PNP Practice Test 1

Which of the following children would require an iron supplement for optimal growth and nutrition? A. 2 month old born at 32 weeks gestation who is exclusively breastfed B. 2 month old born at 37 weeks gestation who is receiving a combination of breast milk and formula C. 2 month old born at 39 weeks gestation who is exclusively breastfed D. 2 month old born at 41 weeks gestation who is receiving formula

The correct answer is A - 2 month old born at 32 weeks gestation who is exclusively breastfed Infants born before 37 weeks gestation are at high risk of developing anemia of prematurity as their iron stores are depleted rapidly during postnatal growth. They also have poor GI absorption and if hospitalized, typically undergo frequent phlebotomy procedures causing further anemia. Anemia of prematurity is most pronounced at 1-3 months of life as the infant's maternal red blood cell supply is depleted and their own bone marrow production is just beginning. Treatment for anemia of prematurity is dependent on co-morbid conditions such as cyanotic heart disease, respiratory distress syndrome, and other conditions interfering with oxygen delivery and may include blood transfusions. Recommendations are that all breastfed preterm infants receive 2mg/kg/day of an elemental iron supplement starting at 2 weeks of ages through 12 months. Formula-fed preterm infants should receive 1mg/kg/day of iron supplementation to achieve a total daily dose of 2mg/kg/day. Full term breastfed infants should receive 1mg/kg of an oral iron supplement beginning at 4 months of age, preferably from an iron-fortified cereal; formula-fed term infants do not require supplementation.

For which of the following foreign bodies is endoscopic removal MOST emergent? A. a single button battery in the esophagus B. a single cylindrical battery in the esophagus C. two packets of undetermined drugs in the stomach D. two magnets, one in the stomach and one in the esophagus

The correct answer is A - a single button battery in the esophagus Foreign body ingestions (FBIs) occurs most commonly in children between the ages of 6 months to 3 years as well as in older children with developmental delays. Intentional ingestions are more frequent in adolescents, adults, and in those with underlying behavioral or mental health diagnoses. Interventions for ingestions are based on the object or objects ingested, time since ingestion, anatomic location of the object, and presenting symptoms. Any foreign body lodged in the esophagus is considered an emergency due to the risk of perforation and sepsis. Button battery ingestions have the greatest potential for serious injury. Lodged in the esophagus, a button battery can result in burns and liquefaction necrosis to tissues within 2 to 3 hours of ingestion. An ingested button battery lodged in the esophagus is therefore the most emergent indication for endoscopic removal. A single ingested button battery which reaches the stomach carries a lower risk, but time since ingestion is an extremely important factor, as there may have been adequate exposure within the esophagus to cause severe tissue injury. An algorithm for management of button battery ingestions has been published and adopted by the National Capital Poison Center. Cylindrical batteries may also be ingested, but have been associated with fewer and less serious complications than button batteries. There is limited literature regarding ingestion of cylindrical batteries and no algorithm for management of this ingestion. Practice is usually to remove single esophageal cylindrical batteries within 24 hours. Once these batteries reach the stomach, observation for passage in the stool is appropriate. If multiple cylindrical batteries are ingested, endoscopic removal is typically recommended. Injury from ingestion of high-powered magnets has been the topic of increased literature within the past decade; including management guidelines primarily based on expert opinion in 2012. Ingestion of multiple high-powered magnets, or magnets and metallic objects simultaneously, can result in pressure necrosis of the bowel wall and ischemia or fistula if the magnets or magnet and metallic objects attract across tissues. Ingestion of a single magnet is usually benign after it arrives in the stomach, with the majority passing without incident if no further batteries or metallic objects are ingested or worn on the body or clothes. A single magnet lodged in the esophagus is treated as any blunt object and removed endoscopically within 24 hours if it does not pass into the stomach. Ingesting packets containing drugs is primarily done for purposes of transporting illegal substances without detection. Endoscopic removal of these packets is not indicated, and is avoided due to risk of rupturing the package and causing exposure to potentially fatal amounts of drug. If bowel obstruction or perforation is suspected, immediate surgical intervention is indicated. In those who are asymptomatic, use of laxatives and bowel irrigation has been described. Toxidrome symptoms, if present, are treated until the packet is passed or surgically removed.

Which of the following BEST demonstrates the oral behavior of a 12 month old in relation to readiness for feeding? A. begins chewing meat with rotary movements B. sucks in anticipation of the spoon C. controls liquid taken from cup D. controls bite of soft cookie

The correct answer is D - controls bite of soft cookie During the first several years of life, oral development progresses for both eating and language. Between the ages of 4- 6 months, children begin sucking movements in anticipation of the spoon. Children between 10- 12 months of age can control bites of soft cookie, and begin to use rotary chewing movements, but have not yet accomplished this task with meat. By age 16-18 months, the mouth can control liquid taken from a cup, and by 19-24 months the child can chew meat with rotary movements.

A 3 year old who attends daycare has diarrhea that began with three days of low grade fever and foulsmelling watery stools. One month later, he continues to have loose stools and now has abdominal distention. The MOST probable causative organism is: A. Giardia lamblia B. norovirus C. rotavirus D. Shigella toxicum

The correct answer is A - Giardia lamblia Giardia lamblia is a flagellate protozoan found in contaminated water sources and food. It is the most common parasitic infection in the United States and is commonly transmitted in daycare centers. Symptoms can include abdominal cramps, flatulence, bloating, and watery, greasy foul-smelling stools. The incubation period is 1-4 weeks, and a large majority of children remain asymptomatic or have intermittent symptoms. Stool culture will identify the organism and the treatment of choice is albendazole or metronidazole for 7 - 10 days. Rotavirus presents with acute fever, and vomiting. Watery diarrhea occurs 2-4 days later in children less than 5 years of age. The duration of illness is 3-8 days with a short incubation period of 48 hours. It is a self-limiting virus that occurs more commonly in cooler months. Treatment is supportive through repletion of fluids and electrolytes. The advent of the rotavirus vaccine in 2006 has decreased the burden of the disease dramatically. Infection with Shigella presents with abdominal cramping, fever, and diarrhea. It is most common in children 6 months-3 years with an incubation period of 24-48 hours and a duration of illness of 4-7 days. The majority of cases are self-limiting and do not require antimicrobial therapy with the mainstay of treatment being supportive to correct fluid and electrolyte imbalances. Norovirus presents with abrupt onset of watery diarrhea, nausea, vomiting, and abdominal cramping with a duration of 24-60 hours. The incubation period is 12-48 hours. Viral transmission is most common in the cooler months. Treatment is supportive to maintain fluid and electrolyte balance.

INITIAL treatment for a child with amblyopia and a droopy left eyelid includes: A. correction of the ptosis B. lubrication of the eye at night C. atropine solution in the left eye D. apraclonidine solution in the right eye

The correct answer is A - correction of the ptosis Amblyopia is a problem leading to loss of vision and can have many causes. Types of amblyopia are: -deprivation amblyopia: results from occlusions of the visual axis, -refractive amblyopia: occurs when a child's refractive errors are not similar and vary by a wide margin, -strabismic amblyopia: results from misalignment of the visual axes. Amblyopia can be corrected when identified early, ideally before 5 - 7 years of age, and if the inciting factor is corrected. Amblyopia is suspected when a preverbal child resists having the eye with good vision covered or restricted. Additionally, when the pupil is consistently restricted due to conditions such as ptosis, a persistent stye, or a hemangioma in the lid area, amblyopia should be considered as a consequence. Treatments for amblyopia include patching and pharmacologic blurring of the unaffected eye using atropine. However, if there is occlusion of an eye, this must be corrected before any other treatment will be beneficial. Apraclonidine (Iopidine) ophthalmic solution is used to confirm the lack of sympathetic input in Horner syndrome. Lubrication of an affected eye at night is used for protection from injury due to the incomplete closure of the eyelids.

An adolescent presents with a complaint of 3 syncopal episodes in the past 2 months. History is negative for exertional syncope, medications, cardiac problems, or sudden death in family members. Neurologic and cardiac exams are normal including orthostatic vital signs and an electrocardiogram. The MOST appropriate follow-up plan of care is to A. educate about syncope prevention and advise to avoid caffeine. B. advise to avoid weight-bearing exercises and keep a syncope diary. C. refer to neurology for an encephalogram and advise to avoid caffeine. D. refer to cardiology for an echocardiogram and educate about life-threatening signs.

The correct answer is A - educate about syncope prevention and advise to avoid caffeine. The incidence of fainting or simple syncope occurs in 15% of children aged 8-18 years of age and is most commonly seen in girls ages 13 to 18 years. The key is distinguishing a life-threatening cardiac event from benign syncope. A detailed history, physical exam, and electrocardiogram (ECG) are indicated for a child with a syncopal event. Thorough history should include: Present history - onset and prodrome (e.g., exercise, posture, injury, coughing, neck-stretching, hair brushing, micturition, dysmenorrhea), duration of loss of consciousness, frequency, and any consequence such as injury or incontinence Past medical history - cardiac and neurologic problems (heart murmur, seizures, hypo-/hypertension, electrolyte imbalance), pregnancy, medications, drug use, or carbon monoxide exposure Family history - sudden death of a relative under 40 years or early-onset heart disease A negative history and physical exam for cardiac or neurologic problems, with normal orthostatic vital signs and normal ECG is usually sufficient to exclude cardiogenic syncope and indicates neurally mediated/vasovagal reflex syncope. Management of vasovagal syncope is supportive and includes family reassurance, adequate hydration, elimination of caffeine, and getting at least 8 hours of sleep per night. The adolescent and family should be educated in identifying precipitating factors and prevention strategies. Additional laboratory and/or diagnostic testing are not warranted if history and physical exam are negative. Drug therapy may be indicated if syncope is unresponsive to supportive therapy. Referral to cardiology/neurology is necessary only if cardiac/neurologic concerns arise.

Which of the following methods is MOST effective in preventing childhood gun injuries and death? A. eliminating children's access to guns B. practicing gun safety skills with individual children C. teaching children to inform an adult when they see a gun D. making children aware that guns that are in the home are locked

The correct answer is A - eliminating children's access to guns The American Academy of Pediatrics maintains that the most reliable and effective means of preventing gun deaths and injury is the removal of guns from children's homes and communities. It is widely believed that teaching gun safety to young children is effective in keeping them from handling guns when found, thus decreasing childhood gun deaths and injury. The most advertised program is the National Rifle Association's "Eddie Eagle Gun Safety Program" that teaches children when they find a gun to "stop, do not touch, leave the area, and tell an adult." The Straight Talk About Risks (STAR) Program, developed by the Center to Prevent Handgun Violence, emphasizes learning about guns, practicing gun safety skills, role playing, and self-reflection using common coping mechanisms for anger and fear. In a controlled study looking at actual behavior in matched groups, (half who had a gun safety program based on the STAR principles and half who had no gun safety instruction), there were no significant differences found in the percentage of children who handled the gun, left the area, and contacted an adult. No controlled study has been done on the effectiveness of the Eddie Eagle Gun Safety Program.

A preschooler who was adopted internationally has a history of a positive purified protein derivative (PPD) skin test. Which of the following is MOST important to ascertain FIRST? A. history of Bacille Calmette-Guérin (BCG) vaccination B. chest radiograph result C. age at positive PPD D. size of reaction

The correct answer is A - history of Bacille Calmette-Guérin (BCG) vaccination Almost 80% of all childhood tuberculosis (TB) is due to contact of the child or a household member with an individual from a foreign country who has an active infection. Bacille Calmette-Guérin (BCG) immunization can produce a positive tuberculin skin test result. BCG is a live attenuated vaccine that while rarely used in the United States, is one of the most widely used vaccines in the world. Determining if a tuberculin skin test (TST) is positive due to a history of BCG vaccination or true TB disease is performed in a reference laboratory through a positive interferon-gamma release assay (IGRA). QuantiFERON-TB Gold In-Tube (QFT) and T-SPOT.TB are IGRAs and are the preferred tests to screen for tuberculosis infection in asymptomatic children 5 years and older who have been vaccinated with BCG. The AAP Red Book provides information entitled "Guidance on Strategy for Use of TST and IGRA by age and BCG-Immunization Status."

Three siblings ages 7-15 years present for new patient visits having recently moved cross country. The MOST effective guidance related to injury prevention includes A. incorporating knowledge of risks specific to the community. B. asking about previous injuries each child has sustained. C. covering as many age specific areas as possible. D. directing counselling specifically to each child.

The correct answer is A - incorporating knowledge of risks specific to the community. Anticipatory guidance for safety and injury prevention is an integral part for the care of children and should be directed towards the caregivers as they have the capability to modify the child's environment to promote safety. Safety counseling includes general preventative measures such as the use of car seats and safety belts as well as developmentally appropriate safety considerations. Studies have demonstrated that anticipatory guidance surrounding injury prevention are effective. However, to be retentive, teaching must be limited to a number of topics and not a fully exhaustive list. The effectiveness of safety counseling can be improved if a health care provider knows the risks specific to the local population, especially for new families unfamiliar with potential risks. For example, recreational activities such as all-terrain vehicles, snowmobiles, and/or personal watercraft are specific to geographic locations and safety prevention should be tailored to meet these topics. Health care providers should adapt their age specific safety anticipatory guidance to meet the needs of the child and family on the basis of risks in the local community as well as the expressed needs of the patient and families.

A 2 year old presents with a history of fever and intermittent bone pain and now has an apparent abdominal mass. Which is the MOST likely diagnosis? A. neuroblastoma B. non-Hodgkin's lymphoma C. osteogenic sarcoma D. Wilms tumor

The correct answer is A - neuroblastoma Neuroblastoma is the most common extracranial solid tumor in children and the most commonly diagnosed malignancy in early childhood. The median age at diagnosis is 22 months, and approximately 90% of cases have been diagnosed by 5 years of age. Neuroblastoma may develop at any site of sympathetic nervous system tissue with over half developing in the adrenal glands. Symptoms may mimic many other disorders and can be hard to diagnose. Metastasis of neuroblastoma typically occurs in children over 1 year of age and most commonly includes the lymph nodes, long bones and skull, bone marrow, liver, and skin. Signs and symptoms reflect the tumor site and extent of disease, but may include fever, failure to thrive, bone pain, cytopenias, orbital proptosis, masses, bowel obstruction or spinal cord compression. Wilms tumor is an embryonal malignancy of the kidney that can also present with an abdominal mass. Sarcomas of the extremities are more likely to occur in older children.

When used in treatment of acne vulgaris, topical retinoids A. normalize desquamation of the follicular epithelium. B. minimize development of antibiotic-resistant Propionibacterium acnes. C. generate free radicals to oxidize proteins in the cell wall of Propionibacterium acnes. D. work within the cell ribosomes to alter upstream signals affecting inflammatory pathways.

The correct answer is A - normalize desquamation of the follicular epithelium. Therapeutic objectives in the management of acne vulgaris are to reduce sebum production, prevent formation of microcomedones, suppress Propionibacterium acnes, and reduce inflammation to prevent scarring. Topical retinoids, vitamin A derivatives that bind to retinoid receptors in the skin, are a key component of primary acne management. Topical retinoids normalize desquamation of the follicular epithelium to prevent new formation of microcomedones, the precursors of both comedonal and inflammatory lesions. Additionally, retinoids promote clearing of existing microcomedones, and work within the nucleus to alter downstream signals that affect inflammatory pathways. The 2013 evidence-based guidelines for treatment of acne support use of topical retinoids as monotherapy or in combination with other agents for all types and severities of acne in children and adolescents.

A school-age child has rhinorrhea, nasal congestion, a sore throat, and is sneezing. Physical examination is significant for Dennie's lines, pale boggy nasal mucosa, and clear nasal mucus. These findings are MOST characteristic of: A. perennial allergies B. sinusitis C. streptococcal pharyngitis D. upper respiratory infection

The correct answer is A - perennial allergies The description of this school-age child's physical exam is consistent with an upper respiratory infection, but special attention should be paid to other findings of Dennie lines (or Dennie-Morgan folds) and pale, boggy nasal mucous membranes. These Dennie lines are prominent symmetric skin folds that extend in an arc from the inner canthus beneath and parallel to the lower lid margin. These findings along with clear rhinorrhea, congestion, and sneezing are most suggestive of allergic rhinitis. Allergic rhinitis (AR) can be seasonal, perennial, or episodic, with the nasal mucosa being particularly vulnerable to inhaled allergens.

A mother is concerned about a lump identified under the nipple of her 10-year-old daughter's breast. The child recently completed leukemia treatment. On examination the right nipple is elevated with palpable non-tender, soft tissue. The MOST appropriate next step is to A. reassure that this is normal breast development for the child's age. B. obtain bloodwork to assess hormone levels and blood counts. C. arrange an ultrasound to assess the swelling. D. consult with the child's oncologist.

The correct answer is A - reassure that this is normal breast development for the child's age. Initial breast development usually begins as unilateral disc-like sub-areolar swelling. Many adolescents and their parents present with concerns of breast tumors at time of initial development. Breast budding is expected between 9-10 years of age, and occurs in 97% by age 12, which supports this as a normal finding. Parents of childhood cancer survivors are concerned about relapse and second malignancies. Reassurance about normal growth and development are often needed to minimize anxiety. An ultrasound or blood work are unnecessary, as is consulting oncology

A caregiver who is primarily Spanish-speaking reports during a visit that her 24 month old is bilingual and speaks four words. Which of the following is the BEST initial management? A. refer to a pediatric speech pathologist with access to translators B. encourage caregiver to choose one language for communication C. advise the caregiver to read to the child daily D. refer to audiology for a hearing evaluation

The correct answer is A - refer to a pediatric speech pathologist with access to translators Language and speech development is a critical area to address at preventative exams. At two years of age a child should be speaking short phrases of two to three words and about 50 words of which 25% are intelligible to strangers. Children from bilingual homes or who are bilingual tend to develop language more slowly, mixing words and phrases from the two languages; however, milestones should continue to fall within expected ranges. Bilingual children with significant delays in vocabulary require the same evaluation as delayed monolingual children. The first step in management for children with delayed vocabulary is referral to a pediatric speech pathologist with access to translators. Having older siblings monitor speech at home is not culturally appropriate and does not address the needs of the child. Daily reading does help with language development and should be a part of the anticipatory guidance at this age; however, this child is showing signs of language delay. A hearing evaluation is an appropriate option for assessing speech and language delays, but the initial step is referral to pediatric speech pathologist

The developmental language assessment of an 18 month old reveals that the toddler can understand commands, speak 10 words, recognize names of body parts, and enjoys books and playing with others. Caregivers are concerned that the toddler is not talking as much as older siblings did at this age. The MOST appropriate response includes that A. speaking at least 10 understandable words is developmentally appropriate. B. sounds can also have meaning and be interpreted as words. C. language comprehension is less advanced than expression. D. subsequent children are often not quite as verbal.

The correct answer is A - speaking at least 10 understandable words is developmentally appropriate. The normally developing 18 month old has an average of 10 words but can understand about 50 words and seeks to interact with others. Toddlers also use different sounds or jargon to communicate. Language development occurs as the vocabulary increases rapidly, combining words and jargon. Parents can usually understand what the child is saying when others cannot. Around 18 months, the toddler uses 2-3 words omitting several to make a sentence and let his needs or wants be known such as "go bye-bye". Frequently second-born children or other subsequently born children are quite verbal because of an older sibling talking to and playing with them.

During a follow-up visit, a child's asthma control test score demonstrates poor control with reports of asthma symptoms present 3 days per week, nighttime awakenings 2 times per week, and use of a shortacting beta-2 agonist for symptom control 3 days per week. Spirometry reveals FEV1 at 70% of predicted and FEV1/FVC at 80%. Which of the following actions is MOST appropriate? A. step-up one step in therapy B. initiate home peak expiratory flow monitoring C. prescribe a short course of oral corticosteroids D. continue current plan and reevaluate 4 weeks

The correct answer is A - step-up one step in therapy In primary care, asthma should be monitored using a standardized instrument, which may include the Asthma Control Test (ACT). ACT scores less than or equal to 19 suggest asthma symptoms may not be well controlled. The assessment of asthma symptoms allows providers to determine if the asthma is well controlled, not well controlled, or very poorly controlled. Spirometry is the gold standard for diagnosing asthma and should be used on a regular basis to monitor, evaluate, and manage asthma. Forced expiratory volume in 1 second (FEV1) represents the amount of air exhaled from the lungs in 1 second. FEV1 less than 75% of predicted suggests a degree of obstruction. Forced vital capacity (FVC) represents the amount of air expelled by lungs. The FEV1/FVC ratio represents the amount of air expelled in the first second over the total amount of air expelled from the lungs and should be greater than 90% of predicted. A stepwise approach to asthma management is recommended by the 2007 National Heart, Lung, and Blood Institute (NHLBI) National Asthma Education and Prevention Program's "Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma". If asthma is determined to be well controlled, it is recommended to maintain the current step and follow-up every 1-6 months and then to consider step down if well controlled for at least 3 months. If asthma is determined to be not well controlled, it is recommended to step-up one step in therapy after reviewing medication adherence, inhaler technique, and environmental controls. If asthma is determined to be very poorly controlled, it is recommended to consider a short course of oral systemic corticosteroids and to step up 1-2 steps after reviewing medication adherence, inhaler technique, and environmental controls.

When performing monocular visual acuity testing on a 4 year old for a pre-school check-up, a referral to an ophthalmologist is indicated if the child is A. unable to identify the majority of the 20/40 line. B. has a 1-line difference between each eye. C. unable to identify the majority of the 20/30 line. D. has less than 1 mm of pupillary asymmetry.

The correct answer is A - unable to identify the majority of the 20/40 line. Visual acuity testing in the office begins at 3 years of age and is an important part of the well child examination. If a child is uncooperative with the exam then retesting should occur in 6 months. Visual acuity is tested by a picture and shape chart for children who do not know the alphabet. The Snellen Chart is commonly used for those who know the alphabet. Each eye is tested separately then both together. The examiner begins the eye test asking the child to identify those letters on the acuity line expected for that age child (see table below). If the child misses 2 or more letters on that line, then the examiner tests the child on the previous line. Referral to an ophthalmologist would be made if the child had a pupillary asymmetry greater than1 mm, or visual acuity difference of two or more lines between eyes. In this situation, it is expected that the 4 year old child would have a visual acuity of 20/40 and not able to identify the majority of the 20/30 line. If the child cannot identify the majority of the 20/40 line, a referral should be made. Discrepancy in visual acuity between the right and left eye is not unexpected before age 5, nor is a visual acuity above 20/40. Recommendations for preventative care in pediatrics can be found in periodicity schedules from the American Academy of Pediatrics and Bright Futures.

Which of the following is the BEST anticipatory guidance about driving that can be given to a family and their adolescent who is hoping to be licensed soon? A. "Other than a parent, no passengers should be in the car when you drive." B. "No one in the family should text or talk on their phones while driving." C. "It is important to provide at least 20 hours of practice driving." D. "Practice driving should be limited to when the roads are dry."

The correct answer is B - "No one in the family should text or talk on their phones while driving." The leading cause of death for adolescents is motor vehicle accidents (MVAs). At least 6 adolescents are killed in MVAs daily in the U.S. Every state in the U.S. has a graduated license requirement for adolescents and families should be familiar with the list of requirements and parameters. The requirements include how many driving hours are needed, the number and type of passengers in the car with the learning driver, age requirements for a learner's permit, when the adolescent can drive alone, and the age and relationship of passengers. Recommendations are that adolescents have at least 50 hours of driving practice including on a variety of road conditions. Passengers should be limited, as the risk of a fatal crash increases as the number of passengers increase. Adolescents should not text or talk on the phone while driving. As role models parents and other adults need to adhere to this safety requirement too as adolescents are constantly watching their parents and mirroring behaviors

Palivizumab (Synagis®) prophylaxis against respiratory syncytial virus is recommended for which of the following infants? A. 4 month old born at 32 weeks gestation who required 7 days of supplemental oxygen during the neonatal hospital stay B. 5 month old with hemodynamically significant heart disease C. 6 month old with Down syndrome who is otherwise healthy D. 9 month old with cystic fibrosis

The correct answer is B - 5 month old with hemodynamically significant heart disease The most common reason for hospitalization of infants in the first year of life is bronchiolitis. The most common causative agent for bronchiolitis is respiratory syncytial virus (RSV). The American Academy of Pediatrics' 2014 guidelines for palivizumab (Synagis®) vaccination recommend prophylaxis in the first year of life for infants: born prior to 29 weeks, 0 days gestation; with hemodynamically significant heart disease and; with chronic lung disease of prematurity, defined as those born prior to 32 weeks 0 days gestation who required supplemental oxygen for the first 28 days of life or longer. Other groups may be considered for prophylaxis. Routine palivizumab prophylaxis is not recommended for children with Down syndrome or cystic fibrosis who do not meet criteria for prematurity, heart disease, or chronic lung disease. Infants with cystic fibrosis who have clinical evidence of chronic lung disease and/or nutritional compromise may be considered for prophylaxis in the first year of life. Infants with neuromuscular disease or a congenital anomaly that impairs the ability to clear upper airway secretions may also be considered for palivizumab (Synagis®) administration in the first year of life. Additionally, palivizumab (Synagis®) may be considered in the second year of life for children with cystic fibrosis who have manifestations of severe lung disease or inadequate growth.

The parent of an 8 month old reports switching the baby's formula to cow's milk due to the continued expense of formula. Which is the BEST response? A. Switching to cow's milk sooner than 1 year will not cause any harm. B. Cow's milk does not contain adequate nutrition, and poses a higher risk for allergy. C. Cow's milk has a lower protein and fat content, which will impede growth of the baby. D. There is no need to continue formula as long as the child is receiving other baby foods.

The correct answer is B - Cow's milk does not contain adequate nutrition, and poses a higher risk for allergy. During the first year of life, infants should receive only formula or breast milk. The use of cow's milk is contraindicated because of its high protein content, inappropriate nutrition composition, lack of iron sources, and the risk of gastrointestinal bleeding and allergic reactions. If an infant is switched sooner than one year, the practitioner should encourage the family to resume use of formula or breast milk until the one-year birthday. Despite the addition of table foods or baby solid foods, formula and breast milk are still the dietary mainstay at this age.

The MOST likely diagnosis for a child who presents with fever, poor appetite, abdominal pain, diarrhea, and recurrent aphthous ulcers is: A. acute gastroenteritis B. Crohn disease C. enterocolitis D. pseudomembranous colitis

The correct answer is B - Crohn disease Fever, diarrhea and abdominal pain in children can range from a short-lived viral illness to more urgent surgical conditions. The initial presentation of a chronic illness should also be considered. Most children with Crohn disease present with the classic symptoms of diarrhea, abdominal pain, and weight loss. Chronic perianal disease including skin tags, fissures, fistulae, and abscesses may be present. Recurrent aphthous stomatitis are also suggestive of Crohn disease. Poor appetite, fever and iron deficiency anemia are also commonly noted at initial presentation. A child with acute gastroenteritis often presents with vomiting, diarrhea, decreased appetite, and occasionally low grade fever. Enterocolitis is inflamation of the small and large intestines typically presenting with fever, abdominal distention and bloody stools. Symptoms of pseudomembranous colitis can start after a couple days of taking an antibiotic, and include blood or pus in diarrheal stools, with abdominal pain and fever.

A caregiver states she has been giving her 18 month old's hand a slap when the toddler is rough with the family dog, but that it does not seem to be correcting the behavior. Which of the following is the BEST response? A. Suggest explaining to the toddler that the actions are hurting the dog. B. Discuss child development and advise saying "no" while removing child from environment. C. Explain that because toddlers lack a sense of morality they are unable to understand why behavior is wrong. D. Inform the caregiver that while physical punishment can be effective there is a risk of psychological damage.

The correct answer is B - Discuss child development and advise saying "no" while removing child from environment. The American Academy of Pediatrics states that "effective discipline requires three essential components: (1) a positive, supportive, loving relationship between the parent(s) and child; (2) use of positive reinforcement strategies to increase desired behaviors; and (3) removing reinforcement or applying punishment to reduce or eliminate undesired behaviors." Children require rules, limits, and expectations but must be done so in a developmentally appropriate way. In this scenario, the best option is to control the child's environment by giving a verbal "no" and removing the child from the situation. Consistency is key, and the toddler cannot developmentally understand behavior is wrong. A toddler's sense of morality is primarily associated with pleasing the caregiver rather than through their own internal controls, which do not develop until the preschool years. Slapping is a form of punishment that only serves to retaliate against the undesired behavior rather than teaching to correct the behavior. Slapping should be avoided in favor of other discipline methods. Physical punishments can be effective but do carry the risk of physical and emotional harm.

Anticipatory guidance for completing a full course of antibiotics to treat group A streptococcal pharyngitis is for the prevention of: A. acute glomerulonephritis B. acute rheumatic fever C. pediatric autoimmune neuropsychiatric disorders associated with streptococcus (PANDAS) D. scarlet fever

The correct answer is B - acute rheumatic fever Antibiotic therapy for group A streptococcal (GAS) pharyngitis can prevent acute rheumatic fever, decrease the duration of the illness, decrease spread of the infection to others, and prevent suppurative complications such as peritonsillar and retropharyngeal abscesses. Antibiotics should be initiated by the 9th day of acute GAS pharyngitis to prevent acute rheumatic fever. Scarlet fever is an infection caused by pyrogenic exotoxin producing GAS. It should be treated with appropriate antibiotic therapy, but the infection is not prevented by completing a full course of antibiotics. Acute poststreptococcal glomerulonephritis can develop after an asymptomatic latent period following a GAS strep infection, but the effectiveness of antibiotics for prevention of this has not been demonstrated. PANDAS is a group of neuropsychiatric disorders for which a possible relationship with GAS infection has been hypothesized. There is insufficient evidence to date to prove a causative relationship between GAS and PANDAS, and thus currently it cannot be concluded that completing a course of antibiotic therapy for GAS pharyngitis will have an impact on prevention of these disorders.

The procedure for treatment of a wart using liquid nitrogen includes A. applying for 20-30 seconds or until patient complains of discomfort. B. applying until an area 1-3 mm beyond the wart turns white. C. retreating weekly until wart resolution. D. avoiding use on hyperkeratotic warts.

The correct answer is B - applying until an area 1-3 mm beyond the wart turns white. Liquid nitrogen should be applied to the wart for 2 to 10 seconds until an area of 1-3 mm beyond the wart turns white, or the child complains of pain. The goal of liquid nitrogen treatment is to form a blister at the epidermal-dermal junction. Freezing of warts over joints and lateral aspects of digits is more painful and typically not well tolerated by children. Retreatment may be needed to be successful. At home treatments include: salicylic acid which is applied to the wart with a toothpick once a day for 4-6 weeks, and duct tape applied for 12 hours a day for 6 days. These treatments have varied success rates and are typically slow to work. They are usually not successful for warts measuring under 5 mm in diameter.

The MOST appropriate pharmacologic treatment for localized cat scratch disease is: A. amoxicillin for 7 days B. azithromycin for 5 days C. ceftriaxone for 5 days D. cephalexin for 7 days

The correct answer is B - azithromycin for 5 days Cat scratch disease is one of the most common causes of benign regional lymphadenopathy in children. The causative organism is Bartonella henselae. Humans are most often infected by a scratch or bite from kittens. The most common presenting sign in immunocompetent persons is regional lymphadenopathy approximately 2 weeks after the scratch or bite. Other symptoms of localized disease include low grade fever and mild malaise, anorexia, fatigue and headache. Most cases of the disease are self-limiting and resolve spontaneously in 2 to 4 months. Although the use of antibiotics to shorten the course is debated, azithromycin has been shown to decrease lymph node volume more rapidly than allowing gradual resolution without the use of medications. Thus, some experts recommend a 5 day course of oral azithromycin. Antimicrobial therapy may shorten the duration of illness when acute or severe illness is accompanied by systemic symptoms. Antimicrobial therapy is recommended for all patients with immunosuppressive conditions. The optimal length of treatment for systemic disease is unknown but may be several weeks.

While at daycare a child with phenylketonuria accidentally receives a peanut butter sandwich and milk. The child is MOST at risk for developing: A. anaphylaxis B. cognitive deficits C. lactose intolerance D. behavioral outbursts

The correct answer is B - cognitive deficits Phenylketonuria (PKU) is a genetic disorder characterized by a mutation in the phenylalanine hydroxylase gene, the gene responsible for converting the amino acid phenylalanine to tyrosine. This gene mutation can lead to an excessive buildup of phenylalanine which interferes with the developing brain. A phenylalanine-restricted diet is the primary treatment for PKU. Foods with high amounts of phenylalanine include protein-rich foods like meat, eggs, milk, and peanut butter. These foods must be avoided. Nonadherence to the phenylalanine-restricted diet can result in cognitive deficits, developmental delays, seizures, EEG changes, anxiety, and depression. Anyone with PKU will also require daily supplementation of phenylalanine-free elemental medical foods for nutritional support. Most state laws require that insurance companies cover the cost of these foods. When diagnosed and treated early with appropriate dietary interventions, children with PKU can progress in school like their peers.

A pediatric nurse practitioner is considering a position with a pediatric pulmonologist in a clinic which specializes in the treatment of cystic fibrosis. However, there are patients in the practice who are over the age of 21 years. Which is the BEST action to take? A. decline the job offer for one in which only pediatric patients will be seen B. contact the state board of nursing regarding regulations related to patient populations C. agree to take the job since cystic fibrosis is a pediatric illness regardless of the patient's chronological age D. contact the certification agency to determine their rulings regarding patients over the age of 21

The correct answer is B - contact the state board of nursing regarding regulations related to patient populations Pediatric nurse practitioners (PNP) must base practice decisions on national and state legislation, which is usually guided by recommendations from organizations such as the American Academy of Pediatrics (AAP) and the National Association of Pediatric Nurse Practitioners (NAPNAP). Practice standards and competencies exist for this purpose. Ultimately, though, individual states determine licensure regulations and the PNP must be familiar with these rulings in order to practice under a state's jurisdiction. Some states require various types of physician collaborative agreements which can spell out specifics such as the age of patients being seen. The AAP and NAPNAP both offer support in the care of older patients with specific pediatric problems. The group of licensing, accreditation, certification and educational organizations known as LACE who have monitored the implementation of the APRN Consensus Model has also written guidance on this topic. Before taking any position, it is important for the PNP to examine specific state guidelines and be familiar with practice recommendations from all recognized organizations.

A 2 year old with mild iron deficiency anemia and an initial hemoglobin level of 10.5 g/dL has been taking ferrous sulfate 3 mg/kg/day for 1 month. Based on these current laboratory results (see below), what is the BEST course of action? A. increase ferrous sulfate dose to 6 mg/kg/day B. continue current dose for 3 months C. discontinue ferrous sulfate D. refer to hematology

The correct answer is B - continue current dose for 3 months Iron deficiency anemia (IDA) is a common problem in toddlers and preschoolers. The definition of IDA includes a hemoglobin (Hb) concentration 2 SDs below the mean Hb concentration for a normal population of the same gender and age range, as defined by the World Health Organization, the United Nations Children's Fund, and United Nations University. Anemia in children between ages 12 and 35 months is defined as a hemoglobin of less than 11.0 g/dL for both male and female children. For mild to moderate cases of IDA, recommendations are to administer ferrous sulfate, 3 mg/kg/day for a period of 3-4 months after the hemoglobin has returned to normal. It is expected that in one month there will be an increase of 1 g/dL increase in hemoglobin, so with a return to normal hemoglobin/hematocrit values, continuing the therapy is the appropriate action. If the level does not increase appropriately, checking a serum ferritin level along with a C-reactive protein (CRP) is recommended by the American Academy of Pediatrics.

The parents of an otherwise healthy 4 year old diagnosed with immune thrombocytopenia purpura (ITP) are frustrated because they feel "nothing was done" for their child. Physical exam reveals an active, playful child with multiple purpura and petechiae scattered over the skin but no mucocutaneous bleeding. A repeat complete blood count shows platelets of 45,000/mm3, hemoglobin of 9 mg/dL, and no abnormalities of the red or white blood cells. The NEXT step includes A. referral for intravenous immunoglobulin (IVIG) infusion. B. discussion regarding safety concerns. C. referral for hospital admission. D. initiation of steroid therapy.

The correct answer is B - discussion regarding safety concerns. Immune thrombocytopenia purpura (ITP), occurs in approximately 4 - 5 children per 100,000 with a peak incidence between the ages of 2 and 5 years. The cause is unknown, but thought to be related to immune factors. Expectant management is all that is required for most children and includes regular follow-up visits and repeated blood counts. Complete remission is seen in 89-90% of children within 6 - 9 months. Treatment is generally not indicated unless the course of the illness is chronic, the platelet count is less than 20,000/mm3, there is extensive bleeding, or when a protective home environment cannot be provided. Platelet transfusions are generally reserved for children with life-threatening complications such as an intracranial bleed. Although removal of the spleen produces a normal platelet count in 75% of the children with ITP, this surgery is reserved for children with long-term persistent problems due to the risk of fulminant post-splenectomy sepsis. Intravenous immunoglobulin (IVIG) is an alternative treatment for ITP and will induce a rapid rise in platelets, which may then decrease again. It also requires hospitalization and is expensive.

A parent of an adolescent refuses to leave the exam room so that a private opportunity can be offered to discuss risk-taking behaviors. The BEST response is to A. suggest it is the adolescent's responsibility to share any information with the parent. B. explain that parental presence can contribute to misdiagnosis and mistreatment. C. allow parent to stay in the room if adolescent is on their health plan. D. request permission from the adolescent for the parent to remain.

The correct answer is B - explain that parental presence can contribute to misdiagnosis and mistreatment. Concerns about confidentiality are associated with adolescents not seeking care for sexual and reproductive health services. A study by the CDC found that 12.7% of adolescents and young adults, the majority of whom are 15-17 years old, and remain on their parent's health plan, elect not to seek sexual and reproductive health services as they are worried that their parents may find out. Spending time alone with a provider during a visit has been associated with increased reports of sexual health concerns and optimal delivery of these treatment services. Encouraging the adolescent to talk with their parent regarding any concerns and asking the adolescent if they would like the parent to be in the room may undermine the therapeutic trust between the patient and provider. Allowing the parent to remain in the room while sexual and reproductive health concerns are discussed may lead to decreased reporting of concerns by the adolescent. At the beginning of the visit, explain to the parent and adolescent how the visit will be conducted. The provider will talk to both parent and adolescent about concerns or questions the parent may have. Then the parent is asked to step out while the provider asks the adolescent about sexual health, drug/alcohol use, and/or smoking. Adolescents need to understand what is discussed with the health care provider is confidential and will not be relayed to the parent unless there is concern about the risk of harm to self or others.

A school-age male presents with a recurrent episode of tea colored urine. Urinalysis results are negative for both nitrites and leukocyte esterase but positive for trace proteinuria with greater than 50 red blood cells per high power field. The MOST likely diagnosis is: A. drug/medication use B. glomerulonephritis C. myoglobinuria D. urinary tract infection

The correct answer is B - glomerulonephritis Glomerulonephritis is a noninfectious process characterized by findings of hematuria and proteinuria in which the amount of proteinuria does not exceed amount of hematuria. Myoglobinuria is ruled out by the number of red blood cells present, and the negative nitrite and leukocyte esterase make a urinary tract infection unlikely. Although drug or medication use can discolor urine, the findings of blood and protein in the urinalysis suggest another etiology.

An otherwise healthy adolescent presents with right upper quadrant pain, dark urine, and pruritus of the skin. Current medications include a daily multiple vitamin and kava for sleep problems. Which of the following is the MOST likely cause? A. cholecystitis B. liver toxicity C. pancreatitis D. renal stones

The correct answer is B - liver toxicity Kava, a member of the pepper family, is an herbal supplement included in products sold in the United States for a variety of uses, including insomnia and short-term reduction of stress and anxiety. These products are marketed to men, women, children, as well as seniors. Although scientific studies provide some evidence that kava may be beneficial for the management of anxiety, the U.S. Food and Drug Administration (FDA) has issued a warning that using kava supplements has been linked to a risk of severe liver damage. In March 2002, the FDA issued an advisory to consumers of the potential risk of severe liver injury from the use of dietary supplements containing kava (also known as kava kava or Piper methysticum). Reports from health authorities in Germany, Switzerland, France, Canada and the United Kingdom have linked kava use to at least 25 cases of liver toxicity, including hepatitis, cirrhosis, and liver failure, prompting some of these countries to remove kava from the market. Although liver damage appears to be rare, the FDA believes consumers should be informed of this potential risk. The National Center for Complementary and Alternative Medicine (NCCAM) funded studies on kava were suspended after the FDA issued its warning.

For an adolescent presenting with a scaly, copper-penny colored rash limited to the torso, palms of hands, and soles of feet, which is the next BEST step? A. obtain a scrapped skin culture of the rash B. obtain a treponemal automated test C. prescribe topical steroids D. prescribe oral antifungals

The correct answer is B - obtain a treponemal automated test While non-specific scaly rashes are common in children and adolescents, it is important to differentiate possible causes so that management is appropriate. Scaly patches that are copper-penny in color and involve the torso, palms of the hands, and soles of feet should prompt consideration of secondary syphilis for which the treponemal automated test is appropriate. In 2015-2016, the rate of primary and secondary syphilis cases increased 13% among teens aged 15-19 years. Active nonintervention is appropriate for pityriasis rosea, although oral antihistamines may be used for those who have associated itching. Culturing of scrapped specimens is used for herpes infection testing. While topical steroids are effective for eczematous lesions, eczema is rarely found on the palms of hands and soles of feet. Oral antifungal medications may be used in the treatment of tinea versicolor.

A caregiver expresses concern for her 12 month old's lack of interest in playing with other children, especially due to a family history of autism spectrum disorder. Which of the following is the MOST appropriate response? A. evaluate for social interactions such as peek-a-boo and pat-a-cake B. offer reassurance that interactive play begins at age 3 C. attempt to engage the child in imitating behaviors D. refer for a developmental evaluation

The correct answer is B - offer reassurance that interactive play begins at age 3 Play is an essential component in assessing development. Because there is a slight increased risk of autism spectrum disorder in familial studies, the caregiver is appropriately concerned for the child's risk. Peek-a-boo and pat-a-cake are developmentally appropriate engaging behaviors at this age; however, this does not address the concerns of the caregiver. Imitating behaviors begin between ages 2-3 years, so the child is too young to be evaluated for this type of play. Despite family concerns, a developmental evaluation is not needed as the child's lack of interactive play does not warrant a referral at 12 months of age. By educating about age-appropriate types of play, the specific concerns are being addressed.

Appropriate instruction for a young adolescent male considering strength training to enhance muscle mass includes that A. workouts should focus on 1-2 muscle group on any exercise day. B. powerlifting should be delayed until later in reproductive maturation. C. strength training should occur at least five times a week to be effective. D. other forms of exercise should be avoided on days that strength training is done.

The correct answer is B - powerlifting should be delayed until later in reproductive maturation. Strength training refers to the progressive use of mixed movement speeds to increase muscle strength and stamina. The use of weight machines, free weights, jumping and jogging increase stamina and strength. Strength training has been found to be beneficial, even to young athletes as long as it is done safely and supervised by a coach or experienced trainer. Powerlifting should be avoided in prepubescent children due to possible injury to long bones and growth plates as well as the back. Exercises should be balanced among all muscle groups, including strengthening for core muscles. All training sessions should begin and end with a period of warm-up and cool-down exercises that include stretching and dynamic movement such as a slow jog, jumping, or skipping. Athletes should do strength training no more than two or three times a week, and on nonconsecutive days to allow for recovery and to produce the greatest gains in strength building.

Anticipatory guidance for a caregiver of a 6 month old includes that which of the following foods is CONTRAINDICATED for introduction at this time? A. peanut powder B. raw honey C. scrambled eggs D. wheat cereal

The correct answer is B - raw honey Clostridium botulinum is a gram-positive, spore forming anaerobe which lives in dirt, soil and marine sediments. Botulinum toxin is the most poisonous toxin known. The toxin blocks neuromuscular transmission and causes acute, flaccid paralysis causing death through airway muscle paralysis. Raw honey can contain Clostridium botulinum spores, which can germinate in an infant's immature digestive system causing botulism, a rare but potentially fatal illness. For this reason, honey is never recommended for children less than 1 year of age. Newer data suggests that the early introduction of other foods may actually prevent individual food allergies with later introduction actually increasing food sensitization. Therefore, peanut powder, scrambled eggs, and wheat cereal are all safe and recommended to be introduced at this time.

Older adolescents with congenital heart defects should be transitioned to adult congenital heart specialists in order to A. provide subacute bacterial endocarditis (SBE) prophylaxis. B. reduce the risk of long-term complications. C. prepare for the next procedure. D. refill medications.

The correct answer is B - reduce the risk of long-term complications. Many children with congenital heart disease (CHD) undergo palliative, not corrective, procedures when young. As these children grow, they continue to require close follow-up to note when subtle changes occur and when potential future procedures or surgeries are needed. Studies have shown that as these older adolescents transitioned to adult CHD specialists, only a small percentage received the follow-up care they needed. Sometimes several years passed from the time of recommended transition until they were seen by an adult CHD specialist, usually prompted by new or increased symptoms. Not all patients with congenital heart disease require SBE prophylaxis or medications. If these patients are on medications, the prescribing health care provider should follow them serially to assess how they are doing, and if any new signs or symptoms have developed. Pregnancy is also not recommended for women with severe congenital heart lesions and appropriate counseling and birth control options need to be discussed.

A continuous murmur is auscultated on an asymptomatic 2 month old, born at 35 weeks gestation. Which of the following is the NEXT step? A. obtain an echocardiogram B. refer to pediatric cardiologist C. obtain an electrocardiogram D. refer to pediatric cardiothoracic surgeon

The correct answer is B - refer to pediatric cardiologist Congenital heart disease is a common disorder in the pediatric population. Murmurs are one of the most common clinical features of a congenital heart defect, with auscultation of both innocent murmurs and those that are concerning. The most important next step would be to have the infant referred to a pediatric cardiologist for further care and management of the murmur. It is best to refer to a pediatric cardiologist. Studies such as chest radiograph, ECG, ECHO, and CBC will most likely be ordered

The benefit of fluoride is achieved through which of the following mechanisms? A. bactericidal effect on Streptococcus mutans B. remineralization of carious lesions C. prevention of plaque adherence D. destruction of milk sugars

The correct answer is B - remineralization of carious lesions It is important for health care providers to screen for dental caries and to identify risk factors for development of decay. Caries occur from the overgrowth of the bacteria Streptococcus mutans, Streptococcus sobrinus, and lactobacillus species, which are part of normal human flora. These bacteria adhere well to the tooth surface. Topical fluoride is effective in assisting in the prevention of caries by inhibiting demineralization and aiding in the remineralization of carious lesions. While fluoride does not prevent plaque adherence, it can alter the enamel of teeth making it more resistant to the destructive effects of the bacteria found in the mouth. Milk sugars are a common cause of caries providing a medium for the bacteria to flourish

A 7 year old fell, injuring the right wrist. Radiographs of the wrist were negative, and the child was treated for a moderate sprain and sent home with a sling. Ten days later the child is still complaining of wrist pain with point tenderness. Which should be the NEXT step in management? A. discontinue use of the sling B. repeat wrist radiographs C. refer to orthopedics D. order a bone scan

The correct answer is B - repeat wrist radiographs Subtle fractures and Salter I fractures can be missed initially; repeat films 10 to 14 days after an injury may be necessary to confirm the diagnosis of a fracture. Because this child is still symptomatic with complaints of pain and point tenderness after the fall, follow up radiographic studies are indicated. Bone scanning is useful in diagnosing stress fractures, but not appropriate in this situation with a history of a known injury. It is likely that this is a simple fracture that will heal quickly with immobilization, with no disruption to bone growth. If the follow-up radiograph showed evidence of trauma to growth plates, a referral to an orthopedic provider would then be appropriate.

Administration of the 23-valent pneumococcal polysaccharide vaccine is indicated for a child who has: A. plans for travel to India B. stage 3 chronic kidney disease C. a sibling with human immunodeficiency virus infection D. Down syndrome with a closed ventricular septal defect

The correct answer is B - stage 3 chronic kidney disease The 23-valent pneumococcal polysaccharide vaccine (PPSV23) is recommended for children two years and older with underlying medical conditions that put them at risk for invasive pneumococcal disease caused by serotypes not usually acquired by otherwise healthy children. These medical conditions include chronic heart disease, particularly those associated with heart failure and cyanosis, chronic lung diseases including asthma requiring high steroid doses for treatment, diabetes mellitus, cerebrospinal fluid leaks, cochlear implants, sickle cell disease, hemoglobinopathies, congenital and acquired asplenia, human immunodeficiency virus (HIV) infection, chronic renal failure and nephrotic syndrome, and other illnesses associated with immunosuppressive medications and immunodeficiency. In particular, if cochlear implant or elective splenectomy is planned or immunosuppressive therapy is expected, the PPSV23 should be administered two weeks before the planned procedure. A second dose of PPSV23 is administered five years after the first for those individuals with a condition that causes immunocompromise, including asplenia. There are no indications for this vaccine related to travel. While immunization of groups can offer herd immunity, there are no special indications for this vaccine related to siblings with HIV.

A child presents with a two-day history of perianal erythema, itching, pain, and a fever reaching 100.5 F (38 C). Which of the following is the MOST important history question? A. "Was a fever-reducer given?" B. "Have you changed bath soaps recently?" C. "Has the child had a sore throat recently?" D. "Does anyone in the house have a similar rash?"

The correct answer is C - "Has the child had a sore throat recently?" The child in this scenario is likely presenting with a perianal streptococcal infection. Common symptoms include erythema, pain, local itching, and blood streaked stools. While presentation with fever can occur, many cases do not involve systemic symptoms. The infection is usually a result of autoinoculation from a recent group A streptococcal infection. On physical exam the perianal area is erythematous with distinct margins that can extend up to 2 cm from the anus. While the history questions posed in the options are appropriately asked, the most important is whether there is history of a recent sore throat which would cause the streptococcal autoinoculation. Rapid strep test of a perianal swab assists in confirming the diagnosis. Treatment for perianal infection is the same as for streptococcal pharyngitis with penicillin V or amoxicillin being the most appropriate antibiotics. Perianal pruritis is also seen with pinworm infections. However, these children typically present with irritability, hyperactivity and insomnia. They are not painful and do not present with systemic symptoms. On exam during nighttime, long, white threadlike worms can be seen at the anus.

An adolescent female reports being sexually active with a single male partner. When discussing contraceptive options, which of the following methods should be identified as having the HIGHEST failure rate? A. depot medroxyprogesterone acetate (DMPA) B. intrauterine device (IUD) C. male condom D. vaginal diaphragm

The correct answer is D - vaginal diaphragm The vaginal diaphragm has the highest rate of failure among the methods listed. Use of vaginal diaphragms requires determining proper fit and placement, use of spermicide, and must remain in place for a minimum of 6 hours after intercourse. Depot medroxyprogesterone acetate (DMPA) is very effective given that it is a hormonal injection and does not have to be repeated during each episode of intercourse. Intrauterine devices (IUD) are safe and effective and can last 5-10 years after being placed at an experienced provider's office. Male condoms are less effective than hormonal contraceptives or an IUD but have a higher success rate than vaginal diaphragm as they are easier to use.

The parents of a 5 year old are frustrated by their child's need to select her own clothing, despite weather and safety. Which is the BEST example of a parent statement to the child that will promote self-esteem? A. "Go ahead and wear the sandals, but you will be cold." B. "Wear the sandals, but take your shoes and socks in case you change your mind." C. "You must wear shoes and socks, but you can choose between the red or black ones." D. "It is too cold to wear sandals, and we cannot leave until you decide to put on shoes and socks."

The correct answer is C - "You must wear shoes and socks, but you can choose between the red or black ones." Children need to have limits identified and consequences clearly stated. The goal of discipline is to ultimately teach the child, not to punish them. Children at age 4 and 5 are at Erikson's developmental stage of "initiative vs. guilt," and Piaget's "intuition" or preoperational thinking. In order to facilitate the development of and foster self-esteem, the parent needs to provide guidance, but allow the child some choices. Limit setting paired with providing options for the child, like the choice of which shoes to wear, while maintaining that the child cannot wear sandals, supports developmental theories and fosters a child's self-esteem. There may be times when allowing the child full autonomy in dressing is acceptable, but safety and health concerns must be considered first by the parents.

An adolescent used a prescribed emergency contraceptive, after having unprotected sexual intercourse. A return visit and pregnancy test should be advised if there is no period within: A. 1 week B. 2 weeks C. 3 weeks D. 4 weeks

The correct answer is C - 3 weeks An emergency contraceptive can be prescribed for adolescents who are sexually active to prevent a pregnancy in the event that a condom breaks, no contraceptive was used during vaginal intercourse, or contraceptive was forgotten. Some references advise pre-emptive prescription of emergency contraception for all female adolescents who are sexually active. Plan B One Step is a single tablet of levonorgestrel and is to be taken within 72 hours of unprotected intercourse for increased efficacy. Guidance should include that after taking an emergency contraceptive, the adolescent should return for a pregnancy test within 3 weeks if menses has not started. In the meantime, the adolescent should use condoms or refrain from sexual intercourse until the next cycle starts. Emergency contraceptives may also alter the schedule of menses, but in general menses will likely come sooner than expected.

Which scenario BEST represents an example of child ASSENT in health care research? A. 5 year old who passively shrugs when asked for permission to participate in a clinical trial B. 6 year old who is shown pictures of the research opportunity and agrees with a nodding of the head C. 9 year old who verbally refuses then consents to participate the following day D. 10 year old who is asked by the parents to participate and is silent when approached

The correct answer is C - 9 year old who verbally refuses then consents to participate the following day Assent, or the child's permission to participate, is influenced not only by the child's chronological age but perceived developmental understanding. Thus, the capacity to engage in assent is best described as on a continuum, with a positive assent dependent upon the child's developmental level and capability. The younger child, due to developmental limitations, cannot be viewed as an independent decision maker despite informational methods used. Additionally, assent should be an affirmative choice and not simply silence or passive resignation. When seeking child assent, the child's choices should be taken seriously. Therefore, the child's dissent should also be respected.

The caregiver of a 2 week old states that though the infant was fed Enfamil LIPIL™ with iron in the hospital, he is now receiving ProSobee LIPIL™ formula due to a concern about allergies in an older sibling. Which is the BEST information to share? A. Continue to use Enfamil LIPIL™ because ProSobee LIPIL™ does not contain an adequate amount of iron. B. Continue to use Enfamil LIPIL™ to prevent development of future allergies. C. Both formulas contain equal amounts of nutrients including iron. D. Both formulas contain carbohydrates in the form of lactose.

The correct answer is C - Both formulas contain equal amounts of nutrients including iron. As outlined in federal regulations, formulas contain equal nutritional value as long as they are designated for infant feeding. The difference between ProSobee LIPIL™ and Enfamil LIPIL™ is in the carbohydrate content; the carbohydrates in Enfamil LIPIL™ are milk- based. ProSobee LIPIL™ contains carbohydrates in the form of corn syrup solids instead of lactose. Lactose is sometimes responsible for allergic type reactions, although they are rare in newborns.

Which blood test is the MOST sensitive early indicator for musculoskeletal inflammatory disorders? A. anti-nuclear antibodies (ANA) B. complete blood count with differential (CBC) C. C-reactive protein (CRP) D. erythrocyte sedimentation rate (ESR)

The correct answer is C - C-reactive protein (CRP) The C-reactive protein (CRP) is an acute phase reactant serum protein which rises rapidly under an inflammatory stimulus. The erythrocyte sedimentation rate (ESR) also documents inflammation and assists in following the course of some chronic rheumatic disorders. The ESR can be falsely low in some illnesses, and the results are affected by prolonged storage of the blood or tilting of the calibrated tube. The CRP has an advantage over the ESR in that it may be performed on freeze-dried specimens and is most sensitive for early infections and inflammatory processes. The complete blood count (CBC) with differential may indicate infection but is not always elevated in the presence of inflammation. Anti-nuclear antibodies (ANA) is often present in individuals with pauciarticular disease and fairly common in late onset rheumatoid disease but is not an early indicator.

An infant who has short stature and is hypotonic with hypogonadism and feeding problems is MOST likely to have: A. DiGeorge syndrome B. fragile X C. Prader-Willi syndrome D. trisomy 21

The correct answer is C - Prader-Willi syndrome Prader-Willi syndrome is characterized by hypogonadism, intellectual disability, short stature, and obesity. Additional characteristics include a narrow bifrontal diameter, strabismus, almond-shaped eyes, and small hands and feet. Neonates with this syndrome are profoundly hypotonic, typically causing dysphagia leading to feeding problems in the first year of life which is sometimes significant enough to cause failure to thrive. Prader-Willi syndrome is a genetic abnormality, paternally derived and documented through the use of a fluorescence in situ hybridization (FISH) study. Characteristics of an infant with trisomy 21 include short stature, epicanthal folds, hypotonia, a small mandible, and developmental delays. Approximately one third of infants with complete DiGeorge syndrome have cardiac defects, growth or developmental delay, and genital hypoplasia. Fragile X syndrome accounts for 3% of males with mental disabilities. Characteristics include cognitive delays, behaviors consistent with autism, macroorchidism, and characteristic facial features.

Which of the following is the MOST appropriate information to provide to a pregnant 16 year old whose immunizations were last updated at age 12? A. Tdap vaccine is not recommended during pregnancy. B. Tdap vaccine is recommended every 10 years, the next dose should be given in 5 years. C. Tdap vaccine is recommended with every pregnancy. D. After the initial Tdap series, only the tetanus toxoid vaccine is recommended every 10 years.

The correct answer is C - Tdap vaccine is recommended with every pregnancy. The Advisory Committee on Immunization Practices (ACIP) published revised recommendations for the Tdap vaccine in 2013. In 2011, the ACIP previously recommended that unvaccinated pregnant women receive the vaccine; the update now recommends Tdap with each pregnancy regardless of previous history. During several years prior to this recommendation, substantial increases in the cases of infant pertussis occurred, thus prompting the new recommendations. Newborn and very young infants are unable to mount a cell-mediated response and rely solely on maternal antibody for protection from pertussis. Vaccinating the pregnant woman stimulates development of maternal antibodies against pertussis, which are then transferred across the placenta to the fetus. The mother is also protected around the time of delivery, decreasing her risk of contracting pertussis and transmitting it to the infant. Tdap may be administered at any time during pregnancy but is preferred during the third trimester, to provide the greatest transfer of maternal antibody nearer to the time of birth. Studies in nonpregnant adolescents and adults have not shown any serious adverse events in persons who received Tdap and tetanus and diphtheria toxoids (Td) or Tdap-inactivated polio vaccines at short intervals between doses. These studies include small numbers of persons, and thus may not identify rare but significant adverse events. No significant adverse events have been noted in large studies of tetanus toxoid use during pregnancy. Tetanus toxoid and Td have been used extensively worldwide in pregnant women for prevention of neonatal tetanus. There is a theoretical risk for severe local reactions for pregnant women who have multiple pregnancies within short intervals, but the evidence suggests no increased risk of severe adverse effects for women receiving Tdap with every pregnancy. The ACIP believes that the morbidity and mortality associated with pertussis in infants outweighs the possible theoretical concerns of severe adverse events.

Shortly after administration of vaccines, a child develops generalized pruritus and dyspnea. What is the MOST appropriate initial action? A. administer supplemental oxygen B. call 911 for transport to an emergency facility C. administer intramuscular epinephrine D. provide monitoring until symptoms subside

The correct answer is C - administer intramuscular epinephrine Although rare, vaccines are not without adverse effects. The measles, mumps and rubella (MMR), varicella zoster, influenza, hepatitis B, meningococcal, and tetanus-containing vaccines all have the potential for an anaphylactic reaction. Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. Most cases of anaphylaxis are the result of activation of mast cells and basophils by allergen-specific IgE molecules. Patients initially must be exposed to the responsible allergen to generate allergen-specific antibodies, then when re-exposed, mast cells and basophils release a variety of mediators (histamine, tryptase) and cytokines that can produce allergic symptoms in any or all target organs. Initial symptoms vary but may include any of the following: pruritis, a sensation of warmth, weakness, apprehension (feeling of impending doom), flushing, urticaria and angioedema, tightness in throat, dry staccato cough and hoarseness, nasal congestion, sneezing, dyspnea, deep cough and wheezing, nausea, abdominal cramping, vomiting, faintness, and loss of consciousness. Although transporting to an emergency facility and administering supplemental oxygen, in addition to the administration of a PO H1-blocker, corticosteroids, nebulized albuterol, and volume expanders may be necessary, the most important medication in treating any anaphylactic reaction is epinephrine. There should be no delay in its administration. Recognizing an anaphylactic reaction and responding promptly will promote a culture of patient safety.

In addition to hypoglycemia, the MOST common complications found in infants born to mothers with diabetes or gestational diabetes include: A. neural tube defects, anemia, and respiratory distress B. cardiomegaly, polycythemia, and hypotonia C. cardiomegaly, respiratory distress, and polycythemia D. hepatosplenomegaly, hypotonia, and anemia

The correct answer is C - cardiomegaly, respiratory distress, and polycythemia About 36% of infants born to mothers with diabetes or gestational diabetes are generally large for gestational age (LGA) and predisposed to many anomalies and metabolic disorders related to diabetic control throughout the pregnancy. Hypoglycemia develops in about 27% of these infants, with only a small percentage actually demonstrating symptoms of jitteriness, hyperexcitability and poor feeding. Five to 8% have major congenital malformations. Cardiomegaly is common in infants of diabetic mothers, occurring about 30% of the time and associated with anomalies including asymmetrical septal hypertrophy, subaortic stenosis, atrial septal defect, and transposition of the great arteries. Additional anomalies can include neural tube defects, and defects of the GI tract and kidneys. These infants have a higher risk of respiratory distress (34%), an increased incidence of hyperbilirubinemia, renal vein thrombosis, and polycythemia (5%).

Which of the following findings in a 13 month old would warrant a referral for a more thorough developmental evaluation? A. cruises but does not walk independently B. does not use a sipping cup or spoon C. favors use of right hand D. afraid of strangers

The correct answer is C - favors use of right hand Developmental evaluation should be performed at each well child check according to established developmental guidelines. Gross motor development follows a predictable pattern from the central nervous system's head to toe maturation. Gross motor delays are fairly common and range from mild to severe. Some of the children's delays will self-correct without intervention while other ones will need intervention. After a gross motor delay is identified, evaluation and treatment may be warranted. Mild delays may be closely surveilled in the primary practitioner's office where other delays such as regression of motor skills or loss of strength require expert evaluation and referral. Hand dominance is usually not exhibited before 18 months of age. Early hand preference may indicate weakness of the contralateral extremity. Children usually walk by 9-15 months of age. Children exhibit stranger anxiety between 6-18 months of age. Children often do not use household items appropriately until 15-18 months of age, therefore a 13 month old may not yet use a sipping cup or a spoon.

Which of the following is the MOST appropriate advice for caregivers regarding a child's exposure to virtual violence? A. provide supervision by co-playing or co-viewing first-person shooter games B. limit exposure to virtual violence to cartoon violence for children under the age of 6 C. implement a "media diet" due to the proven link between virtual violence and real-world aggression D. allow exposure to media violence in a controlled virtual reality environment as an outlet to safely release aggression

The correct answer is C - implement a "media diet" due to the proven link between virtual violence and real-world aggression Exposure to violence in media, referred to as virtual violence, places children and adolescents at risk for negative health effects. Counseling on media consumption is an important way that pediatric health care providers can reduce the risk of youth violence. Although it is recommended that caregivers co-view programming or co-play games, first-person shooter games are not recommended for children of any age. Additionally, because children under the age of 6 can have difficulty separating fantasy from reality, this group should not be exposed to any type of virtual violence, including cartoon violence. A common misconception is that children can safely release aggression in a virtual reality environment. However, it has been shown that experiencing virtual violence in this way can increase aggression in children and adolescents. Caregivers should be guided in developing a healthy "media diet" with a focus on time constraints as well as content choice. The link between virtual violence and real-world aggression has been scientifically proven.

A school-age child presents with fatigue and weight loss. Which of the following complaints would MOST likely prompt referral for suspected diabetic ketoacidosis? A. blurred vision B. increased urination C. nausea and vomiting D. increased thirst and hunger

The correct answer is C - nausea and vomiting Early symptoms of type 1 diabetes mellitus include polydipsia, polyphagia, polyuria, nocturia, blurred vision, weight loss, fatigue, and vaginal moniliasis in females. If not recognized early, prolonged hyperglycemia and insulin deficiency will lead to ketoacidosis with progressive symptoms of abdominal pain, nausea, vomiting, fruity-smelling breath, weakness, mental confusion, and flushed cheeks and face. Without prompt recognition, referral, and treatment, ketoacidosis can progress to brain swelling, coma, eventual brain herniation, and brain death.

A school-age child presents with a five-day history of high fever (greater than 102.2 F or 39 C) with no other symptoms reported except a rash for the past three days. The physical exam reveals a fine, rough, papular rash in the axilla and groin. Which of the following tests should be ordered FIRST? A. complete blood count B. erythrocyte sedimentation rate (ESR) C. rapid strep test D. urinalysis by dipstick

The correct answer is C - rapid strep test Scarlet fever is a common illness in childhood, especially among school-age children, and is caused by group A beta hemolytic streptococcus. The incubation period is 1-7 days, and symptoms are typically of abrupt onset and can include fever, malaise, vomiting, sore throat, lymphadenopathy and headache. A typical rash associated with scarlet fever is red and described as feeling like "sandpaper" that begins on the neck and spreads to the trunk and extremities; it is prominent in the axilla and groin. A rapid strep test confirms a diagnosis of group A streptococcal infection and is most appropriate to obtain first as clinical presentation is consistent with diagnosis. Differentials for a school-age child presenting with a 5- day history of fever and rash, include viral illness, Kawasaki disease, and a urinary tract infection. If the rapid strep test is negative, then urinalysis, ESR, and CBC would be appropriate to obtain to rule out other differentials

A school-age child presents with a 6-week history of a skin rash and limping associated with bilateral inflammation of knee joints with a more recent 2-week history of fever. Which is the MOST likely diagnosis? A. acute rheumatic fever B. dermatomyositis C. systemic juvenile idiopathic arthritis D. systemic lupus erythematous

The correct answer is C - systemic juvenile idiopathic arthritis Juvenile idiopathic arthritis (JIA), previously referred to as juvenile rheumatoid arthritis (JRA) is the most common type of arthritis in children. The exact etiology of JIA is unknown but likely due to an environmental influence in genetically pre-disposed individuals. There are six JIA subtypes. Systemic JIA is considered an autoinflammatory disease; whereas, the other types are considered autoimmune diseases. Systemic JIA causes inflammation in one or more joints for 6 weeks' duration in a child younger than 16 years of age and is often accompanied by a high fever (103° F [39.4° C] or higher) that lasts at least 2 weeks, fatigue, inflammation of joints, and a skin rash. Pericarditis, pleuritis, anemia, or enlargement of lymph nodes, liver or the spleen may also occur. About 10 percent of children with JIA will have the systemic form. Researchers believe there is a genetic component to JIA and a virus may trigger the disease process. Systemic lupus erythematous (SLE) is a chronic systemic rheumatic disease. Symptoms include fatigue, skin rashes, fever and joint involvement with non-deforming arthritis with effusion and tenderness. SLE can involve many organ systems (kidney, skin, blood cells and nervous system). A malar rash across the cheeks and bridge of the nose in the shape of a butterfly is seen in 95% of SLE cases. The most common manifestation of acute rheumatic fever is polyarthritis of large joints. The latency period from infection with group A streptococcal infection until the onset of arthritis is about 2-6 weeks. Acute rheumatic fever is most common in children 5-15 years of age. Dermatomyositis is an autoimmune myopathic illness affecting the pediatric population. Proximal muscle weakness in addition to thick scaling on extensor surfaces, known as Gottron papules, are characteristic of dermatomyositis. Results of laboratory studies are often normal at the time of diagnosis. The standard of definitive diagnosis is through muscle biopsy and management is through rheumatology. Without adequate treatment, muscle weakness will often continue to progress. Early recognition of Gottron papules is key to the diagnosis of dermatomyositis.

Emollients have not been effective for a child with psoriasis who has involvement of the eyelids. Which of the following is the BEST choice of topical medication? A. calcipotriene B. salicylic acid C. tacrolimus D. tazarotene

The correct answer is C - tacrolimus Topical therapies for different areas and skin thicknesses can vary. In general, the lower potency topical steroids (TCS) are used in areas of thinner skin such as the face, eyelids, flexures and folds, while the higher potency TCS are used for areas of thicker skin. The eyelids or face are at increased risk for adverse effects from long-term steroid use, so the appropriate agent is tacrolimus. Calcipotriene is a vitamin D analogue. These agents are better suited for treatment in areas of thicker plaques including the scalp, extremities, palms and soles. Salicylic acid is a keratolytic, a peeling agent used to debulk thick, localized plaques on the scalp, palms and soles. Tazarotene is also reserved for thicker plaques away from intertriginous sites.

Which BEST describes the meaning of sun protection factor (SPF) 6 labeled on sunscreen? A. application of the sun screen will protect the child from UVA rays for 6 hours B. application of the sun screen will protect the child from UVB rays for 6 hours C. the sun screen prolongs the time to sun burn by a factor of 6 D. the sun screen will continue to work for 60 minutes in water

The correct answer is C - the sun screen prolongs the time to sun burn by a factor of 6 Sunscreens provide a chemical or physical barrier blocking the sun's rays. Most sunscreens include multiple chemicals to provide broad coverage for different types of light, i.e., UVA and UVB. SPF or Sun Protection Factor is the measure of the sunscreen's ability to prevent UVB from damaging skin. In midday sun (10am-4pm) it takes approximately 20 minutes for unprotected skin to start turning red. Therefore, sunscreen with SPF 6 should prevent reddening of skin 6 times longer or about 2 hours. The American Academy of Dermatology recommends that children should be protected with an SPF 30 or higher. Sweat, swimming and wind will affect the longevity of the sunscreen, so it should be reapplied as directed on the package or bottle. A sun resistant sun screen will function for 40 minutes in water and waterproof sunscreens work for 80 minutes in water.

Risk for sudden infant death syndrome, middle ear effusions, upper respiratory infections, and asthma are increased in infants with exposure to: A. aerosolized pesticides B. fossil fuel related air pollution C. tobacco smoke D. wood burning stoves

The correct answer is C - tobacco smoke Secondhand tobacco smoke is caused by the burning end of cigarettes and the smoke breathed out by smokers. Secondhand smoke contains more than 7,000 chemicals, many of which are carcinogenic, as well as causing many health problems in children and adults. Thirdhand smoke results from the chemicals and smells that remain on the clothing of smokers after smoking. Children exposed to secondhand tobacco smoke have increased frequency of viral respiratory infections, and middle ear effusions than children without exposure. Higher levels of nicotine and cotinine have been found in infants who die from SIDs than those who have died from other causes. Infants whose mothers smoked during pregnancy have an increased risk of SIDs. Air pollution is associated with increased risk of asthma and other respiratory diseases as well as an increased risk for SIDS but not with middle ear effusions. Wood burning stoves dry out the air which predisposes infants to more upper respiratory infections and ear infections. The toxic effects of pesticide exposure include polyneuropathy, central nervous system dysfunction, hormonal imbalances, cancer and pulmonary fibrosis. Asbestos is a carcinogen but has not been shown to increase the risk for the other conditions listed.

An adolescent with a history of severe motion sickness is concerned about an upcoming family vacation by car. Which of the following medications is the MOST appropriate recommendation? A. aprepitant (Emend) B. hydroxyzine (Vistaril) C. meclizine (Medi-meclizine) D. ondansetron (Zofran)

The correct answer is C- meclizine (Medi-meclizine) Meclizine (Medi-Meclizine, Dramamine Less Drowsy, others) is an antiemetic and antihistamine approved by the FDA for prevention and treatment of motion sickness and management for vertigo. No clinical studies have been done to establish safety or effectiveness in children, and therefore it is not recommended for children under the age of 12 years. It is available over the counter in 12.5 mg and 25 mg dosages in oral formulations including tablets and chewable tablets. Aprepitant (Emend) is a substance P/ neurokinin 1 receptor agonist that is FDA approved for prevention of acute and delayed nausea and vomiting in ages 18 years and above. Although it has no approvals for pediatric patients, it is used off-label in children for prevention of chemotherapy-induced nausea and vomiting. It has been used in this clinical setting in both tablet form as well as an extemporaneous preparation of an oral solution. Hydroxyzine is an anxiolytic, antiemetic, antihistamine and sedative. In its oral form, it is approved by the FDA for use in treatment of anxiety, pruritus, and preoperative sedation in pediatric patients with no ages specified. In its parenteral form it is additionally approved as an antiemetic in infants, children, and adolescents as well as adults. Ondansetron is an antiemetic in the 5-HT3 receptor antagonist family. Its oral formulations are FDA approved for prevention of nausea and vomiting associated with moderately and emetogenic chemotherapy in children ages 4 years and up. In parenteral formulation, it is approved for prevention of nausea and vomiting associated with emetogenic cancer chemotherapy in infants 6 months of age and older through adults, and in prevention of postoperative nausea and vomiting in infants 1 month of age through adults. Although nausea and vomiting are symptoms of motion sickness, ondansetron is not approved for this use.

A mother who recently immigrated co-sleeps with her 4 week old. When counseling about the risk of sudden infant death syndrome (SIDS), which of the following statements BEST represents a culturally competent and client-centered response? A. "Infants younger than 3 months old who bed-share have a 5-fold increase in the risk of SIDS." B. "I know you prefer to have your baby next to you during the night, but the safest place for your baby to sleep is in a crib." C. "I understand that in your native country sleeping with your baby is a common practice, but it contributes to SIDS." D. "I understand that it is important to have your baby sleep with you for bonding, but let's talk about ways to keep your baby close and in the safest sleep position possible."

The correct answer is D - "I understand that it is important to have your baby sleep with you for bonding, but let's talk about ways to keep your baby close and in the safest sleep position possible." Incorporating culturally sensitive and competent care into all client interactions is an important ethical and professional responsibility. Much evidence in the literature has found that co-sleeping can contribute to increased risk of sudden infant death syndrome (SIDS) in infants 1-6 months of age because of overheating, asphyxia, or entrapment. While it is important to educate and inform caregivers of all risks to child safety and make recommendations, truly culturally competent care involves active listening to understand the priorities and values that underpin a particular cultural practice. This understanding of the family's context enables the development of a collaborative environment for negotiating a plan of care that is mutually beneficial and acceptable. Option A provides only empiric data and while Option C acknowledges co-sleeping as a common practice, it does not demonstrate an understanding of the family's values. Option B reflects an understanding of family preferences but does not show that the mother's priorities and concerns for cosleeping were uncovered. Option D demonstrates an understanding and acknowledgement of the mother's concern about adequately bonding with her baby as the rationale for bed-sharing. It also shows an attempt at negotiating a plan of care that meets both caregiver and provider priorities.

A toddler is diagnosed with grade I unilateral vesicoureteral reflux (VUR). When providing counseling to the caregivers, which of the following statements is MOST appropriate? A. "Most children do not outgrow their vesicoureteral reflux." B. "Antibiotics will need to be taken daily to prevent urinary tract infections." C. "Your child will have scarring in the kidneys and is at risk for chronic renal disease." D. "Prompt evaluation will be needed if your child has any signs of illness such as fever."

The correct answer is D - "Prompt evaluation will be needed if your child has any signs of illness such as fever." Most children with vesicoureteral reflux (VUR), particularly those that are young and have unilateral VUR, will eventually outgrow the reflux. VUR does not cause scarring, but infection does. VUR can increase the risk of pyelonephritis and therefore scarring and long-term damage to the renal system. Current standards support prophylactic antibiotics in children less than1 year of age and older children with grade II-IV VUR, although some research is questioning the efficacy of UTI prevention in VUR. Because children with VUR are at high risk for kidney infection, prompt evaluation for UTI is necessary for early diagnosis and treatment to prevent long-term sequelae

To address an adolescent's obesity, which of the following is the MOST appropriate approach to begin a motivational interview? A. "What is one thing you think you could change about your lifestyle?" B. "Your blood pressure is elevated and you seem nervous. How are you feeling?" C. "What do you already know about ways to improve your physical health and lose weight?" D. "Your blood pressure is a little high and that worries me. Can you tell me a little bit about your eating habits?"

The correct answer is D - "Your blood pressure is a little high and that worries me. Can you tell me a little bit about your eating habits?" Patients and their parents often appear to lack sufficient motivation to make significant changes in eating behaviors, dietary composition, and physical activity. Motivational interviewing uses a nonjudgmental and supportive mode of communication between the health care provider (HCP) and patient, designed to enhance motivation for behavior change, rather than the more traditional emphasis on the transfer of information about healthy diet or exercise. The steps in motivational interviewing include, establishing a rapport with the patient, setting an agenda, identifying the patient's ability to change, and establishing a plan. When beginning a motivational interview, developing rapport allows the HCP and patient to establish a trusting relationship which includes active listening and thoughtful reflection. The HCP must engage in active reflective listening to respond effectively to the patient's or parent's questions and statements. Once the patient or parent acknowledges both concern about the blood pressure and a belief that behavior change will be effective in overcoming the problem, it then becomes much more likely that goals for behavior change can be articulated, agreed on, and ultimately achieved

An adolescent presenting for a pre-college physical reports being a sexually active lesbian. Which is the MOST immediate action? A. assess for potential psychosocial difficulties B. ensure human papilloma virus vaccination is up-to-date C. provide confidential, current, factual, and nonjudgmental care D. counsel about sexually transmitted infections and contraception

The correct answer is D - counsel about sexually transmitted infections and contraception An Institute of Medicine report describes that adolescent lesbian and bisexual females are more likely to have been pregnant when compared to their heterosexual peers. A CDC survey among adolescents regarding sexual identity and sexual contacts further conferred that some respondents who self-identified as heterosexual, only had sexual contact with same sex partners while others who self-identified as lesbian, gay, bisexual (LGB) had either had no sexual contact or only had heterosexual sexual contact. Thus, LGB adolescents and young adults are at greater risk for unplanned pregnancy; therefore, it is important to counsel about accidental pregnancy even with women who have sex with women. Providing sexual and reproductive health education that includes information about abstinence, contraception and sexually transmitted infections (STIs) is necessary for all adolescents and young adults. Additionally, information about contraception should be offered to all females regardless of their sexual orientation. Pre-college visits present an excellent opportunity to ensure that all immunizations are current, not just the human papilloma virus vaccine. Adolescents and young adults, including those who know or are unsure about their sexuality, may have psychosocial concerns. Providing care that is confidential, current, factual, and nonjudgmental is required with all patients, regardless of their sexual orientation.

For a school-age child exposed to violence, which of the following scenarios would warrant referral to a mental health professional? A. parents report no ongoing concerns with future safety B. parents wish to be referred to support groups C. child's behavior has improved slowly over time D. event led to the death of a parent

The correct answer is D - event led to the death of a parent Unfortunately, violence is common and children are frequently witnesses or victims. Children witness violence in a number of ways including intimate partner violence, as well as in the community and with exposure to media. Violence affects children psychologically, behaviorally, and their self-esteem as they grow up. Future relationships may be affected, especially for those children who have witnessed intimate partner violence. Children exposed to violence can experience terror, helplessness, and fear and can come to view the world as a dangerous and unpredictable place. Additionally, research has demonstrated that exposure to violence at a young age can cause several physiologic health problems, including asthma and obesity. Screening for violence should occur on a regular basis for both parents and children in a nonjudgmental fashion, starting at approximately 8 years of age. Pediatric providers can counsel patients and families who have been exposed to violence by referring them to local support groups, providing guidance on how to speak with their child about the event, and assist in reassuring the child's sense of safety and stability. A referral to a mental health professional for additional treatment is appropriate: • when the symptoms are chronic (more than 6months in duration) or not improving, • if the violent event involved the death or departure of a parent, • if the caregivers are unable to empathize with the child, or • if the ongoing safety of the child is a concern.

A 16 year old is prescribed a combination oral contraceptive pill for birth control. In the event that she were to miss three consecutive pills during a time in which she has had unprotected sexual intercourse, appropriate anticipatory guidance would include that she A. use the Yuzpe method. B. purchase Plan B over the counter. C. call the office for a prescription for ulipristal (Ella). D. fill and use the prescribed levonorgestrel 1.5 mg.

The correct answer is D - fill and use the prescribed levonorgestrel 1.5 mg. One of the major ongoing public health objectives continues to be reducing adolescent pregnancy. There are a variety of strategies that begin with prevention, but emergency contraception can be indicated with events such as sexual assault, unprotected intercourse, breakage of condoms, or missed or late doses of hormonal contraceptives. Studies have shown that adolescents are more likely to use emergency contraception if a prescription (such as levonorgestrel) has been given in advance of a recognized need. Levonorgestrel has fewer adverse effects such as nausea and vomiting, and increased effectiveness when compared to combined hormone emergency contraceptive methods known as the Yuzpe method. Levonorgestrel is available by several brand names, including Plan B, Plan B One-Step, and Next Choice. In most states, an adolescent must be 17 years or older to purchase levonorgestrel (Plan B) without a prescription

Which of the following activities is MOST consistent with cognitive rest requirements for an adolescent who is recovering from a concussion? A. texting with friends B. watching television C. reading in a quiet place D. going for ice cream with friends

The correct answer is D - going for ice cream with friends Physical rest following a concussion is generally understood, but cognitive rest is a harder concept for patients and families to understand and implement. Cognitive rest can be as extreme as no school attendance, no home/school work, no reading, no video games, no texting or computer time. Following an acute concussive injury, the goal is to keep cognitive activity below the level that triggers symptoms such as headache or fatigue. Patient reports have indicated that activities such as drawing or baking, which allow for self-pacing, may be tolerated for a short time period. Other activities, which may help prevent social isolation but should be monitored, include short phone calls with friends, brief non active activity with friends such as going for ice cream, or a meal with family. It is important for the patient to stop any activity which causes symptoms to worsen.

A school-age child who is an established patient presents with a sore throat and fever for less than 24 hours. When obtaining an interval health history, which of the following is MOST beneficial to update since the last visit? A. surgeries B. antibiotics prescribed C. allergic reactions to medication D. health care provider visits outside the practice

The correct answer is D - health care provider visits outside the practice A comprehensive history usually needs to be completed only once for patients who are new to a practice. After that, for routine scheduled health maintenance visits, the history is updated only from the last contact to the present. The format remains the same as for the complete history; however, questions are modified to verify that the information remains the same or needs to be updated. All areas of the history should be assessed to identify changes. Information that the patient has been seen by another health care provider provides the basis to explore answers to the information covered in the other options above. For example, a newly prescribed antibiotic or surgery would assume that the patient was treated by another health care provider outside of the practice. Ascertaining a recent allergic reaction is not likely to be helpful in guiding the diagnosis for the presenting problem.

An adolescent presents with a one-week history of fever, exudative pharyngitis, lymphadenopathy, and hepatosplenomegaly. Which of the following laboratory studies is MOST appropriate to order? A. antistreptolysin O titer B. complete blood count C. Epstein-Barr virus titers D. heterophile antibody test

The correct answer is D - heterophile antibody test This adolescent's symptoms raise suspicion for mononucleosis. The most appropriate laboratory test to order would be a heterophile antibody test. This is a nonspecific test and is positive in 85% of adolescents with mononucleosis within the first two weeks of the illness, but is often negative in children under the age of 4 years. A complete blood count does not provide any diagnostic information. Epstein- Barr virus titers are used if the primary screening test result is negative and there is strong suspicion for mononucleosis, or in young children in which primary screening tests are unreliable. The antistreptolysin O titer tests for recent strep infection, but these symptoms are not consistent with strep.

Which of the following antibiotics is the BEST choice for prevention of pneumococcal infection in a 4 week old with Hemoglobin S Beta + thalassemia? A. amoxicillin B. azithromycin (Zithromax) C. erythromycin (E.E.S.) D. penicillin V potassium

The correct answer is D - penicillin V potassium Sickle cell disease (SCD) is a chronic, inherited disease of the red blood cells and is estimated to affect 1 out of every 500 Black or African-American births, and 1 out of every 36,000 Hispanic-American births. There are several distinctly different types of SCD: HbSS, usually the most severe form of the disease, with a child inheriting two sickle cell "S" genes, one from each parent; HbSC, usually a milder form of the disease; HbS beta thalassemia - inheriting one sickle cell "S" gene and one gene for beta thalassemia; there are 2 types: o HbS B0 - usually severe; o HbS B+ thalassemia, usually milder. HbS B+ thalassemia is the mildest of the sickle disorders. Most children with this condition are not at risk for frequent pain, anemia or stroke. However, children with HbS B+ thalassemia remain at risk for pneumococcal sepsis. Penicillin VK remains the best choice for prophylaxis of pneumococcal infection in children with any sickle disorder. Erythromycin may be used as an alternative treatment in the case of penicillin allergy. Amoxicillin has been substituted when there have been shortages of oral penicillin in local pharmacies, but it is not the most effective choice.

A 5-year-old male presents with an intermittent limp exacerbated with exertion and is associated with mild or intermittent pain. Which imaging study is BEST ordered to confirm the diagnosis? A. bone scan B. MRI of leg C. pelvic CT D. radiographs hips and pelvis

The correct answer is D - radiographs hips and pelvis Legg-Calvé-Perthes disease is an idiopathic, juvenile avascular necrosis of the femoral head, which is five times more common in boys and occurs between 4-8 years of age. There is an initial ischemic episode of unknown etiology that interrupts vascular circulation to the capital femoral epiphysis. The articular cartilage hypertrophies, and the epiphyseal marrow becomes necrotic. The area revascularizes, and the necrotic bone is replaced by new bone. This process can take 18-24 months. There is a critical point in these dual processes when the subchondral area becomes weak enough that fractures of the epiphysis occurs. At this time the child becomes symptomatic. With fracturing, further reabsorption and replacement by fibrous bone occurs, and the shape of the femoral head is altered. Articulation of the head in the hip joint is interrupted. The bone reossifies with or without treatment, but without treatment the femoral head flattens and enlarges, causing joint deformity. These children need prompt referral to an orthopedist. The etiology is unclear but certain risk factors have been identified in children based on gender, socioeconomic group, and the presence of an inguinal hernia and urinary tract anomalies. Routine pelvis and frog-leg lateral radiographic views are used to confirm the diagnosis as well as to follow disease progression and response to treatment. However, there may be no radiographic findings early in Legg-Calvé-Perthes disease. MRIs and bone scans are helpful in recognizing early disease but are of limited value for following disease progression.

Which of the following beverages is MOST appropriate for an adolescent AFTER prolonged strenuous activity? A. water B. caffeinated beverages C. water with a sodium supplement D. sports drink with a small amount of carbohydrates and sodium

The correct answer is D - sports drink with a small amount of carbohydrates and sodium Sports drinks that contain small amounts of carbohydrates and sodium are the best choice for rehydration after strenuous activities and sporting events. These drinks enhance rehydration. Water is a good beverage choice before and during competition. Sodium supplements are not advised for rehydration due to higher salt content which can cause dehydration. Caffeinated beverages can increase urine output, which can also cause further dehydration.

A child presents with fatigue, failure to thrive, chronic diarrhea with large, foul-smelling pale stools, and abdominal distension. Which of the following tests should be ordered INITIALLY? A. anti-endomysial (EMA) IgA and anti-gliadin IgA B. anti-endomysial (EMA) IgA and anti-reticulin IgA C. tissue transglutaminase (TTG) IgA and anti-gliadin IgA D. tissue transglutaminase (TTG) IgA and total serum IgA

The correct answer is D - tissue transglutaminase (TTG) IgA and total serum IgA Celiac disease is an autoimmune-mediated disease in which gluten ingestion damages the small intestine. Signs and symptoms of celiac disease include failure to thrive, abdominal pain, diarrhea, and bloating. If celiac disease is suspected, serologic testing should be ordered. Available serologic tests for celiac disease include tissue transglutaminase (TTG) IgA and IgG, anti-endomysial (EMA) IgA, antigliadin IgA and IgG, and anti-reticulin IgA. TTG IgA and total serum IgA are recommended for initial screening. TTG IgA and EMA IgA are equally accurate. EMA IgA, however, is not advised for initial testing because it is expensive, labor-intensive, and prone to misinterpretation. Anti-gliadin IgA and IgG and anti-reticulin IgA are not as specific and sensitive as the other serologic markers and thus are not recommended for initial testing. An elevated TTG IgA with a sufficient total IgA count is suggestive of celiac disease. The diagnosis should be confirmed by intestinal biopsy, which is the gold standard for diagnosis. Treatment for celiac disease is strict adherence to a gluten-free diet.

A fully immunized 4 month old presents with history of 3-day fever of 103 F (39.4 C) with several episodes of vomiting. The infant is well-hydrated and the physical exam and vital signs are otherwise within normal limits. Which of the following tests should be ordered FIRST? A. chest radiograph B. complete blood count with differential C. lumbar puncture D. urinalysis and culture

The correct answer is D - urinalysis and culture The differential diagnosis for an infant with fever without focus includes upper and lower respiratory tract infections, urinary tract infections, meningitis, gastrointestinal infections, and osteomyelitis. A 4-month-old fully immunized against pneumococcal disease and H. influenzae with a non-toxic appearance is classified as low risk for serious bacterial illness. The next step for this infant based on the fever without focus algorithm is a catheterized urinalysis and culture. A complete blood count with differential would be indicated if the infant was unvaccinated. A chest radiograph is indicated if there are signs of respiratory illness such as tachypnea, hypoxia, or respiratory distress. The risk of bacteremia for this infant is <1% and thus a lumbar puncture is not required for firstline testing in a well appearing infant.