Exam 3 Test Bank
A toddler is able to jump in place and balance on one foot as well. She can also speak in full sentences and feed herself. What is the approximate developmental age of this child? A) 2 years B) 3 years C) 4 years D) 5 years
3 years These milestones are consistent with a physical, cognitive/language, and social and emotional developmental age of 3 years.
A 32-year-old white female presents to labor and delivery fully effaced and delivers a 5.8-lb (2,500-gram) infant female with Apgar scores of 6 and 8. The mother has had no prenatal care and in the nursery you perform the newborn examination. With the Ballard scoring system, the neuromuscular examination score is 15. Looking at physical maturity, you see superficial peeling and few veins on the skin. The lanugo hair has bald areas and the plantar surface of the foot has creases on two thirds of it. The areola is stippled with a 2-mm bud. The pinna is well curved, is firm, and has instant recoil. The labia majora and minora are equally prominent. Add the score of the neuromuscular components to your score of physical maturity to determine weeks of gestation. How many weeks of gestation has this child had? A) 34 weeks B) 36 weeks C) 40 weeks
36 weeks Superficial peeling with few veins gives a score of 2 points; lanugo with balding areas gives a score of 3 points; the plantar surface being covered by two thirds gives a score of 3 points; the stippled areola with a 2-mm bud gives a score of 2 points; the well-formed pinna with instant recoil gives a score of 3 points. The equal labia majora and labia minora give a score of 2 points. Adding these numbers up gives a score of 15 points for physical maturity. Adding that to the 15 points for neuromuscular maturity gives a point total of 30, which correlates to a gestational age of 36 weeks. This would be expected with a birth weight of 2,500 grams.
1. During the delivery of a male infant, you are there to assess the Apgar score. He was born through an intact pelvis and had no complications during labor or delivery. At 1 minute he is pink all over and grimaces. He is flexing his arms and legs occasionally. He is breathing well and his heart rate is 110. At 5 minutes he is still pink all over but now is crying vigorously, with active movement. His respiratory effort is good and his heart rate is 130. What is his Apgar score? A) 8 at 1 minute, 10 at 5 minutes B) 7 at 1 minute, 9 at 5 minutes C) 9 at 1 minute, 10 at 5 minutes D) 8 at 1 minute, 9 at 5 minutes
8 at 1 minute, 10 at 5 minutes In checking the Apgar, five things are looked at during the 1-minute and 5-minute marks. The color, reflex irritability, muscle tone, respiratory effort, and heart rate are evaluated. In this case, at 1 minute he received 2 points for being pink all over, 1 point for grimacing, 1 point for flexion of the arms and legs, 2 points for strong respiratory effort, and 2 points for a heart rate over 100. This gives a 1-minute total of 8. At 5 minutes he was given 2 points for being pink all over, 2 points for vigorous crying, 2 points for active movement, 2 points for strong breathing, and 2 points for a heart rate over 100. This gives a 5-minute total of 10. These are normal, healthy Apgar scores.
You are observing an infant who is able to pull to a stand, uses "mama" and "dada" specifically, and indicates his wants by vocalization and pointing. Where would you place this child's developmental age? A) 12 months B) 10 months C) 8 months D) 6 months
8 months Assessing developmental milestones is of major importance during the first year and beyond. These accomplishments in the physical, cognitive/language, and social domains are normal for an 8-month-old infant.
A clinician is reading the chart of a full-term newborn whose mother had an uneventful pregnancy in the hospital for the first time on the day of birth. In reviewing the infant's chart, the clinician notes that, in the delivery room, at 5 minutes, the infant had a heart rate > 100, strong respiratory effort, was crying vigorously, moving actively, and had good color except for some acrocyanosis of the hands & feet. The infant's APGAR score is closest to which of the following?
9
You note that your 11-year-old female patient is at Tanner stage II. You would advise her mother that menarche will probably start in: A) 2 to 3 years B) 3 to 4 years C) 5 years D) It is dependent on the girl's genetic makeup
A) 2 to 3 years Menarche normally begins approximately 2 to 3 years following Tanner stage II (breast budding). Median age of menarche in the United States is 12.43 years. It usually occurs within 2 to 3 years after breast budding (American College of Obstetricians and Gynecologists, 2015).
The posterior fontanel should be completely closed by: A) 3 months B) 4 months C) 5 months D) 6 months
A) 3 months The posterior fontanel normally closes by 3 months of age. The anterior fontanelle closes between 12 and 18 months of age.
Which of the following is considered an abnormal finding? A) A "clunk" sound heard while performing the Ortolani maneuver B) A 6-month-old infant who starts to babble C) A 10-year-old boy with aching pain on the front of the thighs that starts in late afternoon or at night D) A 12-month-old who is "cruising"
A) A "clunk" sound heard while performing the Ortolani maneuver The "clunk" sound during the Ortolani maneuver is a positive finding and signifies a possible hip abnormality (hip dysplasia) in infants. Refer the infant to a pediatric orthopedist. Infants start to babble at 6 months. At 12 months, babies learn to "cruise" or to hold onto furniture while walking. Some boys and girls may have "growing pains" on both legs (or both thighs, calves, or behind the knees), which are usually felt in the late afternoon, evening, and/or at night. These symptoms should not interfere with the child's ability to play and affect children from age 3 to 12 years. Stretching exercises of the thighs and hamstrings, massaging the area, and warm packs are helpful. If pain affects only one leg or hip, it is abnormal (rule out bone cancer, sarcoma, leukemia, hip abnormalities). In such cases, refer the patient to a pediatric orthopedist.
You note bony nodules located at the proximal interphalangeal joints on both the hands of your 65-year-old female patient. Which of the following is most likely? A) Bouchard's nodes B) Heberden's nodes C) Osteoarthritic nodules D) Tophi deposits
A) Bouchard's nodes Bony nodules at the proximal interphalangeal joints of the hands are called Bouchard's nodes. Heberden's nodes are nodules on the distal interphalangeal joints. Tophi deposits are seen with gout, in which high levels of uric acid occur in the blood and cause nodules in the joint that can eventually destroy the bone. Osteoarthritic nodules develop in the joints of the hands.
A 14-year-old female adolescent is worried that she has not started to menstruate like most of her friends. During the gynecological examination, the nurse practitioner tells the mother, who is in the room with the patient, that her daughter is starting Tanner stage II. What are the physical exam findings during this stage? A) Breast buds and some straight pubic hair B) Fully developed breasts and curly pubic hair C) Breast tissue with the areola on a separate mound with curly pubic hair D) No breast tissue and no pubic hair
A) Breast buds and some straight pubic hair Tanner stage II in females is noted for breast and papilla elevated as a small mound and increased areola diameter (breast buds). Tanner II pubic hair for females is sparse, lightly pigmented straight hair along the medial border of the labia.
The red reflex examination is used to screen for: A) Cataracts B) Strabismus C) Blindness D) Blinking response
A) Cataracts Instruct patient to look straight ahead and avoid moving the eyes. Use a direct ophthalmoscope (set at "0"), stand about 18 inches from the patient and shine the light directly on the eyes. Examine each eye, and then both eyes. A normal red reflex exam will show an orange to red color and round shape, with both eyes symmetrical. If the red reflex test of an infant shows white-colored reflection, rule out retinoblastoma or congenital cataract. Refer any patient with an abnormal light reflex to an ophthalmologist (American Academy of Pediatrics, 2008).
In the majority of children, the first permanent teeth start to erupt at the age of 6 years. Which of the following are the first permanent teeth to erupt in this time period? A) First molars B) Second molars C) Lower or upper incisors D) Canines
A) First molars The first molars are the first permanent teeth to develop; they appear at approximately 6 years of age.
The complications of untreated gout include: A) Impaired joint mobility and renal damage B) Impaired joint mobility and liver damage C) An increased risk of urinary tract infections D) Bladder cancer
A) Impaired joint mobility and renal damage Left untreated, gout can develop into a painful and disabling chronic disorder. Persistent gout can destroy cartilage and bone, causing irreversible joint deformities and loss of motion. High urate levels can deposit in the kidney and also lead to kidney stones.
The Phalen test is used to evaluate: A) Inflammation of the median nerve B) Rheumatoid arthritis C) Degenerative joint changes D) Chronic tenosynovitis
A) Inflammation of the median nerve The Phalen maneuver is a diagnostic test for carpal tunnel syndrome. The test is performed by pushing the back of the hands together for 1 minute. This compresses the median nerve within the carpal tunnel. Characteristic symptoms (burning; tingling; numbness over the thumb, index, middle, and ring fingers) convey a positive test result.
This case is followed by questions and multiple-choice answers specific to the case. A 20- year-old Asian man reports pain in his right knee after twisting it while playing soccer. The injured knee locks up when he attempts to straighten his leg. Which of the following conditions is most likely? A) Injury to the meniscus of the right knee B) Injury to the patella of the right knee C) Injury to the ligaments of the right knee D) Rupture of the quadriceps tendon Which of the following actions is the best course for this patient? A) Refer him to an orthopedic specialist B) Refer him to a chiropractor C) Advise him that the clicking noise will resolve within 2 to 4 weeks D) Advise him to use an elastic bandage wrap during the first 2 weeks for knee support and to see you again for reevaluation
A) Injury to the meniscus of the right knee Pain in the knee with "locking 684 up" while attempting to straighten the leg is highly suggestive of injury to the meniscus. The best imaging test for meniscus injury is the MRI. A) Refer him to an orthopedic specialist Referral to orthopedics is advised for evaluation of the need for treatment and surgery (arthroscopic repair). If the tear is minor and the pain and other symptoms resolve quickly, muscle-strengthening exercises may be all that is needed to recover fully. In this case, a patient is usually referred to physical therapy. A large meniscus tear that causes symptoms or mechanical problems with the function of the knee joint may require arthroscopic surgery for repair.
You are reviewing the bilirubin level of a 3-day-old full-term neonate. You note that it is 10 mg/dL. The infant has a slight yellow color to his skin, mucous membranes, and sclera. The infant is feeding well, is not irritable, and has eight to 10 wet diapers per day. Which of the following is a true statement? A) Keep monitoring the infant's bilirubin level until it returns to normal in about 1 week B) Recommend that the infant be treated with phototherapy 10 minutes a day until the bilirubin level is back to a normal range C) Refer the infant to a neonatologist as soon as possible D) Refer the infant to the neonatal intensive care unit
A) Keep monitoring the infant's bilirubin level until it returns to normal in about 1 week Bilirubin is excreted through the urine and feces. Increased fluids and wetting eight to 10 diapers a day is sufficient fluid intake/excretion to help bring down the bilirubin level. Levels should continue to be monitored and should improve in approximately 1 week.
The nurse practitioner examines a 4-week-old boy whose mother reports that he has cried for at least 3 hours a day at the same time of day since birth. What is the main goal in the clinical evaluation of this infant? A) Rule out any physiological cause for the crying spells B) Make sure that the infant is well clothed C) Evaluate the environment D) Order laboratory and diagnostic testing
A) Rule out any physiological cause for the crying spells For infants who cry for several hours during the day, ruling out a physiological problem that may be causing the distress is recommended.
Transillumination is useful in helping to diagnose which of the following conditions? A) Sinusitis and hydrocele B) Testicular tumor and acute otitis media C) Nasal masses and other tumors in the facial region D) Hydrocephalus and epididymitis
A) Sinusitis and hydrocele Transillumination is used for evaluation of the frontal and maxillary sinus as well as for a hydrocele. Because light is able to pass through the delicate skin covering the hollow sinus cavities, a light source held against the upper cheek will produce a red dot on the palate if the sinuses are normal (filled with air rather than obstructed). The transillumination test is used to differentiate a hydrocele from hernia—an illuminated scrotum will show the testicle in the center surrounded by water in the hydrocele.
A White 15-year-old male is brought by his father for a physical exam. The father is concerned that his son is "too short" for his age. The father reports that when he was the same age, he was much taller. His son wants to try out for the football team, but the father is concerned because his son might be "too short" to join. Which of the following physical exam findings is worrisome? A) Small, smooth testicles with no pubic or facial hair B) Smooth testicles with rugated scrotum that is a darker color than the patient's normal skin color C) Smooth testicles with coarse and curly pubic hair D) Straight pubic and axillary hair with a long thin penis
A) Small, smooth testicles with no pubic or facial hair Small, smooth testicles with no pubic or facial hair (Tanner stage I) is a worrisome finding at the age of 14 years because it signifies that the boy is not in the pubertal stage yet. The average age of onset of puberty among boys is 12 years (range, 10-14 years). The maximum growth spurt in boys occurs about 2 years after the onset of puberty. Boys start about 1 year later than girls and continue to grow until their early 20s (college)
Café-au-lait spots look like tan to light-brown stains that have irregular borders. They can be located anywhere on the body. Which of the following is a correct statement? A) They are associated with neurofibromatosis or von Recklinghausen's disease B) They may be identified as precancerous after a biopsy C) They are more common in children with darker skin D) They are associated with Wilson's disease
A) They are associated with neurofibromatosis or von Recklinghausen's disease Café-au-lait spots are caused by an increase in melanin content, often with the presence of giant melanosomes. They have irregular borders and vary in color from light to dark brown. Neurofibromatosis causes tumors to grow in the nervous system, and these tumors commonly cause skin changes.
When an infant is found to have tufts of fine dark hair on the sacrum, which of the following tests is recommended? A) Ultrasound of the sacrum B) Plain radiograph of the lumbar sacral spine C) No imaging test is necessary D) Genetic testing
A) Ultrasound of the sacrum An infant with tufts of fine dark hair on the sacrum should be evaluated for occult spina bifida. The first imaging test to order is an ultrasound of the lower spine
A quiet 3-year-old is brought in for a routine check-up when you notice a fresh bruise in the axilla and bilateral bruises over the upper back that appear slightly older. There are brown bruises over his shins as well. His mother said this happened when he fell off of a couch. What diagnosis should be considered? A) Von Willebrand's disease B) Normal childhood bruises from activity C) Abuse D) Seizure disorder
Abuse No one wants to think that a child could be abused. In this case the bruises on the shins are very normal for this age group with normal activity. The presence of bruises in other areas which do not correlate with the given history are important to notice and should make you consider this diagnosis. A very thorough examination must be conducted to search for other lesions that might be consistent with the use of implements such as an electrical cord, clothes iron, cigarette, etc. A social services consult and/or formal abuse evaluation should be considered. Unfortunately, emotional and sexual abuse do not frequently leave outward signs. It is important to keep an open mind to the presence of these other types of abuse as well.
Precocious puberty is defined as the onset of secondary sexual characteristics before the age of: A) Age 7 in girls and age 8 in boys B) Age 8 in girls and age 9 in boys C) Age 9 in girls and age 10 in boys D) Age 9 for both girls and boys
B) Age 8 in girls and age 9 in boys Precocious puberty is defined as onset
You are going to obtain a social history on an early adolescent boy. How should you proceed to obtain the best information? A) Ask his mother to leave the room. B) Ask if he would prefer his mother to leave the room. C) Ask your questions with his mother in the room. D) Ask his mother how she would like to proceed.
Ask if he would prefer his mother to leave the room It is best to ask the patient what he or she would prefer. Because the examination should include a genitalia examination, some children in early adolescence are more comfortable with their parents in the room. Some examiners will provide "confidential time" to both the adolescent and the parent, so that parental concerns can also be adequately addressed. Leaving the parent in the room without asking the adolescent is usually not a good idea and can limit optimal history gathering and examination.
All of the following children are within the parameters of normal growth and development for their age group except: A) A 2-month-old who coos and smiles B) A 14-month-old who understands complex commands C) A 20-month-old who can walk without support D) A 3-year-old who can speak in three- to four-word sentences
B) A 14-month-old who understands complex commands A 14-month-old child should developmentally be able to say "mama" and "dada," know his own name, and know at least two to four words. A 2-year-old is able to understand simple commands.
A concerned new mother reports to you that her son, who is 3 years of age, is not toilettrained yet. Which of the following is an appropriate reply? A) Recommend a referral to a pediatric urologist B) Advise the mother that her child is developing normally C) Recommend a bed-wetting alarm D) Recommend a voiding cystogram
B) Advise the mother that her child is developing normally Toilet-training begins at approximately 2 years of age and may take 1 to 2 years to complete. Boys who are not toilet-trained by 3 years of age may still be developing normally.
The mother of a 4-week-old infant is concerned that her infant's eyes are crossed for a few seconds occasionally. The nurse practitioner would: A) Recommend referral to a pediatric ophthalmologist B) Advise the mother that this is a normal finding in infants up to 2 months of age C) Recommend that multivitamin supplements be given to the infant daily D) Educate the mother on how to patch the infant's eye every 4 hours
B) Advise the mother that this is a normal finding in infants up to 2 months of age Infants' eyes commonly cross over at times, and this is a normal finding up to 2 months of age.
The mother of a 7-year-old boy tells the family nurse practitioner that his teacher has complained to her of her son's frequent episodes of daydreaming. The mother reports that sometimes when her son is at home, he seems not to hear her, seeming to "blank out" for a short period of time. Which of the following is most likely? A) A partial seizure B) An absence seizure (petit mal seizure) C) A grand mal seizure D) An atonic seizure (drop attack)
B) An absence seizure (petit mal seizure) A petit mal seizure is a brief seizure that usually lasts less than 15 seconds. During the seizure, the child may appear not to be listening, to have "blanked out," or to be daydreaming.
Which cranial nerve (CN) is being evaluated when Rinne testing is done? A) CN VII B) CN VIII C) CNs IX and X D) CNXI
B) CN VIII The acoustic nerve, cranial nerve VIII, is being evaluated when 671 the Rinne test is performed. The Rinne test is performed by placing the base ofa vibrating tuning fork against the patient's mastoid bone to evaluate bone conduction. Ask the patient to tell you when the sound is no longer heard. Then place the tuning fork in the front of the ear to evaluate air conduction. The air conduction should be twice as long as bone conduction.
Which cranial nerves (CNs) innervate the extraocular muscles of the eyes? A) CNs II, III, and VI B) CNs III, IV, and VI C) CNs IV, V, and VII D) CNs V, VI, and VIII
B) CNs III, IV, and VI Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) innervate the extraocular muscles. They are tested by inspecting the eyelids for drooping, and inspecting pupil size for equality and their direct and consensual response to light and accommodation.
All of the following describe normal behavior for a 3-year-old child except: A) Speaks in three- to four-word sentences that are understood by most strangers B) Can draw a cross C) Can draw a circle D) Can ride a tricycle
B) Can draw a cross Developmental stages in children include the following: 1 year—walk; 2 years—walks up steps with the same foot; 3 years—pedals a tricycle and copies a circle; 4 years—copies a cross and draws a person with three parts.
Heberden's nodes are commonly found in which of the following diseases? A) Rheumatoid arthritis B) Degenerative joint disease C) Psoriatic arthritis D) Septic arthritis
B) Degenerative joint disease Heberden's nodes are bony nodules on the distal interphalangeal joints, commonly seen in degenerative joint disease.
Podagra is associated with which of the following? A) Rheumatoid arthritis B) GoutC) OsteoarthritisD) Septic arthritis
B) Gout Gout (also known as podagra when it involves the big toe) is characterized by recurrent attacks of acute inflammatory arthritis—a red, tender, hot, swollen joint. The metatarsal-phalangeal joint at the base of the big toe is the most commonly affected (approximately 50% of cases). Pain occurs due to the accumulation of uric acid and salts in the joint.
The mother of a 16-year-old boy is concerned that her son is not developing normally. On physical exam, the patient is noted to have small testes with no pubic or facial hair. What is the most appropriate statement to the mother? A) Her son is developing normally B) Her son's physical development is delayed and should be evaluated by a pediatric endocrinologist C) Her son should be rechecked in 3 months; if he still does not have secondary sexual characteristics, a thorough hormonal workup should be initiated D) Her son's physiological development is slower than normal but is within the lower limit of normal for his age group
B) Her son's physical development is delayed and should be evaluated by a pediatric endocrinologist Puberty may be delayed for several years and still occur normally, in which case it is considered constitutional delay, a variation of healthy physical development. Delay of puberty may also occur due to malnutrition, many forms of systemic disease, or to defects of the reproductive system (hypogonadism) or the body's responsiveness to sex hormones. Hypogonadism occurs when the sex glands produce little or no hormones. In men, these glands (gonads) are the testes. A 16-year-old male without secondary sexual characteristics should be referred to an endocrinologist. If there is no testicular development by 14 years of age, an endocrinology consult is warranted.
You are examining a patient who has just been diagnosed with Bell's palsy. Bell's palsy is characterized by all of the following except: A) Drooling B) C) D) Inability to swallowInability to close the eye on the affected side Drooping of the corner of the mouth on the affected side
B) Inability to swallow Bell's palsy (acute idiopathic facial nerve palsy) is caused by inflammation of cranial nerve VII (facial nerve). CN VII does not innervate the throat, so swallowing is not affected. Signs and symptoms of Bell's palsy come on suddenly and may include rapid onset of mild weakness to total paralysis on one side of the face occurring within hours to days, making it difficult to smile or close the eye on the affected side. Other symptoms are facial droop and difficulty making facial expressions, pain around the jaw or in or behind the ear on the affected side, increased sensitivity to sound on the affected side, headache, a decrease in ability to taste, and changes in the amount of tears and saliva produced. In rare cases, Bell's palsy can affect the nerves on both sides of the face. Early treatment with oral glucocorticoids (prednisone) is recommended. If herpes simplex 1 infection is suspected, use combined therapy with valacyclovir (Valtrex) and prednisone for 1 week.
What does a positive posterior drawer sign in a 10-year-old soccer player signify? A) Normal knee B) Instability of the knee C) Swelling on the knee D) Injury to the meniscus
B) Instability of the knee The drawer test is used to identify mediolateral or anteroposterior plane instability of the knee. The test is performed on the unaffected and affected knee for comparison. The anterior drawer test evaluates the anterior cruciate ligament (ACL). To perform the test, the patient lies supine and the knee is placed at 90-degree flexion. Grasp the posterior aspect of the tibia over the upper calf muscle; then, with a steady force, try to push the lower leg forward and backward. Anterior or posterior movement of the knee is positive. With the leg extended, stabilize the femur with one hand and the ankle with the other. Try to abduct and adduct the knee. There should be no medial or lateral movement.
All of the following statements about phototherapy are correct except: A) Light from the blue-to-white spectrum is used B) It is not always necessary to use a shield for the infant's eyes C) Unconjugated bilirubin in the skin is converted to a water-soluble nontoxic substance that is excreted in the bile D) The infant's eyes should be shielded
B) It is not always necessary to use a shield for the infant's eyes When using phototherapy, the eyes should always be protected by using a shield or goggles to prevent damage to the eyes.
A positive straight leg raising test is indicative of which of the following? A) Myasthenia gravis B) Inflammation of the sciatic nerve/herniated disk C) Multiple sclerosis D) Parkinson's disease
B) Macrocytic and normochromic cells/herniated disk To perform the straight leg test, have the patient lie supine on an exam table. Lift the patient's leg toward his or her head while the knee is straight. If the patient experiences sciatic pain when the straight leg is at an angle between 30 and 70 degrees, then the test is positive and a herniated disk is likely to be the cause of the pain. The straight leg test should be done on the pain-free side first to find out which range of movement is normal and to enable the patient to distinguish between "normal" stretching of muscles and a different sort of pain.
A 45-year-old woman is complaining of generalized morning stiffness, especially in both her wrist and hands. It is much worse in the morning and lasts for a few hours. She also complains of fatigue and generalized body aches that have been present for the past few months. Which of the following is most likely? A) OsteoporosisB) Rheumatoid arthritis C) OsteoarthritisD) Gout
B) Rheumatoid arthritis When rheumatoid arthritis is active, symptoms can include fatigue, loss of energy, depression, low-grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity. During flares, joints frequently become red, swollen, painful, and tender. This occurs because the lining of the tissue of the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovitis).
The cover/uncover test is a screening tool for: A) Color blindness B) Strabismus C) Visual acuity D) Cataracts
B) Strabismus The cover/uncover test screens for strabismus. Color blindness is evaluated by using the Ishihara tool. To use the Ishihara chart, the child must be familiar with reading numbers and be able to follow instructions. Visual acuity (distance vision) is evaluated using the Snellen chart. Cataracts are screened by using the red reflex test. Use the direct ophthalmoscope (set at "0") and shine the light into both the eyes at about 18 inches away from the patient. Instruct the patient to stare in one direction forward (and avoid moving the eyes). Turn off the room light. In someone with advanced cataracts, the red reflex will show a white reflection instead of the normal orange to red color.
At what Tanner stage does puberty start? A) Tanner stage I B) Tanner stage II C) Tanner stage III D) Tanner stage IV
B) Tanner stage II Puberty is defined as the period in life when secondary sexual characteristics begin to develop, identified as Tanner stage II for boys and girls.
When an adolescent male's penis grows more in length than width, in which of the following Tanner stages is he classified? A) Tanner stage II B) Tanner stage III C) Tanner stage IV D) Tanner stage V
B) Tanner stage III In Tanner stage III in males, the testicular volume increases, the scrotum enlarges, and the penis begins to lengthen. Tanner stages are: Tanner I: Prepubertal small penis. Tanner II: The penis length remains unchanged. Tanner III: Penis begins to lengthen. Tanner IV: Penis increases in length and circumference. Tanner V: Scrotum and penis are mature size.
A sexually active 16-year-old girl is brought by her mother for a physical exam. During the exam, the nurse practitioner notices some bruises on both breasts. All of the following are important areas to evaluate in this patient during this visit except: A) Depression B) Tanner stage C) Sexual history D) Sexually transmitted diseases (STDs)
B) Tanner stage The stem of the question is asking for the important areas to evaluate in this patient "during this visit." This is a priority-type question. The priorities to evaluate in this patient are depression, sexually transmitted disease (STD) testing, and sexual history. The Tanner staging does not have to be done "during this visit."
Which of the following is a true statement regarding pes planus in an infant? A) It should be evaluated by a pediatric orthopedist if spontaneous correction does not occur by age 12 months B) The fat pads on an infant's feet can mimic pes planus C) It is always corrected by wearing special orthotic shoes D) It is also called talipes equinovarus
B) The fat pads on an infant's feet can mimic pes planus The fat pads on an infant's feet can resemble pes planus, or flat feet.
During a sports physical exam, a 16-year-old patient is noted to have a few beats of horizontal nystagmus on extreme lateral gaze that disappear when the eyes move back toward midline. Which statement best describes this clinical finding? A) It is caused by occult bleeding of the retinal artery B) This is a normal finding C) It is a sign of a possible brain mass D) This is a borderline result and requires further evaluation
B) This is a normal finding Horizontal nystagmus is a normal variation on physical exam. Full movement of the eyes is controlled by the integrated function of cranial nerves III (oculomotor), IV (trochlear), and VI (abducens). Holding the patient's chin to prevent movement of the head, ask the patient to watch your finger as it moves through the six cardinal fields of gaze. Then ask the patient to look to the extreme lateral (temporal) positions. A few horizontal nystagmic beats are within normal limits (WNL).
Which of the following is useful in primary care when evaluating a patient for possible acute sinusitis or hydrocele? A) Checking for the cremasteric reflex B) Transillumination C) Ultrasound D) CT scan
B) Transillumination Transillumination is a technique used with a light source, such as the otoscope, to visualize fluid below the skin surface, which will appear as a "glow." Ultrasound and CT scan are not readily available in the primary care setting; the patient must be sent to radiology for these tests to be performed.
A newborn who is floppy & limp, blue in color, HR of 60 & minimal respiratory effort has just been delivered. The infant has no grimace & only a very weak cry. What is the best immediate response to the infant in this situation?
Begin neonatal resuscitation APGAR score of 2 at 1 minute & needs immediate resus
A mother brings her 15mos toddler to clinic for preventative health care visit, clinician takes history & observes child's interactions & behaviors & then is ready to begin rest of the examination. Which of the following best describes the general approach to the pediatric examination of the young child?
Begin with the least invasive parts of the examination first
When does an infant triple its birth weight? A) 3 months B) 6 months C) 12 months D) 15 months
C) 12 months By the age of 12 months, an infant is expected to have tripled its birth weight. At 6 months, the infant has doubled his or her birth weight. Birth weight is regained by the second week of life (14 days).
One of the developmental milestones for this age group is the ability to draw a stickfigure "person" with six separate body parts. What is the age group that this finding is associated with? A) 3-year-olds B) 4-year-olds C) 5-year-olds D) 6-year-olds
C) 5-year-olds By 5 years of age, a child can draw a stick person with six body parts, can copy a triangle, can print some letters and numbers, and can count to 10 or more.
Which cranial nerve (CN) is being evaluated when patients are instructed to shrug their shoulders? A) CNIX B) CNX C) CNXI D) CN XII
C) CN XI Cranial nerves (CNs) IX through XII are the glossopharyngeal, vagal, spinal accessory, and hypoglossal, respectively. CN XI tests for spinal accessory. The procedure to test trapezius muscle strength is to have the patient shrug the shoulders against resistance. To test sternocleidomastoid muscle strength, have the patient turn the head to each side with resistance.
A 62-year-old woman complains of chronic severe low-back pain. She also reports mild episodes of fecal incontinence and numbness to her lower legs over the past week. You would suspect which of the following? A) Fracture of the lower spine B) A herniated disk C) Cauda equina syndrome D) Ankylosing spondylitis
C) Cauda equina syndrome Cauda equina is a serious condition caused by 646 compression of the lumbar, sacral, or coccygeal nerve roots in the lower portionof the spinal cord. It is considered a surgical emergency. If left untreated, acute pressure causes ischemia and can lead to permanent nerve damage, including loss of bowel and bladder control and paralysis of the legs. Signs and symptoms include a change in bowel and bladder control (incontinence), saddle-pattern anesthesia (perineum), sciatica, low-back pain, and loss of sensation or movement below level of the lesion. Causes include disk herniation, abscess, tumor, inflammation, and others.
All of the following are true about strawberry hemangiomas found in infants except: A) Most will involute spontaneously by the age of 18 to 24 months B) Watchful waiting is the most useful strategy C) Hemangiomas should be treated with laser therapy if they have not resolved by the age of 12 months D) Strawberry hemangiomas are benign
C) Hemangiomas should be treated with laser therapy if they have not resolved by the age of 12 months True strawberry hemangiomas will eventually resolve by the time the child goes to kindergarten. Most will reduce or disappear in the first 2 years. Laser treatment is rarely needed.
The first teeth to erupt during infancy are which of the following? A) First molars B) Second molars C) Incisors D) Canines
C) Incisors The incisors are the first teeth to erupt during infancy
A neighbor's 14-year-old son, who is active in basketball, complains of pain and 553 swelling on both knees. On physical exam, there is tenderness over the tibial tuberosity of both knees. Which of the following is most likely? A) Chondromalacia patella B) Left knee sprain C) Osgood-Schlatter disease D) Tear of the medial ligament
C) Osgood-Schlatter disease Osgood-Schlatter disease is characterized by bilateral pain over the tibial tuberosity upon palpation, along with knee pain and edema with exercise.
A 65-year-old carpenter complains of morning stiffness and pain in both his hands and right knee upon awakening. He feels some relief after warming up. On exam, the nurse practitioner notices the presence of Heberden's nodes. Which of the following is most likely? A) OsteoporosisB) Rheumatoid arthritis C) OsteoarthritisD) Reiter's syndrome
C) Osteoarthritis Signs of osteoarthritis (OA) include stiffness of joints, 637 especially in the morning and after sitting for long periods. Visible signs of OAare an element in the diagnosis. (Rheumatoid arthritis and gout often rely more heavily on lab tests.) Heberden's nodes (bony overgrowths) are classic signs of OA. They are located at the distal interphalangeal joints. They are felt as hard, nontender nodules usually 2 to 3 cm in diameter but sometimes encompass the entire joint. Enlargement of the middle joint of a finger is called a Bouchard's node.
Which of the following statements is false regarding physiological jaundice in newborns? A) Physiological jaundice is the most common type of jaundice in infants B) The level of unconjugated bilirubin is increased in the newborn's body C) Phototherapy is usually indicated for these infants D) It starts on the second to fourth day of life
C) Phototherapy is usually indicated for these infants The majority of infants with physiological jaundice do not need phototherapy. This form of jaundice is caused by the buildup of unconjugated bilirubin because the infant's immature liver cannot metabolize and excrete it quickly enough.
While checking for the red reflex on a 3-year-old boy during a well-child visit, the nurse practitioner notes a white reflection on the child's left pupil. Which of the following conditions should be ruled out? A) Unilateral strabismus B) Unilateral cataracts C) Retinoblastoma of the left eye D) Color blindness of the left eye
C) Retinoblastoma of the left eye Retinoblastoma is a congenital tumor of the retina. It usually affects only one eye (rarely both eyes are involved). During infancy, the tumor is a small size and it continues to grow with the child. This rare cancer is diagnosed by noting a pupil that appears white or has white spots on it. One or both eyes may be affected. It is often first noted in photographs, because a white glow is present in the eye instead of the usual "red eye" that results from the flash.
An adolescent female's areola, nipples, and breast tissue develop and become elevated as one mound. Which of the following is the correct Tanner stage for this phase of breast development? A) Tanner stage I B) Tanner stage II C) Tanner stage III D) Tanner stage IV
C) Tanner stage III During Tanner stage III, the breast and areola and nipples grow together in one mound. There is no separation yet. At Tanner stage IV, the areola and the nipple separate to form a distinct mound. The most important clue is "secondary mound."
During a sports physical of a 14-year-old girl, you note her breast development. The areola and the breast tissue are all in one mound. In which Tanner stage is this patient? A) Tanner stage I B) Tanner stage II C) Tanner stage III D) Tanner stage IV
C) Tanner stage III Tanner stages for breast development: I, prepuberty; II, breast bud; III, breast and areola one mound; IV, breast and areola secondary mound; V, adult pattern.
A girl whose breasts form a secondary mound is at which Tanner stage? A) Tanner stage II B) Tanner stage III C) Tanner stage IV D) Tanner stage V
C) Tanner stage IV The breast bud stage is Tanner stage II. In Tanner stage IV, the areola and papilla form a secondary mound. Tanner stages for breast development are I, prepuberty; II, breast bud; III, breast and areola one mound; IV, breast and areola secondary mound; and V, adult pattern
A 13-year-old boy is brought in by his mother for a physical exam. During the genital exam, the nurse practitioner notices that the patient is at Tanner stage II. Which of the following is the best description of this Tanner stage? A) The penis is growing more in length than in width and the testicles become larger with darker scrotal skin and the pubic hair is starting to curl B) The penis is growing more in width than in length with darker scrotal skin and more numerous pubic hairs that are darker, curly, and more coarse C) The testicles become larger and the skin of the scrotum starts to become darker with straight, fine, countable hairs on the genitals and the axilla D) The testicles and penile width and length are developing quickly
C) The testicles become larger and the skin of the scrotum starts to become darker with straight, fine, countable hairs on the genitals and the axilla Tanner stage II is when the testicles start to grow. The scrotal skin becomes thicker and starts to get darker (hyperpigmentation). The pubic hair is of a fine texture and straight and there are few countable hairs on the genitals and the axilla.
You are examining an infant in the nursery and notice a soft bump over the posterior right side of the skull. It is not evident on the left. What does this represent? A) Caput succedaneum B) Plagiocephaly C) Craniosynostosis D) Cephalohematoma
Cephalohematoma Cephalohematoma represents bleeding under the periosteum, which is why this lesion does not cross the midline. The blood can contribute to neonatal jaundice as it breaks down. Caput succedaneum is commonly seen as a spongy mass over the vertex, particularly when vacuum extraction is used. Craniosynostosis describes a premature closure of bony skull sutures, and plagiocephaly is a flattening of the parieto-occipital region on one side of the skull, which is frequently thought to be positional.
In caring for children, physicians & other clinicians need to understand child development. Of the following, which is a principle of normal child development?
Child development proceeds along a predictable pathway in a healthy child across all cultures, although adverse experiences prenatally or in childhood can disrupt the trajectory
You are having trouble examining the abdomen of a school-aged child due to ticklishness. What should you do? A) Have the child press on your hand. B) Have the parent insist that the child allow you to examine her. C) Ask the parent to leave the room. D) Make the child realize that this is part of the examination and must be done.
Have the child press on your hand By having the child participate in the examination and pressing on your hand, it will eliminate the ticklishness. Resistance to examination at this age is normal. The last three options only make the situation worse. The key is to have the child participate in the examination in a fun way.
At what age can a child ride a bicycle? A) 2 to 3 years of age B) 3 to 4 years of age C) 4 to 5 years of age D) 5 to 6 years of age
D) 5 to 6 years of age At about the age of 5 to 6 years, most children can ride a bicycle with training wheels. Helmets should always be worn (primary prevention).
Which of the following cranial nerves (CNs) is evaluated when a wisp of cotton is lightly brushed against the corner of the eye? A) CNII B) CN III C) CNIV D) CNV
D) CN V Cranial nerves (CNs) are assessed as follows: CN II (optic)— 667 distance vision, near vision; CNs III, IV, VI (oculomotor, trochlear, abducens) —extraocular movements (EOMs), visual fields of gaze; CN V (trigeminal; three branches are V1 [ophthalmic], V2 [maxillary], V3 [mandibular])—motor portion, clench jaws; sensory portion, corneal reflex/facial sensation. The procedure to test CN V includes inspection for muscle atrophy and tremors, palpation of jaw muscles for tone and strength when the patient clenches teeth, testing of superficial pain and touch sensation in each branch, and testing of temperature sensation if there are unexpected findings to pain or touch. A wisp of cotton is used to test the corneal reflex.
The signs and symptoms of dementia may include all of the following except: A) Personality changes B) Difficulty in verbalizing C) Difficulty in recognizing familiar objects D) Increase in abstract thinking ability
D) Increase in abstract thinking ability Characteristics of dementia include irreversible symptoms with a gradual onset. Short-term memory loss is an early sign of dementia. As symptoms progress, the patient may become incoherent, unable to talk, walk, feed self, or perform self-care.
A nurse practitioner is evaluating an 80-year-old woman who is a resident of a long-term care facility. She instructs the patient to remember the words orange, house, and world. A few minutes later, the patient is asked to recall these three words. Which of the following tests is being described? A) Lachman test B) Neurological exam C) Romberg test D) Mini-Mental State Exam
D) Mini-Mental State Exam The Lachman test is performed on the knee; a positive result is indicative of anterior cruciate ligament damage or rupture. The Romberg test is for assessment of the cerebellum. The Mini-Mental State Exam (MMSE), also known as Folstein Mini-Mental State Exam, is performed to assess for cognitive impairment and dementia. It is also used to estimate the severity of cognitive impairment at a specific time and to follow the course of cognitive changes in an individual over time, thus making it an effective way to document an individual's response to treatment. Requiring about 10 minutes to complete, the MMSE samples several cognitive functions, including arithmetic, memory, and orientation.
A 4-month-old infant has an anterior fontanel that has fused. Which of the following is the best plan for this infant? A) Tell the mother that it is normal in some infants to have early closure of the anterior fontanel B) Order an MRI of the head C) Advise the mother to return in 4 weeks for a recheck D) Refer the infant to a pediatric neurosurgeon
D) Refer the infant to a pediatric neurosurgeon Premature closure of the fontanels is called craniosynostosis. Premature closure of the anterior fontanel ("soft spot") is serious because the brain cannot grow properly. The anterior fontanel usually closes within 9 to 18 months of life. The sutures will have to be surgically separated in the operating room. There are numerous causes for craniosynostosis such as thyroid disease, genetic diseases, metabolic diseases, and so on
A 4-week-old boy is seen in the family practice clinic for a complaint of forceful vomiting that occurs immediately after feeding. The vomitus is composed of infant formula and is not bilious. The infant is bottle-fed with infant formula that was recommended by the pediatrician. The mother reports that the infant seems hungry and sucks on the bottle without any problems. His birth weight was 7 lbs, 5 oz (3.4 kg). The current weight is 7 lbs (3.2 kg). Which of the following clinical findings is an important clue regarding the possible cause of the infant's vomiting? A) Irritable and crying infant B) Sunken anterior fontanel and dry lips C) Positive rooting reflex D) Round olive-like mass located in the right upper quadrant of the abdomen
D) Round olive-like mass located in the right upper quadrant of the abdomen The stem is asking about the "possible cause of the infant's vomiting" (it is not asking about symptoms). Projectile or forceful vomiting after feeding (postprandial vomiting) is a classic symptom of infantile hypertrophic pyloric stenosis. A hypertrophied pylorus is a pathognomonic finding of the disease. An ultrasound of the pylorus is the imaging study of choice. The other signs and symptoms are dehydration (sunken anterior fontanel, dry lips, weight loss), irritability, and crying (usually due to hunger). A positive rooting reflex is a normal finding in a 4-week-old infant.
A faun tail nevus is a sign of which of the following? A) Down syndrome B) Infantile scoliosis C) Congenital heart disease D) Spina bifida
D) Spina bifida A faun tail nevus is an abnormal tuft of hair in the lumbosacral area, which can be a sign of spina bifida. If found, order an ultrasound of the lesion to rule out an opening in the lower spine (spina bifida).
While performing a routine physical exam on a 60-year-old man, the nurse practitioner notices a soft bruit over the carotid area on the left side of the neck. The patient has a history of hypertension. The patient is at higher risk for: A) Temporal arteritis and brain aneurysms B) Dizziness and headaches C) Abdominal aneurysm and congestive heart failure D) Stroke and coronary artery disease
D) Stroke and coronary artery disease Carotid stenosis puts the patient at 682 risk for stroke and coronary artery disease. A bruit is a murmur heard over the carotid artery in the neck, suggesting arterial narrowing and atherosclerosis. It may increase risk of cerebrovascular disease. Bruits at the bifurcation of the common carotid artery are best heard high up under the angle of the jaw. At this level the common carotid artery bifurcates and gives rise to its internal branch. If one hears a bruit only in the base of the neck, or along the course of the common carotid artery, it is referred to as diffuse. Diffuse bruits are not a very specific indicator of internal carotid artery disease. Bruits heard only at the bifurcation are more specific for internal carotid artery origin stenosis.
A fracture on the navicular area of the wrist is usually caused by falling forward and landing on the hands. The affected wrist is hyperextended to break the fall. The nurse practitioner is aware that all of the following statements are true regarding a fracture of the scaphoid bone of the wrist except: A) It has a higher rate of nonunion compared with the other bones in the wrist when it is fractured B) The fracture frequently does not show up on an x-ray film when it is taken immediately after the injury C) The x-ray film will show the fracture if the film is repeated in 2 weeks D) These fractures always require surgical intervention to stabilize the joint
D) These fractures always require surgical intervention to stabilize the joint 666 Common signs and symptoms of a fracture of the navicular area include pain, swelling, and tenderness over the thumb side of the wrist, and "crunchiness" and pain with gripping motions. Immediately following the injury, the fracture may not be found on x-ray, leading to misdiagnosis as a sprain. This fracture may be more accurately diagnosed with a bone scan if it does not appear on an x-ray. However, fracture is usually visible if the x-ray is repeated in 2 weeks. Treatment depends largely on the severity and shape of the fracture line. Fractures that are not displaced (those where the break line is small) are immobilized (casting). Nondisplaced fractures that do not heal after 3 to 4 months often require surgical intervention, and the use of other modalities, such as electrical stimulation.
A 17-year-old boy reports feeling something on his left scrotum. On palpation, soft and movable blood vessels that feel like a "bag of worms" are noted underneath the scrotal skin. The testicle is not swollen or reddened. The most likely diagnosis is: A) Chronic orchitis B) Chronic epididymitis C) Testicular torsion D) Varicocele
D) Varicocele Palpation of varicose veins, described as a "bag of worms," in the scrotum is a classic symptom of a varicocele, an abnormal tortuosity and dilation of the veins of the pampiniform plexus within the spermatic cord. It is most common on the left side and may be associated with pain. It occurs in boys and young men and is associated with reduced fertility. The condition is often visible only when the patient is standing. Chronic epididymitis and chronic orchitis are caused by a bacterial infection and commonly cause burning, urinary frequency, and pain. Testicular torsion is an emergent condition in which the testicle becomes twisted, interrupting the blood supply to the testis; to avoid damage, the condition must be corrected within 6 hours.
An infant presents with a heart rate of 180, a respiratory rate of 68, and an enlarged liver. What diagnosis does this suggest? A) Pneumonia B) Heart failure C) Sepsis D) Necrotizing enterocolitis
Heart failure Heart failure presents differently in infants than in adults. This triad should suggest this diagnosis. Pneumonia, necrotizing enterocolitis, and sepsis should not necessarily cause hepatomegaly. Observe closely for central cyanosis of the lips and tongue. Peripheral cyanosis alone does not mean much in infants. Perform a careful cardiac examination in as quiet a setting as possible, perhaps while the infant is in the mother's arms, to look for evidence of valvular disease.
A clinician is meeting the mother of a 5yo with asthma for the first time. The mother notes that the asthma has been poorly controlled and that the child has had multiple hospitalizations. The clinician inquires about family stressors & finds that the parents are divorced, the mother recently lost her job & child spent 2 months living with her grandparents who both smoke. Which of the following is the best example of the role of health promotion with this family?
Develop a health promotion plan that includes more frequent visits and guidance to assist family with stressors and improve child's asthma symptoms Children with a chronic illness require more frequent health promotion & health management visits to achieve optimal outcomes
Which of the following will help to optimize yield from a pediatric examination? A) Doing the examination out of order if necessary to take advantage of quiet periods for auscultation, etc. B) Being very orderly, so as not to miss a portion of the examination C) Using firmness as needed to make it through your examination D) Making sure to place the infant on the table during the examination while mom watches close by
Doing the examination out of order if necessary to take advantage of quiet periods for auscultation, etc. While order and routine are comforting to the examiner, children should be examined in an order which allows maximum yield. Many prefer to listen to the heart and lungs first while the child is quiet, in a parent's arms. Likewise, you may gain advantage to examining the mouth while the baby is crying. Most view the ENT examination as the most invasive for a child (especially the otoscopic examination), so many leave this for last.
An adolescent male comes to your clinic with a note from his mother stating it is okay for him to be seen today without her presence. He has come in for his annual sports physical required to play football. For his age his physical examination is unremarkable and you sign his school's physical examination form. You decide to take this opportunity to do some health education with him. He admits to wondering a lot lately if he is normal. Although he is in football he really enjoys science and computers more. He is worried that all his buddies will think he is a geek. He is convinced he also won't get a date for the Sadie Hawkins dance next week because the girls all think he is boring, too. He denies any experimentation with tobacco or alcohol, and he blushes when you mention sex. After hitting all the pertinent age-appropriate education points you give him his sports physical form and he leaves. The patient's concerns during the visit most resemble what developmental stage of adolescence? A) Early adolescence (10 to 14 years old) B) Middle adolescence (15 to 16 years old) C) Late adolescence (17 to 20 years old)
Early adolescence (10-14yo) His concern with whether he is normal or not is often seen in the development of social identity in early adolescence. He is also concerned with the present (Sadie Hawkins dance) and not the distant future, as is seen with late adolescence. He also denies the experimentation often seen in middle adolescence.
A foster mother brings a 4-year-old child to see you for an evaluation. She has had custody of the girl for 2 weeks. She knows that the child was born in your state and that her maternal grandmother had custody for 6 months. She received good medical care during that time, but after her biologic mother obtained custody the child was abused and has had no further medical care. She says the child has had many behavioral problems and seems to be very behind on her developmental tasks. When you examine the child you notice short palpebral fissures, a wide nasal philtrum, and thin lips. Her cardiac, pulmonary, musculoskeletal, and abdominal examinations are normal. Her Denver Developmental Screening Test shows most of her milestones have occurred only through the 24th month. What form of congenital retardation is she most likely to have? A) Fetal alcohol syndrome B) Congenital hypothyroidism C) Down syndrome
Fetal alcohol syndrome The facial appearance in fetal alcohol syndrome shows short palpebral fissures, a wide and flattened philtrum, and thin lips. These children often have mild retardation even with good care, but with abuse they may have more profound retardation. This condition may occur with only modest alcohol consumption.
A mother brings her 16-month-old son in for an evaluation. She is afraid he is not meeting his developmental milestones and wants to know if he should be sent to therapy. He was the product of an uneventful pregnancy and a spontaneous vaginal delivery. His Apgar scores were 7 and 9. Until reaching a year old the mother believes he was hitting his milestones appropriately. You decide to administer the Denver Developmental Screening Test. You find that he is using a spoon to eat with and can take off his own shoes and shirt. He can build a tower of two cubes and dump raisins. His vocabulary consists of at least 10 words. He can stand alone and stoop and recover, but he is unable to walk without holding onto someone's hand. What type of developmental delay does he have? A) Personal/social B) Fine motor C) Language D) Gross motor
Gross motor By 16 months a child should be able to walk unaided and even walk backwards and run. This child was referred to physical therapy and did well.
A mother brings her 4-year-old daughter to your office because of fever and decreased eating and drinking. When you ask the little girl what is wrong, she says her mouth and throat hurt. On examination her temperature is 101 degrees. Her ears and nose examinations are unremarkable. Her mouth has ulcerations on the buccal mucosa and the tongue. She also has cervical lymphadenopathy. Her cardiac and pulmonary examinations are normal. She is up to date on her childhood vaccinations. What mouth abnormality does she most likely have? A) Strep throat B) Herpetic stomatitis C) Oral candidiasis (thrush) D) Diphtheria
Hepatic stomatitis With herpetic stomatitis there is often a low-grade fever with small ulcers covering the mucosa of the mouth. The pain from the ulcers leads to decreased oral intake and even dehydration.
You are assessing Tanner staging of the breast in a young woman. You notice projection of the areola and nipple to form a secondary mound above the level of the breast. Which Tanner stage would this be? A) I B) II C) III D) IV
III This would be a Tanner stage III because there is elevation of the nipple and areola above the level of the surrounding breast tissue and because the areola has not receded to the general contour of the breast.
A mother brings her infant to you because of a "rattle" in his chest with breathing. Which of the following would you hear if there were a problem in the upper airway? A) Different sounds from the nose and chest B) Asymmetric sounds C) Inspiratory sounds D) Sounds louder in the lower chest
Inspiratory sounds It is important to distinguish upper airway sounds from lower because many benign conditions cause upper airway noise, such as viral upper respiratory infections. It is reassuring to hear the same noises at the nose as at the chest. Lower respiratory conditions also are generally symmetric, and sounds are louder at the upper chest versus the lower chest. They are usually very harsh and loud, which concerns parents.
You have been unable to hear normal S2 splitting in children up to this point. What technique will maximize your chances of hearing this phenomenon? A) Listen with the diaphragm over the left lower sternal border. B) Listen with the bell over the 2nd left intercostal space. C) Listen with the bell over the apex. D) Listen with the diaphragm in the axilla.
Listen with bell over 2nd LLSB S2 is made of aortic and pulmonic components. Of these, the pulmonic componen is much softer and heard best over the pulmonic area. Even in the proper location, the pulmonic component may be difficult to hear with the diaphragm because it is a soft, low-pitched sound. For this reason, the bell should be used to listen for S2 splitting over the pulmonic area during inspiration, when splitting should be maximized. Breathing also changes heart rate more rapidly in children. One may think an arrhythmia is present until she notices that this rate change is related to the respiratory cycle.
A young Hispanic mother brings in her 2-month-old son. She is upset because her neighbors have threatened to call the Child Protective Agency because they think his birthmark is a bruise. Her son was the product of an uneventful pregnancy and spontaneous vaginal delivery. On examination you see a large, smooth-bordered bluish mark on his buttock and lower back. Otherwise his examination is unremarkable. What form of birthmark is this likely to be? A) Café-au-lait spot B) Salmon patch C) Mongolian spot
Mongolian spot Mongolian spots are large, smooth-bordered birthmarks found on the back and/or buttocks. They are found more often in darker-pigmented infants such as in the Hispanic or Asian population. They are commonly mistaken for bruises.
A 15-month-old is brought to you for a fever of 38.6 degrees Celsius and fussiness. The ear examination is as follows: external ear, normal appearance and no tenderness with manipulation; canal, normal diameter without evidence of inflammation; tympanic membrane, bulging, erythematous, and opaque. Insufflation is deferred due to pain. What is your diagnosis? A) Otitis externa B) Cholesteatoma C) Ruptured tympanic membrane D) Otitis media
Otitis media There is no inflammation of the outer ear, including the canal, thus excluding otitis externa. Cholesteatoma is a painless white lesion behind the TM. There is no drainage from the TM; thus, rupture is unlikely. This is a classic description of otitis media. Many examiners will forego insufflation if the diagnosis is clear, because this can cause discomfort in an already uncomfortable ear.
Parents of a 21mos child explain that their son used to speak nearly 50 words & was using 2 word phrases. In last month or so, child has not been using as many words & tends to echo what is being said to him rather than use language spontaneously. They want to know if this is normal. After taking a thorough developmental history, the clinician finds that the child makes poor eye contact & does not play with toys in a purposeful manner. The physical examination is normal except for child's limited social interactions. There is a family history of autism in two first cousins. Which of the following would be the response response to the parents at this time?
Refer the child to a developmental & behavioral pediatrician Any loss of milestones of this duration & severity requires that the examiner take a thorough medical, developmental, family & social history.
A 6-month-old infant is brought in for a well check. It is noted his head circumference is off the chart and at a much higher percentile than was previously measured. What should you do next? A) Recommend a neurology consult. B) Order a CT of the head. C) Remeasure the circumference. D) Admit the child to the hospital for further workup.
Remeasure the circumference It is difficult to obtain accurate measurements of a squirming infant. The first step would be to remeasure. Some recommend starting with three measurements and averaging or picking the middle measurement. Height is technically not measured until a child is standing, so infants' measurements are recorded as length.
A mother brings in her 3-year-old son for a well-child check-up. She is concerned that he seems different in size from all of the other preschool boys. He was the product of an uneventful pregnancy and vaginal delivery. He has hit all of his developmental milestones on time. On examination he is 26 lbs (11.8 kg) and is 35 inches (89 cm) tall. Otherwise his examination is unremarkable. You give the correct education for his age and then discuss his size. For his age, what are his growth chart percentiles? A) Tall and heavy for his age (>95%) B) Average height and weight for his age (5 to 95%) C) Small and light for his age (<5%)
Small & light for his age (<5%) According to the growth charts, this child is less than the fifth percentile for both height and weight, indicating that he is small and light for his age. This can be from a growth hormone deficiency but is usually due to genetic factors (such as short, light parents). It is most important to follow the trend of growth. It is more significant if this child was previously at the 50th percentile for height and weight than if he has always been about the same percentile and following a line parallel to expected growth lines.
A 24-year-old mother who is a smoker and cocaine addict gave birth at 39 weeks to a 2,000-gram female infant who is in the neonatal intensive care unit. Using the Intrauterine Growth Curve chart, you determine whether the infant's weight is appropriate for her gestational age. In which category does the infant best fit? A) Large for gestational age B) Normal for gestational age C) Small for gestational age
Small for gestational age For a 39-week infant, any weight less than 2,500 grams would be considered small. Intrauterine growth retardation and low birth weight would be expected in a smoker who also abuses cocaine.
A clinician arrives at the hospital several hours after the birth of a full-term infant. The infant is rooming in with her parents & appears to be doing well. There were no problem with the pregnancy, labor or delivery. The nurse asks if the baby should be taken back to the nursery for examination. What is the best response to the nurse?
State that the infant should be examined in the presence of the parents so they can be taught about what their newborn can do
You are examining a 5-year-old before he begins school. You notice a systolic, grade II/VI vibratory murmur over the LLSB and apex with normal S2 splitting. He has normal pulses as well. Which of the following is most likely? A) Tricuspid stenosis B) Mitral stenosis C) Still's murmur D) Venous hum
Still's murmur This description is consistent with Still's murmur, a very common and benign murmur of childhood. Tricuspid and mitral stenosis would be diastolic murmurs and the venous hum is usually not heard in this area. Further evaluation is usually not necessary.
A mother is upset because she was told by another provider that her child has a worrisome murmur. You listen near the clavicle and notice both a systolic and diastolic sound. You remember that diastolic murmurs are usually indicative of bad pathology. What would you do next? A) Cardiology referral B) Echocardiogram C) Supine examination D) Reassure the mother
Supine examination The next step would be to examine the patient in the supine position. If this is a venous hum, this murmur will resolve almost completely in the supine position. This is a very common phenomenon in school-aged children, particularly over the clavicle, but can also occur outside this range. Reassurance cannot be given without further examination, especially with a diastolic murmur. Cardiology referral and echocardiography are unnecessary if examination in the supine position reveals no murmur.
A 38-week gestation, 2500-gram infant is placed on your service. How would she be described? A) Term, normal birth weight B) Term, low birth weight C) Preterm, normal birth weight D) Preterm, low birth weight
Term, normal birth weight Preterm is defined as less than 37 weeks; term, 37-42 weeks; and post-term, over 42 weeks of gestation. Birth weights have similar limits: extremely low birth weight, less than 1000 grams; very low birth weight, less than 1500 grams; low birth weight, less than 2500 grams; and normal birth weight, equal to or more than 2500 grams. These have prognostic implications and impact on how closely to watch and how aggressively to treat these infants.
A mother brings her 9mos son to practice for the first time, concerned that he is not yet sitting by himself. After taking a careful hx, the physician notes that the infant has good head control & can grasp a rattle but is unable to roll over, crawl or pull to stand. What should the clinician explain to the mother?
The delay in his physical motor skills is concerning and warrants a more complete developmental history & possible referral for early intervention
The nurse in the newborn nursery reports that she is concerned about Baby Boy Jones, who was born full-term by C-section for failure to progress. The pregnancy was complicated only by a maternal UTI in the first trimester. He had APGARs of 9 & 10 at 1 minute & 5 minutes & had been doing well. However, now, on the fourth day of life, the infant has developed a tremor. Which of the following factors would cause the most concern about the tremor?
The infant also has asymmetric limb movements Tremor is a concerning sign in a newborn infant unless it only occurs while the infant is crying vigorously and is brief & suppressible
You are assessing an infant and notice that his nares flare, he has a soft grunt with each breath, and the skin between his ribs is pulled inward with inhalation. What is the significance of these findings? A) These are indicative of a CNS process. B) These are indicative of respiratory distress. C) These are indicative of muscular dystrophy. D) These are frequently accompanied by stridor.
These are indicative of respiratory distress It is critical to notice these findings of respiratory distress. Muscular dystrophy may not allow the appearance of these signs because they are caused by muscular effort. It is hard to find a cause for these signs in the CNS. Stridor is usually inspiratory, so while nasal flaring and retractions may occur, grunting is unusual because exhalation is unimpeded.
An infant is born at 4 weeks preterm to a mother with hx of HTN, severe DM, ETOH abuse, infant noted to be SGA, weighing 1500g, which of the following is the most important reason for assessing both gestational age & birth weight for any infant?
These two factors help to anticipate certain medical & developmental problems
A mother brings her 15-month-old daughter to your office for evaluation of a rash and fever. She says the rash started one day and the fever developed the next day. Her daughter has had all of her vaccinations up to 10 months. The mother sheepishly admits that she hasn't had time to bring her daughter in since her 10-month check-up. On examination you see a mildly sick-appearing toddler with a 102-degree temperature. Looking at her skin you see at least 100 of a variety of papules, vesicles, and ulcers in different stages of development. What illness prevented by proper vaccination does this toddler have? A) Varicella (chickenpox) B) Measles C) Smallpox
Varicella (chickenpox) Normally the first vaccine for varicella is given at 12 to 15 months. The characteristic rash in waves of lesions is in a pattern of papules, vesicles, ulcers, and scabs. Because of the number of persons who still get shingles (an outbreak of varicella in one dermatome following the original infection by years), there is still enough virus in the United States to easily get chickenpox without vaccination. This child is regarded as contagious to others until all of the lesions are "scabbed over." Smallpox would appear different in that all of the lesions would be in the same stage of development.
