Midterm

1. A 3-year-old child with pressure-equalizing tubes (PET) in both ears has otalgia in one ear. The primary care pediatric nurse practitioner is able to visualize the tube and does not see exudate in the ear canal and obtains a type A tympanogram. What will the nurse practitioner do? a. Order ototopical antibiotic/corticosteroid drops. b. Prescribe a prophylactic antibiotic medication. c. Reassure the parent that this is a normal exam. d. Refer the child to an otolaryngologist for follow-up

ANS: A A normal, or type A, tympanogram in a child with PET may indicate a clogged tube. Ototopical antibiotic/corticosteroid drops can occasionally clear a clogged PET. Prophylactic antibiotics are not recommended to prevent otitis media. It is not necessary to refer unless the pain continues in spite of standard measures. 1

7. What will the primary care pediatric nurse practitioner teach the parents of a child who has new pressure-equalizing tubes (PET) in both ears? a. Parents should notice improved hearing in their child. b. PET will help by reducing the number of ear infections the child has. c. The child should use earplugs when showering or bathing. d. The tubes will most likely remain in place for 3 to 4 years.

ANS: A By reducing middle ear fluid, the child with hearing loss from this condition should show improvement in hearing. Children may still have infections but without persistent effusion. Earplugs are not necessary unless the child's head is submerged. PETs usually fall out on their own; if they are still in place 2 to 3 years after placement, they should be removed by the otolaryngology surgeon.

7. Because of their inability to ambulate, children with cerebral palsy should be evaluated for which nutrients? a. Calcium and vitamin D b. Fat-soluble vitamins c. Iron and zinc d. Sodium and potassium

ANS: A Children who do not place weight on their bones are at risk for osteopenia and should have vitamin D and calcium levels monitored and supplemented if indicated.

2. The primary care pediatric nurse practitioner performs a well child examination on a 9-month-old infant who has a history of prematurity at 28 weeks' gestation. The infant was treated for retinopathy of prematurity (ROP) and all symptoms have resolved. When will the infant need an ophthalmologic exam? a. At 12 months of age b. At 24 months of age c. At 48 months of age d. At 60 months of age

ANS: A Children who have a history of ROP requiring treatment, even if ROP has completely resolved, will need yearly ophthalmologic follow-up. Less frequent follow-up is required for children with ROP who did not require treatment.

6. The primary care pediatric nurse practitioner reviews hematology reports on a child with beta- thalassemia minor and notes an Hgb level of 8 g/dL. What will the nurse practitioner do? a. Evaluate serum ferritin. b. Order Hgb electrophoresis. c. Prescribe supplemental iron. d. Refer for RBC transfusions.

ANS: A Children with beta-thalassemia minor may have low hemoglobin without iron deficiency so, before prescribing iron, the PNP should measure serum iron levels or serum ferritin. Hgb electrophoresis is indicated in a child whose diagnosis is unknown to diagnose this disorder. Supplemental iron should only be ordered when there is documented iron deficiency. RBC transfusions are controversial and used only for more severe iron deficiency.

2. A child who has sustained a head injury after falling on the playground is brought to the clinic. The parents report that the child cried immediately and was able to walk around after falling. The primary care pediatric nurse practitioner notes slight slurring of the child's speech and the child has vomited twice in the exam room. Which course of action is warranted? a. Admit the child to the hospital for a neurology consult. b. Observe the child in the clinic for several hours. c. Order a head CT and observe the child at home. d. Send the child home with instructions for follow-up.

ANS: A Children with certain symptoms, such as vomiting or slurred speech after a head injury, should be admitted to the hospital for neurologic consultation. If the child had not exhibited these symptoms, any of the other options would be acceptable.

6. A primary care pediatric nurse practitioner working in a community health center wishes to develop a program to assist impoverished children and families to have access to healthy foods. Which strategy will the pediatric nurse practitioner employ to ensure the success of such a program? a. Asking community members to assist in researching and implementing a program b. Designing a community garden approach that involves children and their parents c. Gaining support from the corporate community to provide needed resources d. Providing evidence-based information about the importance of a healthy diet

ANS: A Community collaboration can be fostered through community-based participatory research (CBPR), which is transformative research that bridges the gap between science and practice by actively engaging communities with formally trained researchers. In this type of research, community members formally participate in all aspects of the process, making the findings more relevant to the community it affects the most. Designing a community garden approach without first knowing whether the community needs or wants it does not ensure success. Gaining support from the corporate community without input from the affected community does not guarantee success. Giving evidence-based information does not involve the community members in research and does not increase success.

2. A 2-year-old child who has SCA comes to the clinic with a cough and a fever of 101.5°C. The child currently takes penicillin V prophylaxis 125 mg orally twice daily. What will the primary care pediatric nurse practitioner do? a. Admit the child to the hospital to evaluate for sepsis. b. Give intravenous fluids and antibiotics in clinic. c. Increase the penicillin V dose to 250 mg. d. Order a chest radiograph to rule out pneumonia.

ANS: A Fever and pulmonary symptoms are two conditions warranting referral or emergency admission to the hospital to rule out sepsis and acute chest syndrome. Increasing the dose of penicillin V or giving IV antibiotics is not indicated.

10. The parents of a special needs child tell the primary care pediatric nurse practitioner that they are planning a 3-month visit to their home country in Africa. The pediatric nurse practitioner assists the family to obtain a sufficient supply of medications and formula and to make sure that the child's equipment can be transported and used during the trip and at the destination. This is an example of a. global application. b. global awareness. c. system application. d. system awareness.

ANS: A Global application involves having a willingness and ability to adjust to the needs of clients, families, and communities both nationally and globally. Global awareness involves knowledge of diseases, political, and economic factors worldwide that affect health. System application involves assisting clients to overcome institutional barriers to effective interventions. System awareness is knowledge of these barriers.

1. A male patient has a history of recurrent epistaxis. Prior to a scheduled surgery, the provider asks about a family history of bleeding disorders. The patient reports no female relatives who had excessive bleeding episodes, but states that a maternal uncle and his maternal grandfather both had post-surgical complications related to bleeding. Based on this history, which diagnosis is possible? a. Hemophilia b. Thrombocytopenia c. Thrombophilia d. Von Willebrand disease

ANS: A Hemophilia is an X-linked recessive disorder affecting only males and carried by females. A family history of maternal males with bleeding disorders should clue the provider that this disorder is likely. Thrombocytopenia is usually an acquired disorder. Thrombophilia causes clots and thrombi, not bleeding. Von Willebrand disease is an autosomal genetic disorder affecting both males and females.REF: Pathophysiology and Clinical Presentation

1. A child who has otitis externa has severe swelling of the external auditory canal that persists after 2 days of therapy with ototopical antibiotic/corticosteroid drops. What is the next step in treatment for this child? a. Insert a wick into the external auditory canal. b. Irrigate the external auditory canal with saline. c. Order systemic corticosteroids. d. Prescribe an oral antibiotic medication.

ANS: A If significant swelling is present, inserting a wick into the EAC is helpful and should be impregnated with antibiotics as long as it is in place. Irrigation is contraindicated during an acute infection. Systemic steroids and antibiotics are not indicated.

9. The primary care pediatric nurse practitioner prescribes a twice daily inhaled corticosteroid for a 12- year-old child. At a well child visit, the child reports not using the medication on a regular basis. Which response by the pediatric nurse practitioner demonstrates an understanding of client-centered care? a. Asking the child to describe usual daily routines and schedules b. Referring the family to a social worker to help with medication compliance c. Reviewing the asthma action plan with the parent and the child d. Teaching the child how the medication will help to control asthma symptoms

ANS: A In a client-centered relationship, there is reciprocal communication and understanding. The PNP should be able to understand the client's perspective and unique situation. The first step is to evaluate possible reasons for nonadherence and not to make referrals or re-educate until potential barriers have been identified and negotiation with the client has occurred.

2. The primary care pediatric nurse practitioner performs a well baby examination on a 4-month-old infant who is exclusively breastfed and whose mother plans to introduce only small amounts of fruits and vegetables in addition to breastfeeding. To ensure that the infant gets adequate amounts of iron, what will the nurse practitioner recommend? a. Elemental iron supplementation of 1 mg/kg/day until cereals are added b. Elemental iron supplementation of 3 mg/kg/day for the duration of breastfeeding c. Monitoring the infant's hemoglobin and hematocrit at every well-baby checkup d. Offering iron-fortified formula to ensure adequate iron intake

ANS: A Infants who are exclusively breastfeeding or who receive more than half of their diet from breast milk should be given 1 mg/kg/day of supplemental iron until iron-containing foods are added to the diet. It is not necessary to monitor Hgb/Hct regularly unless the child has symptoms. Formula is not necessary for breastfeeding infants. 1

5. The pediatric nurse practitioner provides primary care for a 30-month-old child who has sickle cell anemia who has had one dose of 23-valent pneumococcal vaccine. Which is an appropriate action for health maintenance in this child? a. Administer an initial meningococcal vaccine. b. Begin folic acid dietary supplementation. c. Decrease the dose of penicillin V prophylaxis. d. Give a second dose of 23-valent pneumococcal vaccine.

ANS: A Invasive bacterial infection is the leading cause of death in young children with SCA. Meningococcal vaccine should be given initially for all children over the age of 2 years and a booster dose given every 5 years after that. Folic acid supplementation is often used for adults but not for children unless there is a documented deficiency. Penicillin V prophylaxis is started at 2 months of age, with the dose increased at age 3 years. The 23-valent pneumococcal polysaccharide second dose is given 5 years after the first.

2. The primary care pediatric nurse practitioner is examining a child whose parents recently emigrated from a war-torn country in the Middle East. Which is a priority assessment when performing the patient history? a. Asking about physical, psychological, and emotional trauma b. Determining the parents' English language competency and literacy level c. Learning about cultural preferences and complementary medicine practices d. Reviewing the child's previous health and illness records

ANS: A Recent history that includes trauma, loss, and refugee camp experience may exacerbate difficulties adjusting to life in the U.S. and can lead to acute and chronic physical and mental health concerns. All of the other parts of the history will be necessary, but this should be a priority, since the family has escaped a war-torn country.

5. The primary care pediatric nurse practitioner is evaluating health literacy in the mother of a new preschool-age child. How will the nurse practitioner assess this? a. Ask the child how many books he has at home. b. Ask the mother about her highest grade in school. c. Ask the mother to determine the correct dose of a drug from a label. d. Ask the mother to read a health information handout aloud.

ANS: A The "newest vital sign," or health literacy, can be determined quickly by asking the parent how many children's books are in the home. Greater than 10 books in the home is an independent positive predictor of adequate parent health literacy. The other questions may determine a specific level of literacy in general but are not as efficient.

2. The primary care pediatric nurse practitioner is performing a well child assessment on an adolescent and is concerned about possible alcohol and tobacco use. Which assessment tool will the nurse practitioner use? a. CRAFFT b. HEEADSSS c. PHQ-2 d. RAAPS

ANS: A The CRAFFT tool is a six-question tool used to screen for adolescent substance abuse. The HEEADSSS is used as a psychosocial screening tool. The PHQ-2 is a rapid screen for depression. The RAAPS is used to assess risk behaviors that contribute to most morbidity, mortality, and social problems in teens. 1

4. When formulating developmental diagnoses for pediatric patients, the primary care pediatric nurse practitioner may use which resource? a. DC: 0-3R b. ICD-10-CM c. ICSD-3 d. NANDA International

ANS: A The DC: 0-3R refers to the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood and is useful for developmental problem diagnosis. The ICD-10-CM is the International Classification of Diseases-Tenth Revision, Clinical Modification and is useful for identifying physiologic diseases. The ICSD-3 is the International Classification of Sleep Disorders - 3rd edition. NANDA International is used to label problems in the functional health domain.

4. A school-age child is seen in the clinic after a fragment from a glass bottle flew into the eye. What will the primary care pediatric nurse practitioner do? a. Refer immediately to an ophthalmologist. b. Attempt to visualize the glass fragment. c. Irrigate the eye with sterile saline. d. Instill a topical anesthetic.

ANS: A The PNP should never attempt to remove an intraocular foreign body or any projectile object but should refer immediately to an ophthalmologist. Visualizing the object, irrigating the eye, or instilling drops may further injure the eye.

5. The primary care pediatric nurse practitioner cares for children from a Native American family and learns that they used many herbs to treat and prevent illness. Which approach will the pediatric nurse practitioner use to promote optimum health in the children? a. Ask about the types of practices used and when they are applied. b. Provide a list of harmful herbs and ask the family to avoid those. c. Suggest that the family avoid using these remedies in their children. d. Tell the parents to use the herbs in conjunction with modern medications.

ANS: A The challenge, when working with families from different cultural backgrounds, who use alternative or complementary medicines, is to find ways to achieve a mutual understanding of the differences and to negotiate an acceptable plan of care. The first step is to begin a discussion about these practices. Providing a list of harmful herbs, suggesting that the family avoid certain herbs, and suggesting that the herbs are only an adjunct to "modern medicine" will sound disparaging and will convey a sense of mistrust.

3. The primary care pediatric nurse practitioner evaluates a 5-year-old child who presents with pallor and obtains labs revealing a hemoglobin of 8.5 g/dL and a hematocrit of 31%. How will the nurse practitioner manage this patient? a. Prescribe elemental iron and recheck labs in 1 month. b. Reassure the parent that this represents mild anemia. c. Recommend a diet high in iron-rich foods. d. Refer to a hematologist for further evaluation.

ANS: A The child has mild to moderate iron-deficiency anemia and will need iron supplementation. The hemoglobin, hematocrit, and reticulocytes should be reevaluated in 4 weeks after initiation of treatment. The child needs iron supplementation, so reassurance alone is not indicated. It is difficult to get iron from foods, so supplementation will be needed. Children with hemoglobin levels less than 4 g/dL and some children with hemoglobin levels less than 7 g/dL must be referred.

2. The mother of a newborn tells the primary care pediatric nurse practitioner that she is worried that her child will develop allergies and asthma. Which tool will the nurse practitioner use to evaluate this risk? a. Three-generation pedigree b. Review of systems c. Genogram d. Ecomap

ANS: A The three-generation pedigree is used to map out risks for genetic diseases in families, as well as conditions with modifiable risk factors. The review of systems is used to evaluate the history of the child's body systems. The genogram is an approach to developing a family database to provide a graphic representation of family structure, roles, and problems of recurring significance in a family. The ecomap is used to identify relationships in the family and community that are supportive or harmful.

9. The primary care pediatric nurse practitioner is managing care for a child diagnosed with iron- deficiency anemia who had an initial hemoglobin of 8.8 g/dL and hematocrit of 32% who has been receiving ferrous sulfate as 3 mg/kg/day of elemental iron for 4 weeks. The child's current lab work reveals elevations in Hgb/Hct and reticulocytes with a hemoglobin of 10.5 g/dL and a hematocrit of 36%. What is the next step in management of this patient? a. Continue the current dose of ferrous sulfate and recheck labs in 1 to 2 months. b. Discontinue the supplemental iron and encourage an iron-enriched diet. c. Increase the ferrous sulfate dose to 4 to 6 mg/kg/day of elemental iron. d. Refer the child to a pediatric hematologist to further evaluate the anemia.

ANS: A This child has mild to moderate anemia and is showing a good response to the current dose of iron. Ferrous sulfate should be continued for at least 2 to 3 months to normalize hemoglobin, and then continue for 2 to 4 months to replace depleted iron stores. There is no need to increase the dose, since the child is responding appropriately to the current dose. Children with hemoglobin levels less than 4 g/dL should be referred.

1. A preschool-age child is seen in the clinic after waking up a temperature of 102.2°F, swelling and erythema of the upper lid of one eye, and moderate pain when looking from side to side. Which course of treatment is correct? a. Admit to the hospital for intravenous antibiotics. b. Obtain a lumbar puncture and blood culture. c. Order warm compresses 4 times daily for 5 days. d. Prescribe a 10- to 14-day course of oral antibiotics.

ANS: A This child has periorbital cellulitis and must be hospitalized because of having pain with movement of the eye, indicating orbital involvement. LP is performed on infants under 1 year of age. Warm compresses are used for mild cases. Oral antibiotics are not indicated. 1

8. A toddler who presents with anemia and reticulocytopenia has a history of a gradual decrease in energy and increase in pallor beginning after a recent viral infection. How will the primary care pediatric nurse practitioner treat this child? a. Closely observe the child's symptoms and lab values. b. Consult with a pediatric hematologist. c. Prescribe supplemental iron for 4 to 6 months. d. Refer for transfusions to correct the anemia.

ANS: A This child has symptoms and a history consistent with transient erythroblastopenia of childhood (TEC), which is usually self-limited. The PNP should monitor the child closely without treatment unless the anemia gets worse. Any of the other options may be necessary if the child's condition worsens.

4. The primary care pediatric nurse practitioner is examining a 5-year-old child who has had recurrent fevers, bone pain, and a recent loss of weight. The physical exam reveals scattered petechiae, lymphadenopathy, and bruising. A complete blood count shows thrombocytopenia, anemia, and an elevated white cell blood count. The nurse practitioner will refer this child to a specialist for a. bone marrow biopsy. b. corticosteroids and IVIG. c. hemoglobin electrophoresis. d. immunoglobulin testing.

ANS: A This child has symptoms and initial lab tests consistent with leukemia and should be referred to a pediatric hematologist-oncologist for a bone marrow biopsy for a definitive diagnosis. Corticosteroids and IVIG are given for severe ITP. Hgb electrophoresis is used to diagnose SCA. Immunoglobulins are evaluated when immune deficiency syndromes are suspected.

3. A school-age child has a history of chronic otitis media and is seen in the clinic with vertigo. The primary care pediatric nurse practitioner notes profuse purulent otorrhea from both pressure- equalizing tubes and a pearly-white lesion on one tympanic membrane. Which condition is most likely? a. Cholesteatoma b. Mastoiditis c. Otitis externa d. Otitis media with effusion

ANS: A This child has symptoms of cholesteatoma, especially with a pearly white lesion on the TM. Mastoiditis involves the mastoid bone behind the ear.

3. The primary care pediatric nurse practitioner is performing a well child check-up on a 20-month-old child. The child was 4 weeks premature and, according to a parent-completed developmental questionnaire, has achieved milestones for a 15-month-old infant. Which action is correct? a. Perform an in-depth developmental assessment screen at this visit to evaluate this child. b. Reassure the parent that the child will catch up to normal development by age 2 years. c. Re-evaluate this child's development and milestone achievements at the 2-year visit. d. Refer the child to a specialty clinic for evaluation and treatment of developmental delay.

ANS: A This child should be at a 19-month adjusted age for prematurity so, according to the parent screen, is 4 months behind. The PNP should perform a more in-depth screen to evaluate this delay. Waiting to see if the child will "catch up" or assuring the parent that this will happen will cause the delays to become more severe. A referral to a specialty clinic should not be made solely on the basis of the parent-completed questionnaire but only after further evaluation of possible delays.

3. A patient reports recent mild fatigue and palpitations. A complete blood count reveals a decreased hemoglobin level and a normal ferritin level. What other findings are likely to be present? a. Decreased hematocrit b. Decreased MCV, MCH, and MCHC c. Elevated total iron-binding capacity d. Paresthesias, koilonychia, and pica

ANS: A This patient has signs of milder iron-deficiency anemia and will also have a low hematocrit level. The RBC indexes are the last to change as the anemia becomes more severe. When the ferritin level drops, the TIBC will become elevated. Paresthesias, koilonychia, and pica occur with more severe anemia.

2. Which types of lymphomas typically have an aggressive presentation? Select all that apply. a. Adult T cell leukemia-lymphoma b. Burkitt lymphoma c. Diffuse large B cell lymphoma d. Follicular lymphoma e. Splenic marginal zone lymphoma

ANS: A, B, C Adult T cell leukemia-lymphoma, Burkitt lymphoma, and diffuse large B cell lymphoma are all aggressive lymphomas. Follicular lymphoma and splenic marginal zone lymphomas are indolent lymphomas.REF: Non-Hodgkin's Lymphoma/Clinical Presentation

1. A 70-year-old patient reports frequent infections, shortness of breath, fatigue, and palpitations. An exam reveals pallor and petechiae. The provider orders a peripheral blood smear and bone marrow biopsy. Which findings are consistent with a diagnosis of myelodysplasia? Select all that apply. a. Anisocytosis and poikilocytosis of erythrocytes on peripheral smear b. Defects in cellular maturation in all cell lines in bone marrow aspirate c. Hypercellular bone marrow with peripheral cytopenia d. Larger than normal megakaryocytes in bone marrow e. Smaller than normal granulocytes in the peripheral blood smear

ANS: A, B, C, D The key finding in MDS is packed, hypercellular bone marrow with peripheral cytopenia. Erythrocytes in peripheral blood will show anisocytosis, poikilocytosis, or basophilic stippling. The bone marrow will have defects in all cellular maturation. Megakaryocytes in bone marrow will be smaller than normal. Granulocytes in peripheral blood will be larger than normal.REF: Diagnostics

3. A patient with acute myelogenous leukemia (AML) who has a high white blood cell count and diffuse lymphadenopathy is hospitalized during the induction phase of chemotherapy. What monitoring and interventions are critical to assess for complications during this phase of care for this patient? Select all that apply. a. Administration of sodium bicarbonate and allopurinol b. Assessment for bruising and petechiae c. Close monitoring of absolute neutrophil counts d. Daily renal function and chemistry values e. Meticulous assessment of hydration status

ANS: A, D, E This patient has a high WBC load and diffuse lymphadenopathy, so is at increased risk for acute tumor lysis syndrome (ATLS). Close monitoring of renal function, serum renal chemistry values, and hydration status is essential. Adding sodium bicarbonate and allopurinol help to minimize risk. Thrombocytopenia causing bruising and petechiae, along with neutropenia, are common complications of chemotherapy but these symptoms generally occur 7 to 10 days after initiation of therapy.REF: Tumor Lysis Syndrome

5. A child who has had a single non-febrile seizure has a normal neurologic exam. Which diagnostic test is indicated? a. Computerized tomography (CT) b. Electroencephalogram (EEG) c. Magnetic resonance imaging (MRI) d. Polysomnography

ANS: B An EEG is standard for all children after a first non-febrile seizure. CT is not routinely used because of radiation exposure. MRI is used if cognitive changes or postictal focal dysfunction persists, if the seizure lasts longer than 15 minutes, if the child is younger than 6 months of age, and if any new onset of focal neurologic deficit has occurred. Polysomnography is used to assess nocturnal seizures.

4. During a well-baby assessment on a 1-week-old infant who had a normal exam when discharged from the newborn nursery 2 days prior, the primary care pediatric nurse practitioner notes moderate eyelid swelling, bulbar conjunctival injections, and moderate amounts of thick, purulent discharge. What is the likely diagnosis? a. Chemical-induced conjunctivitis b. Chlamydia trachomatis conjunctivitis c. Herpes simplex virus (HSV) conjunctivitis d. Neisseria gonorrhea conjunctivitis

ANS: B C. trachomatis conjunctivitis usually begins between 5 to 14 days of life and causes moderate eyelid swelling, palpebral or bulbar conjunctivitis, and moderate, thick, purulent discharge. Chemical-induced conjunctivitis manifests as nonpurulent discharge. HSV is characterized by serosanguinous discharge. N. gonorrhea causes acute conjunctival inflammation and excessive purulent discharge.

3. A patient has type 1 Von Willebrand disease (vWD). What treatment is generally effective to prevent and treat bleeding episodes in this patient? a. Coagulation factor b. Desmopressin c. Heparin d. Vitamin K

ANS: B Desmopressin may be useful in patients with type 1 vWD. Coagulation factor is used in most patients with hemophilia. Heparin is an anticoagulant. Vitamin K is used to counter warfarin overdose.

1. The primary care pediatric nurse practitioner performs a developmental assessment on a 3-year-old child and notes normal cognitive, fine-motor, and gross-motor abilities. The child responds appropriately to verbal commands during the assessment but refuses to speak when asked questions. The parent tells the nurse practitioner that the child talks at home and that most other adults can understand what the child says. The nurse practitioner will : a. ask the parent to consider a possible speech delay and report any concerns. b. continue to evaluate the child's speech at subsequent visits. c. refer the child for a speech and hearing evaluation. d. tell the parent to spend more time in interactive conversations with the child.

ANS: B Development should be monitored over time and within the context of the child's overall well-being, rather than at an isolated testing session. The child has normal development in observed measures and appears to hear and understand well. By parental report, the child is able to speak. The PNP should continue to evaluate speech over time, since this refusal to speak may be associated with shyness or intimidation in the clinic. It is not necessary to tell the parent that the child has a possible speech delay. Unless an actual speech delay is observed, a referral is not indicated, nor is it necessary to implement a home therapy. 1

6. During a well baby exam on a 9-month-old infant, the parent reports that the baby always uses the left hand to pick up objects and asks if the baby will be left-handed. What will the primary care pediatric nurse practitioner do? a. Explain that it is too soon to tell which hand the infant will prefer later. b. Perform a careful assessment of fine and gross motor skills. c. Teach the parent to encourage the infant to use both hands. d. Tell the parent that a hand preference usually develops between 6 and 12 months.

ANS: B Hand preference before 1 year of age is usually suspect for cerebral palsy and may indicate a lack of motor skills in the other hand. The PNP should perform a careful assessment of fine and gross motor skills. Infants should not exhibit a hand preference until after 1 year of age, so the correct response is to assess further.

10. When performing a neurologic exam to assess for meningeal signs in an infant, the primary care pediatric nurse practitioner will attempt to elicit the Kernig sign by a. bending the infant at the waist to touch fingers to toes. b. extending the leg at the knee with the infant supine. c. flexing the infant's neck to touch chin to chest. d. turning the infant's head from side to side.

ANS: B In an infant, the Kernig sign is elicited by extending the leg at the knee with the infant in a supine position while observing for facial grimacing. Older children can bend at the waist to touch the toes to elicit the Kernig sign. The Brudzinski sign is elicited by passively flexing the neck to cause the patient to spontaneously flex the hip and knees. Turning the infant's head from side to side is not done to elicit either sign. 1

1. The primary care pediatric nurse practitioner sees a 12-month-old infant who is being fed goat's milk and a vegetarian diet. The child is pale and has a beefy-red, sore tongue and oral mucous membranes. Which tests will the nurse practitioner order to evaluate this child's condition? a. Hemoglobin electrophoresis b. RBC folate, iron, and B12 levels c. Reticulocyte levels d. Serum lead levels

ANS: B Infants and children who are fed goat's milk or who are on a strict vegetarian diet are at risk for folic acid and vitamin B12 deficiency. These should be evaluated, along with iron, to rule out IDA. Hemoglobin electrophoresis is used to evaluate diseases associated with altered hemoglobin, such as beta-thalassemia and sickle cell anemia, neither of which is indicated by this child's history. Reticulocyte levels are evaluated to evaluate transient erythroblastopenia of childhood, a condition that frequently follows a viral infection. Serum lead levels are not indicated based on this history.

1. A complete blood count on a 12-month-old infant reveals microcytic, hypochromic anemia with a hemoglobin of 9.5 g/dL. The infant has mild pallor with no hepatosplenomegaly. The primary care pediatric nurse practitioner suspects a. hereditary spherocytosis. b. iron-deficiency anemia. c. lead intoxication. d. sickle-cell anemia.

ANS: B Iron-deficiency anemia is the most common type of anemia in infants and children, accounting for approximately 90% of cases. It is characterized by decreased hemoglobin, with microcytic, hypochromic RBCs. Hereditary spherocytosis is characterized by pallor and jaundice with splenomegaly. Lead intoxication is accompanied by neurobehavioral problems. Sickle-cell anemia involves the presence of HgbS. 1

10. The primary care pediatric nurse practitioner is performing a well child examination on a school-age child who has a history of cancer treated with cranial irradiation. What will the nurse practitioner monitor in this child? a. Cardiomyopathy and arrhythmias b. Leukoencephalopathy c. Obesity and gonadal dysfunction d. Peripheral neuropathy and hearing loss

ANS: B Leukoencephalopathy is a late effect of cancer treatment associated with cranial irradiation. Cardiomyopathy and arrhythmias are related to anthracycline use. Obesity and gonadal dysfunction result from neuroendocrine effects of chemotherapeutic agents. Peripheral neuropathy and hearing loss occur after cisplatin use. 1

4. Which is true about the health status of children in the United States? a. Globalism has relatively little impact on child health measures in the U.S. b. Obesity rates among 2- to 5-year-olds have shown a recent significant decrease. c. The rate of household poverty is lower than in other economically developed nations. d. Young children who attend preschool or day care have higher food insecurity.

ANS: B Obesity rates are a major concern for child health in the U.S. but recently have stabilized in the rate of increase and have declined among 2- to 5-year-olds between 2004 and 2013. Globalism has an increasing effect on child health in the U.S. The rate of household poverty in the U.S. is higher than in other economically developed nations. Young children who attend preschool or day care have lower food insecurity.

9. A child with a history of otitis externa asks about ways to prevent this condition. What will the primary care pediatric nurse practitioner recommend? a. Cleaning ear canals well after swimming b. Drying the ear canal with a hair dryer c. Swimming only in chlorinated pools d. Using cerumenolytic agents daily

ANS: B Otitis externa is most frequently caused by retained moisture in the ear canal after swimming and when the protective barriers on the skin break down. Drying the ear canals with a hair dryer on a low setting helps to remove the moisture. Cleaning the ear canals, swimming in chlorinated water, and using a cerumenolytic remove the wax that protects the ear canal from superficial infection.

3. A child complains of itching in both ears and is having trouble hearing. The primary care pediatric nurse practitioner notes periauricular edema and marked swelling of the external auditory canal and elicits severe pain when manipulating the external ear structures. Which is an appropriate intervention? a. Obtain a culture of the external auditory canal. b. Order ototopical antibiotic/corticosteroid drops. c. Prescribe oral amoxicillin-clavulanate. d. Refer the child to an otolaryngologist.

ANS: B Ototopical antibiotic/corticosteroid drops are the mainstay of therapy for OE. It is not necessary to obtain a culture unless the infection does not respond to treatment. Oral antibiotics are not indicated unless impetigo occurs and is severe. A referral to a specialist is not recommended. 1

4. The primary care pediatric nurse practitioner notes a small, round object in a child's external auditory canal, near the tympanic membrane. The child's parent thinks it is probably a dried pea. What will the nurse practitioner do to remove this object? a. Irrigate the external auditory canal to flush out the object. b. Refer the child to an otolaryngologist for removal. c. Remove the object with a wire loop curette. d. Use a bayonet forceps to grasp and remove the object.

ANS: B Spherical objects are the most difficult to remove and should be referred. Irrigation is not recommended for objects made of organic material and also increases the risk of pushing the object farther down.

7. The primary care pediatric nurse practitioner performs a Hirschberg test to evaluate a. color vision. b. ocular alignment. c. peripheral vision. d. visual acuity.

ANS: B The Hirschberg test, or corneal light reflex, assesses ocular mobility and alignment by looking for symmetry of reflected light. Color vision testing is performed with Richmond pseudo-isochromatic plates. Peripheral vision is tested by watching the child's response to objects as they are moved in and out of the visual fields. Visual acuity is performed using eye charts or visual-evoked potential readings.

8. The primary care pediatric nurse practitioner performs a well baby assessment of a 5-day-old infant and notes mild conjunctivitis, corneal opacity, and serosanguinous discharge in the right eye. Which course of action is correct? a. Administer intramuscular ceftriaxone 50 mg/kg. b. Admit the infant to the hospital immediately. c. Give oral erythromycin 30 to 50 mg/kg/day for 2 weeks. d. Teach the parent how to perform tear duct massage.

ANS: B The infant has symptoms consistent with HPV conjunctivitis and requires hospitalization for topical and systemic antiviral medications to prevent spread to the central nervous system, mouth, and skin. IM ceftriaxone is given for gonococcal conjunctivitis. Oral erythromycin is given for chlamydial conjunctivitis. Tear duct massage is performed for lacrimal duct obstruction.

8. A Somalian immigrant mother is concerned that her 8-year-old child is underweight. The primary care pediatric nurse practitioner notes that the child's weight is at the 25th percentile. After realizing that the mother is comparing her child to a group of American-born children who are overweight, the pediatric nurse practitioner is able to convince the mother that this is a normal weight. Which domain of cultural competence does this represent? a. Global b. Interpersonal c. Intrapersonal d. Organizational

ANS: B The interpersonal domain of cultural competence refers to how cultural competence is manifested between and among individuals and includes all relationships within the health care setting. The PNP becomes aware of cultural norms in body weight and uses this knowledge to discuss healthy weights with the parent. The global domain recognizes a movement toward integration and interconnection of the world population in economic, political, technological, and sociocultural terms. The intrapersonal domain refers to an understanding of the self to understand one's own cultural background. The organizational domain is knowledge of institutional culture and how it affects health care.

6. An 18-month-old child with no previous history of otitis media awoke during the night with right ear pain. The primary care pediatric nurse practitioner notes an axillary temperature of 100.5°F and an erythematous, bulging tympanic membrane. A tympanogram reveals of peak of +150 mm H2O. What is the recommended treatment for this child? a. Amoxicillin 80 to 90 mg/kg/day in two divided doses b. An analgesic medication and watchful waiting c. Ceftriaxone 50 to 75 mg/kg/dose IM given once d. Ototopical antibiotic drops twice daily for 5 days

ANS: B This child has no previous history and only has a mild fever and can be managed by watchful waiting, with parents given instructions about when and why to notify the provider. Analgesia is essential so that the child can be comfortable. If antibiotics are indicated as a result of no improvement after 48 to 72 hours, amoxicillin is the first-line drug. Ceftriaxone is given if the child is vomiting. Topical antibiotics are given when there is a perforation in the tympanic membrane.

5. The primary care pediatric nurse practitioner diagnoses acute otitis media in a 2-year-old child who has a history of three ear infections in the first 6 months of life. The child's tympanic membrane is intact and the child has a temperature of 101.5°F. What will the nurse practitioner prescribe for this child? a. Amoxicillin twice daily for 10 days b. An analgesic medication and watchful waiting c. Antibiotic ear drops and ibuprofen d. Ceftriaxone given once intramuscularly

ANS: B This child has no recent history, is over 24 months, and has relatively mild symptoms, so can be treated by watchful waiting with adequate follow-up and analgesic medication. Antibiotics are not indicated unless the child worsens or does not improve in 48 to 72 hours.

1. The parents of an 18-month-old child bring the child to the clinic after observing a brief seizure of less than 2 minutes in their child. In the clinic, the child has a temperature of 103.1°F, and the primary care pediatric nurse practitioner notes a left otitis media. The child is alert and responding normally. What will the nurse practitioner do? a. Order a lumbar puncture, complete blood count, and urinalysis. b. Prescribe an antibiotic for the ear infection and reassure the parents. c. Refer to a pediatric neurologist for anticonvulsant and antipyretic prophylaxis. d. Send the child to the emergency department for EEG and possible MRI.

ANS: B This child has symptoms of a simple febrile seizure with a focal site of infection and an otherwise normal exam. While this is very frightening to the family, the PNP should treat the infection and provide reassurance to the parents. Lumbar puncture may be performed in infants younger than 12 months. Prophylactic medications aren't indicated for febrile seizures. Antipyretics aren't useful, since most seizures occur when the temperature is either rising or falling. EEG and MRI are not indicated when focal neurological signs are not present.

10. The primary care pediatric nurse practitioner evaluates a school-age child whose body mass index (BMI) is greater than the 97th percentile. The nurse practitioner is concerned about possible metabolic syndrome and orders laboratory tests to evaluate this. Which diagnosis will the nurse practitioner document for this visit? a. Metabolic syndrome b. Nutritional alteration: more than required c. Obesity d. Rule out type 2 diabetes mellitus

ANS: C A problem should never be included on the problem list that is not supported by subjective and objective data found and recorded in the database. This child has a BMI that suggests obesity, so this may be used as a diagnosis. Metabolic syndrome is a diagnosis that is determined by laboratory data, which has not been evaluated yet. Nutritional alteration is a NANDA diagnosis and not acceptable for reimbursement. "Rule out" should not be used as a diagnosis, but may be considered part of a plan. 1

8. The parent of a 4-month-old infant is concerned that the infant cannot hear. Which test will the primary care pediatric nurse practitioner order to evaluate potential hearing loss in this infant? a. Acoustic reflectometry b. Audiometry c. Auditory brainstem response (ABR) d. Evoked otooacoustic emission (EOAE) testing

ANS: C ABR is not a direct measure of hearing but allows for inferences to be made about hearing thresholds and is useful for identifying hearing loss in a young infant. Although sedation is occasionally required, this test is useful in infants and young children unable to cooperate with EOAE or audiometry. Acoustic reflectometry is used to detect middle ear effusion. Audiometry requires a cooperative child. EOAE is used for universal screening in newborns. The American Academy of Pediatrics (AAP) Bright Futures guidelines (AAP, 2014) recommends pure-tone audiometry at 3, 4, 5, 6, 8, 10, 12, 15, and 18 years of age.

5. Which region globally has the highest infant mortality rate? a. Indonesia b. Southern Asia c. Sub-Saharan Africa d. Syria

ANS: C Although Sub-Saharan Africa and Southern Asia together account for 81% of the infant mortality rate globally, Sub-Saharan Africa has the highest infant mortality rate in the world.

10. A 3-year-old child has had one episode of acute otitis media 3 weeks prior with a normal tympanogram just after treatment with amoxicillin. In the clinic today, the child has a type B tympanogram, a temperature of 102.5°F, and a bulging tympanic membrane. What will the primary care pediatric nurse practitioner order? a. A referral for tympanocentesis b. Amoxicillin twice daily c. Amoxicillin-clavulanate twice daily d. Intramuscular ceftriaxone

ANS: C Amoxicillin-clavulanate should be given for failed therapy with amoxicillin or when the child has had AOM treated with amoxicillin within the past month. 1

4. The primary care pediatric nurse practitioner provides well child care for a community of immigrant children from Central America. The pediatric nurse practitioner is surprised to learn that some of the families are Jewish and not Catholic. This response is an example of cultural : a. collectivism. b. constructivism. c. essentialism. d. individualism.

ANS: C An essentialist view of culture, which dominates the health care literature, portrays an ethnic minority group as having a static set of traits and oversimplifies cultural information, applying traits to all members of the group. Assuming that all people from Central America are Catholic is an example of this oversimplification. Collectivism refers to a member of an ethnic group who perceives himself or herself to be intrinsically part of that group. A constructive view recognizes culture as complex and dynamic and sees people as individuals who may belong to multiple cultures simultaneously. Individualism recognizes the individual, and not the group, as the basic unit of survival.

8. A 14-year-old child has a headache, unilateral weakness, and blurred vision preceded by fever and nausea. The child's parent reports a similar episode several months prior. The primary care pediatric nurse practitioner will consult with a pediatric neurologist to order a. a lumbar puncture. b. an electroencephalogram (EEG). c. neuroimaging with magnetic resonance imaging (MRI). d. positron emission tomography (PET) scan.

ANS: C Children who have MS exhibit the symptoms described above and are usually diagnosed with a gadolinium enhanced MRI. Lumbar puncture may be performed later to identify oligoclonal bands. An EEG is used to diagnose seizure activity. PET scans are used to detect tumors.

4. A child who was treated with amoxicillin and then amoxicillin-clavulanate for acute otitis media is seen for follow-up. The primary care pediatric nurse practitioner notes dull-gray tympanic membranes with a visible air-fluid level. The child is afebrile and without pain. What is the next course of action? a. Administering ceftriaxone IM b. Giving clindamycin orally c. Monitoring ear fluid levels for 3 months d. Watchful waiting for 48 to 72 hours

ANS: C Children with AOM may have effusion up to 3 months after the acute infection. The child should be monitored to ensure that this resolves. Antibiotics are not indicated. There is no acute infection, so watchful waiting for worsening of symptoms is not indicated.

7. The primary care pediatric nurse practitioner works with families from a variety of cultures and socioeconomic classes. Which is an example of cultural humility in practice? a. Giving health care advice that takes cultural differences into account b. Identification of other cultures that may be superior to one's own culture c. Receptivity to learning about the perspectives of other cultures d. Respecting other cultures while maintaining the views of one's own

ANS: C Cultural humility is defined as the lifelong commitment to developing mutually beneficial, non-paternalistic partnerships and is based on a model of passive volition, receptivity, and being open to learning from others. Practitioners who have cultural humility are always seeking to learn about other cultures. Cultural humility involves asking questions, rather than giving answers. Cultural humility does not mean identifying one's own culture as inferior. Practitioners who are culturally competent are open to the influence of other cultures.

7. The primary care pediatric nurse practitioner sees a 3-year-old child who chronically withholds stools, in spite of the parents' attempts to stop the behavior, requiring frequent treatments with laxative medications. Which diagnosis will the nurse practitioner use to facilitate third-party reimbursement? a. Altered elimination pattern b. Elimination disorder c. Encopresis d. Parenting alteration

ANS: C Encopresis is a medical diagnosis, classified in the ICD-10-CM, and is recognized for reimbursement purposes. "Altered elimination pattern" and "Parenting alteration" are NANDA International diagnoses and are not recognized for reimbursement. "Elimination disorder" is a developmental diagnosis.

2. A patient is noted to have prolonged bleeding after an intravenous needle is removed. A subsequent laboratory test reveals a prolonged activated partial thromboplastin (aPTT) time with a normal prothrombin time (PT). Based on this result, the provider may suspect alteration in function of which factor? a. Factor V b. Factor VII c. Factor VIII d. Factor X

ANS: C Factor VIII is part of the intrinsic system, which aPTT measures. The other factors are part of the extrinsic system, which is measured by PT.REF: Pathophysiology

3. When providing well child care for an infant in the first year of life, the primary care pediatric nurse practitioner is adhering to the most recent American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care guidelines by : a. focusing less on development and more on illness prevention and nutrition. b. following guidelines established by the Bright Futures publication. c. scheduling well-baby visits to coincide with key developmental milestones. d. seeing the infant at ages 2, 4, 6, and 12 months when immunizations are due.

ANS: C In the most recent AAP Recommendations for Preventive Pediatric Health Care, there is a greater emphasis on behavioral and developmental issues and a recommendation that well child care be based on child and family development rather than the periodicity of immunization schedules. This will require a revision of the current recommendations in Bright Futures.

2. A 60-year-old female patient has recently lost weight and a physical examination reveals a beefy-red, sore tongue, with no neurological findings. Based on these clinical findings, what will the provider anticipate finding in the laboratory data? a. Decreased homocysteine levels b. Leukopenia and thrombocytopenia c. Low hemoglobin and elevated MCV d. Normal methylmalonic acid level

ANS: C Macrocytic anemia caused by vitamin B12 deficiency will have symptoms described above. Although folate acid deficiency causes macrocytic anemia, there are rarely any symptoms. Hemoglobin will be decreased and MCV will increase. Homocysteine levels will be increased. The patient with B12 deficiency will have leukopenia and thrombocytopenia with severe deficiency, characterized by neurologic findings, which this patient does not have. Methylmalonic acid level will decrease.

2. A child has a recent history of leg pain, unexplained bruising, and nosebleeds. The provider notes petechiae and diffuse lymphadenopathy. A complete blood count reveals a WBC of 30,000 cells/mm3 and near normal RBC and platelet counts. What will the provider do next to manage this patient? a. Order coagulation studies to evaluate for coagulopathies b. Perform biochemical studies to look for hyperuricemia c. Refer to a specialist for a bone marrow aspirate and biopsy d. Repeat the complete blood count in two weeks

ANS: C Patients with ALL may have normal blood counts even when the marrow has been replaced with leukemic cells, so a bone marrow aspirate and biopsy is required for the definitive diagnosis. Coagulation and biochemical studies may be performed after the diagnosis is known to evaluate for complications. Waiting and repeating the CBC in 2 weeks is not recommended since the definitive diagnosis is made by bone marrow biopsy.REF: Clinical Presentation/Acute Leukemias/Diagnostics and Differential Diagnosis

1. The primary care pediatric nurse practitioner learns that an African-American family lives in a neighborhood with a high crime rate and suggests that they try moving to another neighborhood for the safety of their children. This is an example of a. cultural sensitivity. b. group bias. c. individual privilege. d. racial awareness.

ANS: C Privilege can be individual- or group-based and refers to the often unconscious lack of understanding of what other groups must deal with. The PNP is not aware that the family may lack the resources to move, may be fearful of moving to a "white" neighborhood, or may even feel safe around people that they know. Cultural sensitivity is an awareness of and respect for other cultures. Group bias is a prejudice, based on cultural, racial, or ethnic differences, toward a group of people. Racial awareness would describe an awareness of cultural differences based on race.

3. A 30-year-old male patient is diagnosed with Hodgkin lymphoma. Initial lab work reveals a WBC of 20 × 109/L, hemoglobin of 10.1 gm/dL, a serum albumin of 45 gm/dL, and lymphopenia of 0.5 × 109/L. Staging studies identify stage III disease. What is this patient's prognostic score? a. 2 b. 3 c. 4 d. 5

ANS: C Risk factors for lymphoma include age >45 years, male gender, serum albumin <40, Hb <10.5, stage IV disease, WBC >15, and lymphopenia <0.6. This patient has 4 risk factors.REF: Prognosis

2. The primary care pediatric nurse practitioner understands that, to achieve the greatest world-wide reduction in child mortality from pneumonia and diarrhea, which intervention is most effective? a. Antibiotics b. Optimal nutrition c. Vaccinations d. Water purification

ANS: C Rotavirus is the most common cause of diarrhea globally and Strep pneumonia is the leading cause of pneumonia, and together these are the leading infectious causes of childhood morbidity and mortality globally. Both are vaccine-preventable diseases. Antibiotics to treat pneumonia, optimal nutrition, and clean water all help to reduce morbidity and mortality, but vaccination prevents the diseases from occurring.

1. The parent of a toddler is concerned that the child may have autism. The primary care pediatric nurse practitioner completes a Modified Checklist for Autism in Toddlers (M-CHAT) tool, which indicates several areas of concern. What will the nurse practitioner do? a. Administer a Childhood Autism Rating Scale (CARS) in the clinic. b. Consult a specialist to determine appropriate early intervention strategies. c. Refer the child to a behavioral specialist for further evaluation. d. Tell the parent that this result indicates that the child has autism.

ANS: C The M-CHAT is a screening tool and is useful for detecting behaviors that may indicate autism. This instrument has been found to have acceptable sensitivity, specificity, and significant positive predictive value. If these behaviors are detected, the PNP should refer the child to a specialist for further assessment, using more diagnostic tools. The CARS may be used but requires specialty training and proper credentials. Until the diagnosis is determined, strategies for intervention are not discussed. The M-CHAT is a screening tool and is not diagnostic.

1. A 20 kg child has iron-deficiency anemia and will begin taking an oral iron preparation. What will the provider teach the child's parents about administration of this medication? a. Iron supplements should be given with food. b. The child must take the iron for 3 months. c. The correct dose is 30 mg twice daily. d. The iron is stopped when the hemoglobin increases.

ANS: C The dose for children is 3 mg/kg/day in divided doses. This child should get 60 mg/day, which is 30 mg/dose twice daily. Iron supplements are best absorbed on an empty stomach. Iron is given for at least 4 to 6 months. Hemoglobin levels will begin to increase in 1 to 2 weeks, but the iron is given until the serum ferritin increases sufficiently in 4 to 6 months.

1. A patient is suspected of having leukemia and the provider orders biochemical studies and a bone marrow aspirate and biopsy. The results include WBCs greater than 200,000 cells/mm3 normal RBCs, hyperplastic myeloid cells, and the absence of serum leukocyte alkaline phosphatase. Which test will the provider order to confirm a diagnosis in this patient? a. Chest radiograph b. Coagulation studies c. Philadelphia chromosome test d. Serum protein electrophoresis

ANS: C The findings from the CBC and bone marrow biopsy, along with a positive Philadelphia chromosome test, confirm the diagnosis of chronic myelogenous leukemia. A chest radiograph and serum protein electrophoresis may be performed to evaluate for associated symptoms. Coagulation studies are usually performed as part of the diagnostic workup for ALL.REF: Clinical Presentation/Chronic Leukemias/Diagnostics and Differential Diagnosis

9. When meeting with a new family, the primary care pediatric nurse practitioner develops a database that identifies family members and others living in the household, relationships with others outside the household, and significant behavioral and emotional problems. Which tool will the nurse practitioner use to record this information? a. CRAFFT b. Ecomap c. Genogram d. Pedigree

ANS: C The genogram is an approach to developing a family database to provide a graphic representation of family structure, roles, and problems of recurring significance in a family. The CRAFFT tool is used to assess substance abuse in adolescents. The ecomap is used to identify relationships in the family and community that are supportive or harmful. The pedigree is used to identify potential genetic disorders.

1. A patient reports a neck mass that has been present off and on for 5 or 6 weeks which varies in size. The provider palpates a lymph node measuring 1.25 cm. Which test will provide proper histologic diagnosis for this patient? a. Bone marrow aspirate b. CT scan with IV contrast c. Lymph node biopsy d. Positron emission tomography scan

ANS: C The lymph node biopsy is used to provide proper histologic diagnosis and precise classification. Bone marrow aspirate identifies the presence of dysplasic cells. PET and CT scans will identify the presence of other lesions.REF: Initial Evaluation/Making the Diagnosis

2. The primary care pediatric nurse practitioner obtains a tympanogram on a child that reveals a sharp peak of -180 mm H2O. What does this value indicate? a. A normal tympanic membrane b. Middle ear effusion c. Negative ear pressure d. Tympanic membrane perforation

ANS: C The type C tympanogram has a sharp peak between -100 and -200 mm H2O and reflects negative ear pressure. A normal tympanogram has a sharp positive peak or a type A tympanogram. Middle ear effusion and a TM perforation both cause a type B tympanogram with either no peak or a flattened wave. 1

1. The primary care pediatric nurse practitioner understands that a major child health outcome associated with worldwide climate change is: a. cost of living. b. education. c. nutrition. d. pollution.

ANS: C There is growing evidence that climate change is having a dramatic effect on food crops that leads to food distribution issues and food insecurity among families.

3. A female infant who was developing normally stops meeting developmental milestones at age 12 months and then begins losing previously acquired skills. What will the primary care pediatric nurse practitioner expect to tell the parents about this child's prognosis? a. Cognitive development will be normal but motor skills will be lost. b. Physical and speech therapy will help the infant regain lost skills. c. The child's intellectual development will not progress further. d. This is a temporary condition with full recovery expected.

ANS: C This child has symptoms of Rett syndrome, which affects females more than males and is characterized by a plateau of development with eventual loss of milestones. Intellectual development remains at the level of plateau. Physical therapy, occupational therapy, and speech therapy help to preserve functional abilities but do not improve skills. The condition is progressive, with variable life expectancy.

5. A 14-year-old child has a 2-week history of severe itching and tearing of both eyes. The primary care pediatric nurse practitioner notes redness and swelling of the eyelids along with stringy, mucoid discharge. What will the nurse practitioner prescribe? a. Saline solution or artificial tears b. Topical mast cell stabilizer c. Topical NSAID drops d. Topical vasoconstrictor drops

ANS: C This child has symptoms of allergic conjunctivitis. Topical NSAIDs work for acute symptoms to reduce inflammation and may be used in children over age 12 years. Saline solution or artificial tears are useful for milder symptoms. Topical mast cell stabilizers are useful for chronic symptoms and maintenance therapy. Topical vasoconstrictors should be avoided because of rebound hyperemia.

4. An adolescent female reports unilateral headache pain associated with abdominal pain and nausea occurring just prior to periods each month. The adolescent has been using naproxen sodium for 6 months but reports little relief from symptoms. What will the primary care pediatric nurse practitioner do? a. Add acetaminophen and ondansetron to the naproxen regimen. b. Consider prophylactic therapy with a beta-blocker or anticonvulsant drug. c. Prescribe sumatriptan nasal spray at the onset of headache and every 2 hours. d. Refer the adolescent to a pediatric neurologist for neuroimaging studies.

ANS: C When there is no response from analgesics, sumatriptan can be started as abortive therapy using the nasal spray formulation. Adding acetaminophen and ondansetron is not indicated; ondansetron is given when vomiting or severe nausea occurs. Prophylactic therapy is indicated for unpredictable or frequent headaches or headaches severe enough to cause a child to miss school. Neuroimaging studies are not used unless the history suggests increased intracranial pressure.

1. The primary care pediatric nurse practitioner performs a well baby exam on a term 4-month-old infant and observes flattening of the left occiput, bossing of the right occiput, and anterior displacement of the left ear. The parents report performing various positioning maneuvers, but say that the baby's head shape has worsened. What will the nurse practitioner recommend to correct this finding? a. Allow the infant to sleep on the tummy when the parents are in the room. b. Lay the infant in the "back to sleep" position, alternating the left and right occiput. c. Order a head CT to evaluate the infant for craniosynostosis. d. Refer the infant for orthotic cranial molding helmet therapy.

ANS: D This infant was term and likely has positional plagiocephaly, which has not responded to repositioning efforts, so a referral should be made for an orthotic helmet. Tummy time is performed when the infant is awake and the parents are present. The "back to sleep" position with alternation of left and right is a repositioning maneuver. Craniosynostosis is characterized by bossing and deformity that follow cranial suture lines.

3. The primary care pediatric nurse practitioner reviews a child's complete blood count with differential white blood cell values and recognizes a "left shift" because of a. a decreased eosinophil count. b. a decreased lymphocyte count. c. an elevated monocyte count. d. an elevated neutrophil count.

ANS: D A left shift occurs when there is an increase in the number of circulating immature neutrophils and indicates a bacterial infection or an inflammatory disorder. Eosinophils are associated with an antigen- antibody response and are elevated with exposure to allergens, inflammation of skin, or parasites. Lymphocytes are non-granulocytes that are elevated with viral infections. Monocytes are non- granulocytes and are elevated in infections and inflammation and some leukemias; elevations of non- granulocytes are referred to as a "right shift."

4. The primary care pediatric nurse practitioner is obtaining a medical history about a child. To integrate both nursing and medical aspects of primary care, which will be included in the medical history? a. Complementary medications, alternative health practices, and chief complaint b. Developmental delays, nutritional status, and linear growth patterns c. Medication currently taking, allergy information, and family medical history d. Speech and language development, beliefs about health, and previous illnesses

ANS: D An assessment model that integrates the nursing and medical aspects of primary care uses three domains: developmental problems (speech and language development), functional health problems (beliefs about health), and diseases (chief complaint). The other examples all use domains associated with the traditional medical model and do not contain nursing aspects associated with functional health problems.

6. During a well child assessment of an African-American infant, the primary care pediatric nurse practitioner notes a dark red-brown light reflex in the left eye and a slightly brighter, red-orange light reflex in the right eye. The nurse practitioner will a. dilate the pupils and reassess the red reflex. b. order auto-refractor screening of the eyes. c. recheck the red reflex in 1 month. d. refer the infant to an ophthalmologist.

ANS: D Any asymmetry, dark or white spots, opacities, or leukokoria should be referred immediately to a pediatric ophthalmologist. The PNP does not dilate pupils or order auto-refractor exams; these are done by an ophthalmologist. Because retinoblastoma is a concern, any unusual finding should be immediately referred.

3. The primary care pediatric nurse practitioner is assessing a toddler whose weight and body mass index (BMI) are below the 3rd percentile for age. The nurse practitioner learns that the child does not have regular mealtimes and is allowed to carry a bottle of juice around at all times. The nurse practitioner plans to work with this family to develop improved meal patterns. Which diagnosis will the nurse practitioner use for this problem? a. Failure to thrive b. Home care resources inadequate c. Nutrition alteration - less than required d. Parenting alteration

ANS: D Because the PNP is planning to intervene by helping the parents to provide appropriate food habits, the correct diagnosis should be "Parenting alteration." "Failure to thrive" is a medical diagnosis and requires a medical and social evaluation to rule out organic causes or detect neglect. "Home care resources inadequate" would be used if the PNP suspects that the family lacks adequate funds to purchase food. "Nutrition alteration" is a NANDA diagnosis and would be used if the PNP planned to consult with a dietician or give nutritional information. 1

6. During a well child exam on a 4-year-old child, the primary care pediatric nurse practitioner notes that the clinic nurse recorded "20/50" for the child's vision and noted that the child had difficulty cooperating with the exam. What will the nurse practitioner recommend? a. Follow up with a visual acuity screen in 6 months. b. Refer to a pediatric ophthalmologist. c. Re-test the child in 1 year. d. Test the child's vision in 1 month.

ANS: D Children age 4 years and older who have difficulty cooperating with a vision screen should be retested in 1 month; if they continue to have difficulty cooperating, they should be referred for a formal examination. Children who are 3 years old should be re-evaluated in 6 months.

2. A 7-month-old infant has had two prior acute ear infections and is currently on the 10th day of therapy with amoxicillin-clavulanate after a failed course of amoxicillin. The primary care pediatric nurse practitioner notes marked middle ear effusion and erythema of the TM. The child is irritable and has a temperature of 99.8°F. What is the next step in management of this child's ear infection? a. Order a second course of amoxicillin-clavulanate. b. Perform tympanocentesis for culture. c. Prescribe clindamycin twice daily. d. Refer the child to an otolaryngologist.

ANS: D Children who have persistent infection who have failed appropriate therapy and those who have had three or more episodes of AOM in 6 months should be referred to an otolaryngologist. Ceftriaxone is ordered when Augmentin fails. The PNP does not perform tympanocentesis. Clindamycin is used for ceftriaxone failure but only if the susceptibilities are known.

9. The pediatric nurse practitioner provides primary care for a 5-year-old child who has cerebral palsy who exhibits athetosis and poor weight gain in spite of receiving high-calorie formula to supplement intake. The child has had several episodes of pneumonia in the past year. Which specialty consultation is a priority for this child? a. Feeding clinic to manage caloric intake b. Neurology to assess medication needs c. Pulmonology for possible tracheotomy d. Surgery for possible fundoplication and gastrostomy

ANS: D Children with CP who have athetosis often have increased calorie needs up to 50% to 100% higher than others. This child is unable to gain adequate weight in spite of receiving extra calories. The child also has possible aspiration pneumonia, probably due to difficulty swallowing or GERD. A fundoplication and gastrostomy can help to prevent GERD and to provide nutrition that doesn't involve swallowing. The feeding clinic would increase calories and nutrients but, without a gastrostomy, cannot increase actual intake. The child is not having seizures or drooling that contribute to this problem, so medications aren't necessary. Unless there is an airway problem, tracheotomy is not indicated.

10. A toddler exhibits exotropia of the right eye during a cover-uncover screen. The primary care pediatric nurse practitioner will refer to a pediatric ophthalmologist to initiate which treatment? a. Botulinum toxin injection b. Corrective lenses c. Occluding the affected eye for 6 hours per day d. Patching of the unaffected eye for 2 hours each day

ANS: D Deviations are initially treated by patching the unaffected eye for 2 hours each day to force the affected eye to move correctly. Botulinum toxin injection may be used with some deviations but is not a first-line therapy. Corrective lenses alone improve amblyopia in 27% of patients. The unaffected eye is patched; 2 hours per day is as effective as 6 hours per day. 1

9. The primary care pediatric nurse practitioner performs a vision screen on a 4-month-old infant and notes the presence of convergence and accommodation with mild esotropia of the left eye. What will the nurse practitioner do? a. Patch the right eye to improve coordination of the left eye. b. Reassure the parents that the infant will outgrow this. c. Recheck the infant's eyes in 2 to 4 weeks. d. Refer the infant to a pediatric ophthalmologist.

ANS: D Esotropia that continues or occurs at 3 to 4 months of age is abnormal, so the infant should be referred to a pediatric ophthalmologist. The PNP does not determine whether an eye patch should be used. Because it is abnormal at this age, the PNP will not reassure the parents that the infant will outgrow this. Esotropia after 3 to 4 months of age must be evaluated by a specialist and not reevaluated in 2 to 4 weeks.

3. The primary care pediatric nurse practitioner in a community health center meets a family who has recently immigrated to the United States who speak only Karon. They arrive in the clinic with a church sponsor, who translates for them. The pediatric nurse practitioner notices that the sponsor answers for the family without giving them time to speak. The pediatric nurse practitioner will : a. ask the sponsor to allow the family to respond. b. develop the plan of care and ask the sponsor to make sure it is followed. c. request that the sponsor translate written instructions for the family. d. use the telephone interpreter service to communicate with the family.

ANS: D Federally funded managed care networks and community health centers are required to have interpreters accessible for clients with limited English proficiency. A commercial telephone interpreter service has been shown to be as effective as an "in-person" interpreter. Relying on family members or community members may not be reliable and may jeopardize patient confidentiality. This interpreter is answering for the clients without hearing what they have to say, which can compromise care.

1. The primary care pediatric nurse practitioner is treating an infant with lacrimal duct obstruction who has developed bacterial conjunctivitis. After 2 weeks of treatment with topical antibiotics along with massage and frequent cleansing of secretions, the infant's symptoms have not improved. Which action is correct? a. Perform massage more frequently. b. Prescribe an oral antibiotic. c. Recommend hot compresses. d. Refer to an ophthalmologist.

ANS: D Infants treated for a secondary bacterial conjunctivitis with lacrimal duct obstruction who do not improve after 1 to 2 weeks of topical antibiotic therapy must be referred to an ophthalmologist for possible lacrimal duct probe. Performing the massage more often or applying hot compresses will not help clear the infections. Oral antibiotics are not indicated.

6. The primary care pediatric nurse practitioner learns that the mother of a 3-year-old child has been treated for depression for over 5 years. Which aspect of this child's development will be of the most concern to the nurse practitioner? a. Fine motor b. Gross motor c. Social/emotional d. Speech and language

ANS: D Maternal depression in the first year of life has been associated with poorer language development at 3 years of age.

2. A patient with myelodysplastic syndrome (MDS) has severe neutropenia and anemia is given erythropoietin (EPO) with improvement in hemoglobin. Which intervention has been shown to prevent infection in patients with MDS who have severe neutropenia? a. Antithymocyte globulin and cyclosporine b. Granulocyte-macrophage colony-stimulating factor (GM-CSF) c. Intravenous immunoglobulin infusions d. Prophylactic treatment with floroquinolones

ANS: D Prophylactic antibiotic therapy with floroquinolones in neutropenic patients has been shown in a large meta-analysis to decrease the incidence of serious infections and reduce all-cause mortality. Antithymocyte globulin and cyclosporine is immune suppression treatment used to reduce the need for transfusions. GM-CSF is given when there is active infection, but does not decrease the actual number of infections. IVIG is not used for these patients and is not a prophylactic measure.

2. A 4-year-old child who has previously met developmental milestones is not toiled trained. The primary care pediatric nurse practitioner notes decreased reflexes in the lower extremities and observe a dimple above the gluteal cleft. Which diagnosis may be considered for this child? a. Arnold-Chiari malformation b. Reye syndrome c. Spina bifida cystica d. Tethered cord

ANS: D Tethered cord occurs when the caudal end of the spinal cord, causing abnormal stretching and damage to nerve cells, fibers, and blood vessels. This can cause symptoms of neurologic deterioration such as incontinence of bladder and bowel and loss of reflexes and sensation in the legs. Arnold-Chiari malformation involves a downward herniation of the caudal end of the cerebellar vermis, which can cause brainstem and upper cervical cord compression. Reye syndrome involves swelling in the brain and signs of increased intracranial pressure. Spina bifida cystica is a myelomeningocele, with symptoms present at birth.

8. A child is in the clinic for evaluation of an asthma action plan. The primary care pediatric nurse practitioner notes that the child's last visit was for a pre-kindergarten physical and observes that the child is extremely anxious. What will the nurse practitioner do initially? a. Ask the child's parent why the child is so anxious. b. Perform a physical assessment to rule out shortness of breath. c. Reassure the child that there is nothing to be afraid of. d. Review the purpose of this visit and any anticipated procedures.

ANS: D The PNP should remember that young children are learning "scripts" for health care visits and may be stressed when recalling previous visits, especially if those involved immunizations. The PNP should explain the purpose and any anticipated procedures for this visit to help put the child at ease.

3. The primary care pediatric nurse practitioner observes a tender, swollen red furuncle on the upper lid margin of a child's eye. What treatment will the nurse practitioner recommend? a. Culture of the lesion to determine causative organism b. Referral to ophthalmology for incision and drainage c. Topical steroid medication d. Warm, moist compresses 3 to 4 times daily

ANS: D The child has symptoms of hordeolum, or stye. Although these often rupture spontaneously, warm, moist compresses may hasten this process. It is not necessary to culture the lesion unless symptoms do not resolve. Referral to ophthalmology is made if the hordeolum does not rupture on its own. Steroids are not indicated.

3. A school-age child is hit in the face with a baseball bat and reports pain in one eye. The primary care pediatric nurse practitioner is able to see a dark red fluid level between the cornea and iris on gross examination, but the child resists any exam with a light. Which action is correct? a. Administer an oral analgesic medication. b. Apply a Fox shield and reevaluate the eye in 24 hours. c. Instill anesthetic eyedrops into the affected eye. d. Refer the child immediately to an ophthalmologist.

ANS: D This child has a traumatic injury with hyphema to the eye, and an ophthalmologist must examine the eye to rule out orbital hematoma or retinal detachment. Any further attempt to examine the child may result in further injury. A Fox shield is used once more serious injury is excluded.

3. A child with a recent history of URI reports tingling and pain in one ear followed by sagging of one side of the face. The primary care pediatric nurse practitioner observes that the child cannot close the eye or mouth on the affected side but does not elicit limb weakness on that side. What will the nurse practitioner do? a. Initiate a short course of antibiotic therapy. b. Perform diagnostic testing to rule out serious causes. c. Prepare the parents for lifelong complications. d. Prescribe oral prednisone 1 mg/kg/day initially.

ANS: D This child has symptoms and a history consistent with Bell's palsy. Oral prednisone is given to reduce inflammation causing paralysis for 1 week with a 1 week taper. Antibiotics are not indicated, since a viral illness often precipitates symptoms. Diagnostic testing is not indicated unless symptoms persist longer than 6 weeks or if other neurologic symptoms occur. Approximately 85% of children recover completely without facial weakness.

7. A school-age child comes to the clinic for evaluation of excessive bruising. The primary care pediatric nurse practitioner notes a history of an upper respiratory infection 2 weeks prior. The physical exam is negative for hepatosplenomegaly and lymphadenopathy. Blood work reveals a platelet count of 60,000/mm3 with normal PT and aPTT. How will the nurse practitioner manage this child's condition? a. Admit to the hospital for IVIG therapy. b. Begin a short course of corticosteroid therapy. c. Refer to a pediatric hematologist. d. Teach to avoid NSAIDs and contact sports.

ANS: D This child has symptoms, a history, and lab work that indicate idiopathic thrombocytopenic purpura. Since platelets are greater than 20,000/mm3, management without specific therapy may be done on an outpatient basis by teaching the family to avoid things that contribute to bleeding. IVIG therapy is used for children with active, severe bleeding. Corticosteroids are given for platelet counts less than 20,000/mm3. Referral to a hematologist is necessary for more severe cases.

4. To evaluate brain tissue disorders in infants, which test is useful? a. Computerized tomography b. Head radiographs c. Magnetic resonance imaging d. Ultrasonography

ANS: D Ultrasonography is used to evaluate brain tissue in infants. CT scans expose patients to high levels of radiation, so they are not used unless indicated. Radiographs have relatively diagnostic value for the neurologic system. Magnetic resonance imaging is useful but is expensive and usually requires sedation.

5. The primary care pediatric nurse practitioner applies fluorescein stain to a child's eye. When examining the eye with a cobalt blue filter light, the entire cornea appears cloudy. What does this indicate? a. The cornea has not been damaged. b. There is too little stain on the cornea. c. There is damage to the cornea. d. There is too much stain on the cornea.

ANS: D When fluorescein stain is applied and the entire cornea appears cloudy, it means that there is too much of the stain. Damaged areas of the cornea should appear greenish after staining with fluorescein dye.

2. A preschool-age child who attends day care has a 2-day history of matted eyelids in the morning and burning and itching of the eyes. The primary care pediatric nurse practitioner notes yellow-green purulent discharge from both eyes, conjunctival erythema, and mild URI symptoms. Which action is correct? a. Culture the conjunctival discharge. b. Observe the child for several days. c. Order an oral antibiotic medication. d. Prescribe topical antibiotic drops.

ANS: D Young children with bacterial conjunctivitis may be treated with topical antibiotic drops. Culturing the eyes is not necessary unless there is no improvement. While most cases of bacterial conjunctivitis are self-limiting, using a topical antibiotic will hasten the return to day care. Oral antibiotics are not indicated. 1