children with blood lead levels of 45 to 50 mcg/dL (A). A chelation agent such as succimer is used. Incorrect: Chelation therapy is the preferred intervention when blood lead level is 45 to 50 mcg/dL. Calcium supplementation (B), exchange transfusion (C), and iron depletion therapy (D) are not warranted. When blood lead levels are higher, hospitalization and expert consultation are needed to avoid serious consequences.

76. Which of the following are risk factors for hypertension in children and teens? (Choose all that apply.) A. obesity B. drinking whole milk C. being exposed to secondhand smoke D. 2 or more hours per day of screen time

76. Correct: A. obesity, and C. being exposed to second- hand smoke Risk factors for hypertension in children and teens include a family history of heart disease, elevated lipid levels, exposure to tobacco smoke (C), poor diet, obesity (A), and lack of physical activity. Incorrect: Drinking whole milk (B) and extensive screen time (D) have not been identified as substantial risk factors for hypertension in children.

77. Fruit juice intake is acceptable in children 6 months and older per which of the following recommen- dations? (Choose all that apply.) A. The juice is mixed in small amounts to flavor water. B. Only 100% juice is used. C. Juice replaces no more than one serving of milk. D. The juice is consumed in the morning with breakfast. E. No more than 6 oz (177 mL.) per day is recommended for children 6 months to 5 years.

77. Correct: A. The juice is mixed in small amounts to flavor water, B. Only 100% juice is used, and E. No more than 6 oz (177 mL) per day is recom- mended for children 6 months to 5 years. Fruit juice does not need to be part of a child's diet, particularly if the child is receiving an adequate supply of vitamin C from fresh fruit. When fruit juice is offered to a child, it should contain 100% juice with no added sugar (B) and can be mixed in small amounts to flavor water to increase fluid intake (A). Fruit juice should be limited to 6 oz per day in young children (E). Incorrect: Fruit juice should not replace the recommended amount of milk or breast milk (C). If fruit juice is being offered to a child, there is no preference for when it should be consumed (D).

78. In evaluating a 9-year-old child with a healthy BMI during a well visit, a comprehensive cardiovascular evaluation should be conducted by the following methods. (Choose all that apply.) A. Obtain fasting lipid profile. B. Screen for T2DM by measuring HbAlc. C. Assess for family history of thyroid disease. D. Assess diet and physical activity.

78. Correct: A. Obtain fasting lipid profile, and D. Assess diet and physical activity. Screening for cardiovascular health is an important aspect in preventive care in children. A fasting lipid profile is the recommended approach, as there is no noninvasive method to assess atherosclerotic disease in children (A). An assessment of diet and physical activity is also an important indicator for future risk of CVD and should be assessed at each well-child visit (D). Incorrect: Screening for T2DM should be limited to children with risk factors for the disease as well as those having a BMI in the 85th percentile for age and sex, weight-for- height greater than the 85th percentile, or weight greater than 120% of that ideal for height (B). An assessment of family history for thyroid disease is not an essential component of the comprehensive cardiovascular evaluation in children (C).

79. At what age is it appropriate to recommend dietary changes to parents if overweight or obesity in the child is a concern? A. 12 months old B. 5 years old C. 10 years old D. 18 years old

79. Correct: A. 12 months old BMI should be measured beginning at 2 years of age. However, if overweight or obesity is a concern beginning at 12 months of age, parents should be advised of dietary recommendations for the child, such as switching to reduced-fat milk, in addition to increasing physical activity (A). Dietary and activity recommendations should be intensified if BMI is greater than the 85th per- centile at 5 years of age.

8. To remove a drug from breast milk through "pump and dump," the nursing mother should refrain from taking the offending medication and the process must be continued for: A. two infant feeding cycles. B. approximately 8 hours. C. three to five drug-free half-lives of the medication. D. a period of time that is highly unpredictable.

8. Correct: C. three to five drug-free half-lives of the medication. The pump-and-dump approach is not effective in remov- ing a medication from breast milk as it creates an area of low concentration in the empty breast. The drug will then move from the area of high concentration (i.e., mother's serum) to the breast. To ensure a minimal amount of offending medication is present in breast milk, the mother should wait at least three to five drug-free half-lives of the medication before nursing the baby (C). Incorrect: The time required to ensure a minimal amount of drug is present in breast milk will depend on the medication half-life and not a set time (B) or the interval of feeding cycles (A). Half-life is a predictable pharmacokinetic property of the medication (D).

85. An acceptable level of total cholesterol (mg/dL) in children and teens is: A. less than 170 mg/dL or 9.4 mmol/L. B. less than 130 mg/dL or 7.2 mmol/L. C. 110 to 130 mg/dL or 6.2 to 7.2 mmol/L. D. 130 to 199 mg/dL or 7.2 to 11 mmol/L.

85. Correct: A. less than 170 mg/dL or 9.4 mmol/L. According to the AAP, an acceptable level of total cholesterol in children aged 2 to 19 years is less than 170 mg/dL (less than 9.4 mmol/L) (A). The borderline level is 170 to 199 mg/dL (9.4 to 11 mmol/L), while an elevated level is 200 mg/ dL or greater (11.1 mmol/Lor greater).

80. Which of the following is not a risk factor for T2DM in children and teens? A. hyperinsulinemia B. abnormal weight-to-height ratio C. onset of nonorganic failure to thrive in the toddler years D. Native American ancestry

80.Correct: C. onset of nonorganic failure to thrive in the toddler years Though a low birth weight and poor infant growth have been identified as risk factors for T2DM, a failure to thrive during the toddler years is not an identified risk factor (C). Incorrect: Risk factors for T2DM in children and teens include obesity (B), sedentary lifestyle, certain ethnicities (D), family history, PCS, and hyperinsulinemia (A).

81. Screening children with a known risk factor for T2DM is recommended at age 10 years or at the onset of puberty and should be repeated how often? A. every other year B. every year C. every 6 months D. every 3 years

81. Correct: A. every other year Current guidelines recommend screening children at risk of T2DM at age 10 years or at the onset of puberty. Screening should continue every 2 years until adult- hood, at which time the adult guidelines should be followed (A).

82. Increased risk for diabetes (prediabetes) in children is defined as which of the following? (Choose all that apply.) A. impaired fasting glucose (glucose level greater than or equal to 100 mg/dL or 5.6 mmol/L but less than or equal to 125 mg/dL or 7 mmol/L) B. impaired glucose tolerance (2-hour postprandial glucose 140 to 199 mg/dL or 7.8 to 11 mmol/I) C. HbA1c 7.5% or greater but 8.5% or less D. random plasma glucose greater than or equal to 250 mg/dL (13.9 mmol/I)

82. Correct: A. Impaired fasting glucose (glucose level greater than or equal to 100 mg/dL or 5.6 mmol/L but less than or equal to 125 mg/dL or 7 mmol/L), and B. impaired glucose tolerance (2-hour postprandial glucose 140 to 199 mg/dL or 7.8 to 11 mmol/L) Prediabetes in children is defined as having impaired fasting glucose (glucose level greater than or equal to 100 mg/dL or 5.6 mmol/L) but less than or equal to 125 mg/dL or 7 mmol/L) (A), impaired glucose tolerance (2-hour postprandial glucose 140 to 199 mg/ dL or 7.8 to 11 mmol/L) (B), or an Alc of 5.7% to 6.4%. Incorrect: An Alc of 6.5% or greater will result in a diagnosis of T2DM (C), as well as a random plasma glucose of 200 mg/dL or greater in conjunction with symptoms of T2DM (D).

83. Risk factors for dyslipidemia in children include which of the following? (Choose all that apply.) A. blood pressure at the 70th to 80th percentile for age B. breastfeeding into the toddler years C. family history of lipid abnormalities D. family history of T2DM

83. Correct: C. family history of lipid abnormalities, and D. family history of T2DM The key risk factors for dyslipidemia in children include a family history of lipid abnormalities (C) and a family history of T2DM (D). Incorrect: Elevated blood pressure during childhood is not a risk factor for dyslipidemia (A), and breastfeeding during the toddler years is also not a risk factor (B).

86. Rates of sepsis in children have lowered in recent years mainly because of: A. more stringent screening and diagnosis of febrile illness. B. increased use of antipyretics. C. longer observation period in children with febrile illness. D. higher rates of select immunization.

86. Correct: D. higher rates of select immunization. Sepsis rates in young children have lowered in recent years predominantly as a result of increased immuniza- tion rates against select infections, particularly influen- zae, H influenzae type B, and S pneumoniae (D). Incorrect: Rates of sepsis have not decreased because of more stringent screening and diagnosis of febrile illness (A) or a longer observation period in children with febrile illness (C). Increased use of antipyretics in children may decrease fever but would not have an impact on the development of sepsis (B).

87 to 91. When evaluating a young child with febrile illness, indicate if each is considered a reassuring or concerning finding. 87. Cyanotic skin 88. Brisk capillary refill 89. Weak or no cry 90. Respiratory rate less than 50% above ULN 91. No recent evidence of urinary output (within past 4 hours)

87. Correct: Concerning 88. Correct: Reassuring 89. Correct: Concerning 90. Correct: Reassuring 91. Correct: Concerning Health-care providers should have the ability to identify reassuring or concerning findings in the febrile young child to help determine whether outpatient management is appropriate or if urgent or emergent care is needed. Reassuring findings include warm, dry, and appropriately colored fingertips, brisk capillary refill (88), lusty cry or smiling during the examination, respiratory rate less than 50% above ULN (90), and the ability to tolerate oral fluids. Concerning findings will include pale or cyanotic skin (87), poor capillary refill, weak or no cry during the exam- ination (89), tachypnea, tachycardia, inability to tolerate oral fluids, and no evidence of recent urinary output (91).

9. When counseling a breastfeeding woman about alcohol use during lactation, you relate that: A. drinking a glass of wine or beer will enhance the let-down reflex. B. because of its high molecular weight, relatively little alcohol is passed into breast milk. C. maternal alcohol use causes a reduction in the amount of milk ingested by the infant. D. infant intoxication can be seen with the mother having as few as one to two alcoholic drinks.

9. Correct: C. maternal alcohol use causes a reduction in the amount of milk ingested by the infant. Small amounts of alcohol ingestion by a nursing mother can cause a reduction in the let-down reflex, decreased milk production, and less rhythmic and frequent suck- ing by the infant, resulting in a smaller volume of milk consumption (C). Incorrect: Alcohol has a low molecular weight that easily passes to breast milk (B). Alcohol consumption can reduce the let- down reflex and result in decreased milk production (A). One or two alcoholic drinks may not lead to infant intoxication as less than 1% of the alcohol will pass to breast milk. However, even small amounts of alcohol consumption can decrease the amount of milk con- sumption by the nursing infant (D).

92. When evaluating an acutely ill febrile child with no clear cause of fever, a stool culture and fecal WBC count should most likely be performed: A. routinely for all febrile children. B. if fever has persisted for more than 48 hours despite use of antipyretics. C. when diarrhea is present. D. when fever exceeds 39.1°C (102.3°F).

92. Correct: C. when diarrhea is present. When evaluating a febrile child with an uncertain cause of the fever, stool culture and fecal WBC count should be limited to only when diarrhea is present to confirm or rule out acute gastroenteritis (C). Incorrect: Fecal tests should not be performed routinely as part of the diagnostic process of the febrile child (A). The pres- ence of diarrhea is the major determinant of whether stool testing is needed and not duration of fever (B) or severity of fever (D).

93. The mechanism of action in fever includes which of the following? A. an increase in systemic vascular resistance B. endogenous pyrogens increase prostaglandin synthesis C. immature neutrophil forms in circulation D. atypical or reactive lymphocytes

93. Correct: B. endogenous pyrogens increase prostaglan- din synthesis Fever can be an important part of a body's defense against infection and consists of a complex physiological reaction that occurs when exogenous pyrogens are introduced to the body. This triggers the production of endogenous pyrogens, while prostaglandins activate thermoregulatory neurons and alter the hypothalamic set point (B). Vaso- motor center reactions increase heat conservation and heat production. The result of this process is fever. Incorrect: Fever does not involve an increase in systemic vascular resistance (which would cause increased blood pressure) (A). Fever is not the result of immature neutrophils in circulation (C) or the presence of atypical or reactive lymphocytes (D).

94. When assessing a febrile child, the NP considers that: A. even minor temperature elevation is potentially harmful. B. nuchal rigidity is usually not found in early childhood meningitis. C. fever-related seizures usually occur at the peak of the temperature. D. most children aged 3 months to 3 years with temperatures of 38.3°C to 40°C (101°F to 104°F) have a potentially serious bacterial infection.

94. Correct: B. nuchal rigidity is usually not found in early childhood meningitis. In seriously ill children with fever, often there is an absence of hypotension, cool skin, and/or nuchal rigidity (i.e., neck stiffness) (B). This is true even in the presence of meningitis, where older children and adults com- monly report nuchal rigidity. Incorrect: Low- or high-grade fevers are unlikely to cause harm to the child (A). Febrile seizure is more likely to occur as body temperature increases and not at the peak (C). The most common cause of fever in the young child is due to a self-limiting viral infection and not bacterial infection, which typically comprises less than 5% of febrile illness in infants and young children (D).

95. Which of the following is not seen during the body temperature increase found in fever? A. lower rate of viral replication B. toxic effect on select bacteria C. negative effect on S pneumoniae growth D. increased rate of atypical pneumonia pathogen replication

95. Correct: D. increased rate of atypical pneumonia pathogen replication Fever can provide benefits to the child in fighting infec- tion, including reducing replication by bacteria, includ- ing atypical organisms (D). Incorrect: Some of the beneficial effects of fever include lowering the rate of viral and bacterial replication (A), having a toxic effect on select bacteria (B), and having a negative effect on growth by S pneumoniae (C).

96. When providing care for a febrile 3-year-old who appears to have a minor, self-limiting illness, the NP bears in mind that all of the following are true except that: A. the use of antipyretics is potentially associated with prolonged illness. B. consistent use of an antipyretic provides a helpful way to shorten the course of infectious illnesses. C. fever increases metabolic demand. D. the presence of fever is associated with reduced morbidity and mortality.

96. Correct: B. consistent use of an antipyretic provides a helpful way to shorten the course of infectious illnesses. The presence of fever can be helpful when trying to resolve a bacterial or viral infection. The consistent use of antipyretic agents has been shown to prolong the course of illness rather than shorten illness duration (B). Incorrect: The use of antipyretics will prolong the duration of ill- ness, especially for viral infections (A). The presence of fever is associated with reduced morbidity and mortal- ity from infection (D). One drawback of fever is that it increases metabolic demand, which can be an issue for a child with certain chronic health problems and would warrant the use of antipyretics (C).

97. Concerning the use of antipyretics in a febrile young child, which of the following statements is true? A. Ibuprofen is preferred for fever caused by viral infections. B. The degree of temperature reduction in response to antipyretic therapy is not predictive of the pres- ence or absence of bacteremia. C. Compared with ibuprofen, acetaminophen has a delayed onset of antipyretic action. D. The duration of action with ibuprofen is shorter than acetaminophen.

97. Correct: B. The degree of temperature reduction in response to antipyretic therapy is not predictive of the presence or absence of bacteremia. There is no substantial correlation between the amount of temperature reduction with use of an antipyretic and the type of infection that is present (B). Incorrect: Acetaminophen and ibuprofen are both appropriate for use during viral infections as they provide similar fever reduction potential and are generally safe in children (A). Ibuprofen and acetaminophen have an onset of action of within 30 minutes (C), and the duration of action of acetaminophen is 4 hours compared to 6 hours with ibuprofen (D).

98. When counseling the family of an otherwise healthy 2-year-old child who just had a febrile seizure, you consider which of the following regarding whether the child is at risk for future febrile seizures? (Choose all that apply.) A. The occurrence of one febrile seizure is predictive of having another. B. Intermittent diazepam can be used prophylactically during febrile illness to reduce risk of recurrence. C. A milder temperature elevation in a child with a history of a febrile seizure poses significant risk for future recurrent febrile and nonfebrile seizures. D. Consistent use of antipyretics during a febrile illness will significantly reduce the risk of a future febrile seizure.

98. Correct: A. The occurrence of one febrile seizure is predictive of having another, and B. Intermittent diazepam can be used prophylactically during febrile illness to reduce risk of recurrence. Though the cause of febrile seizures is unclear, a child who experiences a first febrile seizure is at greater risk of recurrence (A). The use of antiepileptic medications is not routinely recom- mended, as the risk outweighs the small benefit. However, intermittent diazepam at the onset of febrile illness can be considered for prevention, particularly when parents have high anxiety about future episodes (B). Incorrect: Febrile seizures occur as temperature rises and not at the peak of fever. A mild temperature increase will pose little risk for febrile seizures, and a history of febrile seizure is not associated with the occurrence of nonfebrile seizures, such as epilepsy (C). The use of antipyretics during febrile illness does not reduce the risk of future febrile seizure (D).

99. When evaluating a child who has bacterial meningitis, the NP expects to find CF results that include a report of an abnormal number of: A. neutrophils. B. lymphocytes. C. eosinophils. D. monocytes.

99. Correct: A. neutrophils. A bacterial infection is characterized by an elevation of neutrophils (A). Incorrect: An elevation of lymphocytes is a better indication of a viral infection rather than bacterial meningitis (B). Eosinophils are activated during a parasitic infection as well as allergic reactions (C). An elevation in mono- cytes is not specific to a bacterial infection but can be due to other types of infection, such as fungal infection, as well as autoimmune disorders, blood disorders, or other medical conditions (D).