ENPC 6th Edition Pre Exam

Assessment of the fontanelle provides the most useful information for which two components of the primary survey?

Circulation and disability Rationale A sunken fontanelle is a red flag for circulation assessment in pediatric triage and may indicate dehydration . A bulging fontanel is a red flag for disability assessment in pediatric triage and can indicate increased intracranial pressure.

Which of the following is a known cause of pediatric seizures?

Overdiluted formula Rationale Water overload is a well-documented etiology of hyponatremia in infants, which can be caused by excess dilution of formula. Hyponatremia is a known cause of seizures. Benzodiazepine overdose is more likely to result is respiratory depression and coma. CHD and SVT are not readily known to cause seizures.

A 5-year-old child presents to the emergency department after being hit by a car. The patient complains of left upper quadrant pain, and the focused assessment with sonography for trauma (FAST) exam shows fluid around her spleen. Which of the following findings would be an early indication of ongoing blood loss?

Weak peripheral pulses Rationale Early signs of hypovolemic shock include tachycardia and delayed capillary refill. The nurse may note a strong central pulse but weaker peripheral pulses, indicating the child is compensating by shunting blood to their core.

For the infant, what duration of time is consider apneic?

20 seconds Rationale The respiratory rate, depth, and regularity all continue to change the first year of life, making respiratory assessments different than those of older children. Infants breathe faster and less regularly, with apnea not considered as such until 20 seconds without a breath or associated with other physiologic effects such as bradycardia.

Which of the following patients should be evaluated first?

An 18-month-old with bilious emesis Rationale The presence of bilious emesis is especially concerning because it may be indicative of an immediately life-threatening bowel obstruction. A dislodged gastrostomy tube should be reinserted within 4-6 hours to prevent stoma closure. Vomiting following a handlebar injury may be indicative of many possible injuries, but does not take precedence unless other symptoms are present. Infantile colic is described as inconsolable crying in infants, 2 weeks to 4 months old, for up to 3 hours per day, more than 3 days per week, and lasting for more than 3 weeks.

A 14-year-old patient sustained a displaced fracture of the radius and ulna after falling from a bicycle. Which of the following pain control interventions is most likely to result in improvement in symptoms related to pain?

Applying a splint to the affected extremity Rationale Splinting is an effective non-pharmacologic intervention to reduce pain associated with fractures. This will also help to minimize complications. Topical creams and elevation of the extremity will not help with pain control. The application of ice in an appropriate manner can help, but not warmth which would be contraindicated in the early stages of the injury.

A nurse providing trauma informed care to the family of a seriously ill child should be doing which of the following?

Appointing one staff member to stay with the family Rationale Caregivers experiencing the crisis of a critically ill child have low attentiveness and increased stress so would benefit from having a member of the healthcare team to stay with them as much as possible and communicate updates on the plan of care. Caregivers should be allowed to stay with their child as much as possible and not placed in a secluded room away for them.

A 5-year-old with no health problems presents to the emergency department with a sudden onset of chest pain and shortness of breath. Parents state that the family was involved in a bad car crash one week ago. A thorough assessment and workup has not revealed any abnormalities. Which of the following the best next step to take?

Ask about any new bed-wetting or sleep disturbances Rationale Physical complaints are not uncommon in children following a traumatic event. Once any physical injuries or illnesses have been ruled out, assessment for any other behavioral symptoms to facilitate appropriate care and follow-up would be indicated. The incident occurred a week ago so the likelihood any an severe medical issues is pretty low.

An ambulance arrives with a 16-year-old male involved in a dirt bike crash who was intubated prior to arrival. Which of the following is the priority assessment or intervention?

Assess endotracheal tube placement Rationale If a patient arrives with an artificial airway (endotracheal tube or tracheostomy) in place, assess its placement, patency, and the oral airway (in that order) before moving to the next step of the primary survey. The oropharynx should be checked for fluids or objects such as broken teeth. Inserting a gastric tube in an intubated patient and starting a second large caliber IV line should also be done, but they don't take priority over airway.

Which of the following patient presentations should increase suspicion of potential child maltreatment?

Bruising to the left ear of a newborn from sleeping on his side Rationale Any bruises in a non-exploratory location (especially torso, ears, and neck) in children younger than 4 years old and ANY bruising in a child younger than 4 months old is suspicious for child maltreatment. Bruises to the lower extremities of a 2-year-old who is learning to walk on their own is not uncommon. Greenstick fractures are a more common fracture is children due to the immaturity of their bone structure. Martial arts includes many moves that could produce a spiral fracture.

A 6-month-old is seen for a recurrent respiratory infection. During the assessment, the mother adds that the patient's stools seem to be fatty or "greasy". Which of the following disease processes would be a primary concern for this child?

Cystic fibrosis Rationale In patients with cystic fibrosis, thick mucus inhibits the release of pancreatic enzymes necessary for digestion. This results in impaired absorption and the inability to utilize ingested fats. These fats are excreted in the stools and can present as "fatty" or "greasy". Combined with the recurrent upper respiratory infections for an infant, cystic fibrosis should be ruled out. The other three disease processes frequently present with respiratory issues but fatty stools would not normally be seen.

A 4-day-old who is brought to the emergency department with the parental complaint of "not acting right" is found to be hypoglycemic. What is the appropriate glucose concentration to administer to this neonate?

Dextrose 10% Rationale Dextrose 10% is the preferred concentration for neonates with hypoglycemia to protect their fragile vasculature while providing needed glucose. Dextrose 5% is not used to treat hypoglycemia in children. Dextrose 25% is used for children above the age of 5 years. Dextrose 50% is not recommended for use in pediatrics unless it is diluted.

The caregiver of a 7-year old reports witnessing a seizure at home, but no seizure history. The patient is post-ictal with a heart rate of 142 beats per minute, respiratory rate of 36 breaths per minute, and blood pressure of 86/72 mm Hg. Significant burns are noted to the patient's back and lower extremities. The caregiver states the burns accidentally occurred three days ago, but was afraid to bring the patient in due to an ongoing child welfare investigation. Which of the following groups of interventions are the priority for this patient?

Draw a metabolic panel, point of care glucose, and administer a fluid bolus Rationale Burn injuries result in fluid and electrolyte shifts leading to hypovolemia and electrolyte imbalances. Early identification and treatment of electrolyte imbalances can help prevent further seizures. Contacting child protective services and other authorities can wait. The patient is post-ictal so does not require lorazepam medication at this time. Pain medication can and should be considered with significant burns, but is not a priority.

A three-year-old is rescued after being submerged in a pool for several minutes. On arrival the patient is responsive to painful stimuli with shallow respirations, diminished breath sounds, and an occasional cough. Which of the following interventions is the initial management priority?

Endotracheal intubation to provide positive pressure ventilation Rationale The primary survey assessment and treatment of deficits are the priority. Airway control and positive pressure ventilation while preparing for intubation of a child who meets intubation criteria (GCS < 8) should be performed while also maintaining cervical spine stabilization. The child is responsive only to painful stimuli, has shallow respirations, and diminished breath sounds. All of these are breathing problems and must be addressed immediately. Removing wet clothing is necessary, but is not the main priority initially. With intubation an orogastric tube will be placed and abdominal thrusts are not necessary to remove fluid from the abdomen.

You need to draw blood from a 2-year-old. Which of the following is the best approach for this patient?

Have them watch a cartoon on an I-pad or cell phone Rationale The best approach to a toddler who requires interventions is to provide distractions whenever possible. They are in the cognitive development phase of "sensorimotor/preoperational" so having the caregiver present is helpful. You should move from the least invasive to most invasive tasks, and don't let them watch you prepare since it will increase anxiety.

A 3-month-old is brought to the emergency department with new onset of fever. You note the child to be pale, tachypneic, and tachycardic, with weak distal pulses. Which intervention is the priority for this patient?

Infuse a rapid 10-20 mL/kg bolus of an isotonic crystalloid Rationale This patient most likely has septic shock. An immediate goal is to reverse shock and restore tissue perfusion with fluids. An antipyretic may be needed based on the temperature and patient symptoms. An antibiotic should be started within an hour, and vasoactive medications may not be needed if fluid resuscitation is successful.

What is the priority intervention for symptomatic bradycardia in a four-year-old child?

Initiate bag-mask ventilation Rationale Identifying and treating other causes, chest compressions, and epinephrine are interventions for pediatric bradycardia with signs of poor perfusion that are not improved by adequate oxygenation and ventilation. Atropine and pacing may be considered if there is no response to the other interventions.

A 9 month pregnant woman presents to the emergency department and delivers a term neonate vaginally. The neonate is dried and stimulated and the mouth and nose are suctioned using a bulb syringe. After repositioning the head, the neonate remains limp and apneic and the HR is 80 beats/minute. What is the priority intervention?

Initiate positive pressure ventilation Rationale Immediately after delivery all neonates should be warmed, stimulated, and have their mouth then nose suctioned using a bulb syringe. Following this, if the neonate is not breathing or is gasping and/or has a heart rate of less than 100 beats per minute positive pressure ventilation at 21% FiO2 at a rate of 40-60 breaths per minute should be immediately initiated. The heart rate should be assessed after 15 seconds of PPV and if not improving additional measures should be taken (MRSOPA). Vascular access is not always needed but can be worked on by another team member while airway and breathing interventions are being completed.

Which of the following indicates the need for additional caregiver education regarding a urinary tract infection?

My child will grow out of their frequent urinary tract infections. Rationale Urinary tract infections are not a normal occurrence in children and are not something children will "grow out of." Additional investigation and follow-up are needed when a child has frequent urinary tract infections. Drinking extra fluids should be encouraged. Patients should always finish the complete course of antibiotics to eliminate the infection. And follow-up should be done to make sure the infection has been eliminated.

The caregiver of a 2-month-old infant states the patient has had trouble breathing for the past two days. Pediatric assessment triangle (PAT) reveals an age-appropriate general appearance, rapid breathing with mild distress, and pink skin. Mucous is noted in both nares. Which of the following is the best next step?

Suction nasal passages using a bulb syringe Rationale Infants up to four months old are obligate nose breathers and can have respiratory distress when nares are occluded. Mucous can be gently suctioned using a bulb syringe or suction catheter. A good, thorough history should always include immunization status for pediatric patients. The nose needs to be clear before applying oxygen via nasal cannula. Respiratory assessment includes interventions to improve breathing so you would not move to move to circulation until that is accomplished.