A well 12-year-old child recently arrived from South Africa presents for a school physical. She received BCG immunization shortly after birth and is up to date with required immunizations. A PPD is placed and read at 48 hours. Likely findings include which of the following?
- Negative PPD, no further follow-up
- Negative PPD, child requires a follow-up chest X-ray
- Positive PPD, no further follow-up
- Positive PPD, child requires a follow-up chest X-ray
4. Positive PPD, child requires a follow-up chest X-ray
The BCG, or bacilli Calmette–Guérin, is a vaccine for TB. Many foreign-born persons have been vaccinated with the BCG vaccine, especially in countries where there is a high incidence of TB. It is likely that this child will have a positive PPD test. It is not possible to determine in this case, however, if the child has active TB without a chest X-ray.
What behavior in a 2-year-old would be considered worrisome?
- Ability to concentrate on a task for 2 minutes
- Carrying a favorite toy around the house
- Skipping pages in a book to find favorite shapes
- Unable to walk downstairs holding a rail
4. Unable to walk downstairs holding a rail
The nurse practitioner should always be aware of typical expected growth and development parameters. At two years of age, normal expected gross motor skills include having the ability to walk up and down stairs without difficulty. The child should be evaluated further for other delays in gross motor, fine motor, or language/social skills.
Baby Sabrina presents for her 6 month well child check-up. At 40 weeks gestation her documented birth weight was 6 lbs 6 oz, and length of 20 inches. Currently her weight is 10 lbs 4 oz and length is 24 inches. The nurse practitioner concludes the following:
- The infant is failing to meet expected gains in weight only.
- The infant is failing to meet expected gains in both weight and length.
- All findings are within normal limits.
- The findings are acceptable since the mother is 5 feet in height.
2. The infant is failing to meet expected gains in both weight and length.
Infants age 0–3 months gain approximately 1.4 inches in height per month. Baby Sabrina would be expected to have achieved 24 inches in height by 3 months of age. At 5–6 months of age, infants have usually doubled their birth weight.
During a sports physical for an 18-year-old male high school student, which finding would require further follow-up?
- Height of 5 feet 11 inches, and weight of 175 lbs
- Tanner stage of 4
- Snellen eye chart vision screening results of 20/25 in both right and left eyes
- Scoliosis of the spine with a degree of curvature of approximately 10%
2. Tanner stage of 4
Typically, males age 13–18 will have developed to Tanner stage 5. An 18-year-old male that is in Tanner stage 4 should be evaluated for further growth and development deficits. Scoliosis of the spine of 10–15 degrees is generally not considered to be a problem unless the patient expressed concern or discomfort.
A 7-year-old male child is brought to the clinic by his parents for evaluation. The child has no significant PMH. Approximately seven days ago he developed a cold and since then has had a persistent cough and fever. His older sister was also ill with cold symptoms at the same time. The NP performs a physical exam and notes that the child has mild tachypnea, with crackles in both bases and a pulse oximeter of 90%. His temperature is 100.8 °F. There are no wheezes auscultated. The NP suspects that the child has which of the following?
- Bacterial pneumonia
- Viral pneumonia
2. Viral pneumonia
The child presents clinically with pneumonia. Viral pneumonia generally has a gradual onset with less acute symptoms and a low-grade fever. It is usually preceded by an upper respiratory infection. Wheezes are not present in children with pneumonia.
For the 7-year-old child described in the previous question, what does the FNP expect to find on auscultation of the lungs?
- Crackles in a portion of a lung field, no wheezing
- Wheezing in most of the lung fields
- Rales and wheezing in the lower lung bases
- Normal breath sounds in all but one lung field, which will have decreased breath sounds
1. Crackles in a portion of a lung field, no wheezing
The absence of wheezing is a positive predictor for children with pneumonia.
For the 7-year-old child described earlier, what will the FNP have as part of the plan of care?
- Supportive care, return to office in one week, call if worsening symptoms
- CXR now, hospitalization to pediatric unit
- Bronchodilator via nebulizer now, IV fluids in emergency department after nebulizer
- CXR now, supportive care at home; call in one day or if any worsening of symptoms; return to office in 2 days for follow-up evaluation
4. CXR now, supportive care at home; call in one day or if any worsening of symptoms; return to office in 2 days for follow-up evaluation
All children with a diagnosis of pneumonia should be carefully monitored. The child has a classic viral pneumonia presentation, which tends to be less severe and can be cared for at home.
A 6-month-old male is being seen with his caretaker for a barking cough which is making the caretaker anxious. The baby seems to have mild respiratory distress and the oximetry reads at 94%. The FNP sends the baby for a CXR. What findings are likely to be reported?
- Ground glass appearance over affected lung field(s)
- Pneumothorax of an upper lung field
- Steeple-shaped appearance with narrowing in upper airway
- CXR will have normal markings
3. Steeple-shaped appearance with narrowing in upper airway
Children with croup will usually present with a brassy bark sounding cough, inspiratory stridor, and a steeple sign (or wineglass) appearance on a chest X-ray.
The most common organism responsible for otitis media is which of the following?
- Haemophilus influenzae
- Streptococcus pneumonia
- Staphylococcus aureus
3. Streptococcus pneumonia
Streptococcus pneumonia is the most common organism responsible for otitis media. Amoxicillin remains the first choice of treatment for otitis media with a suspected bacterial etiology.
A 19-year-old mother brings her 2½-month-old-boy to your clinic with a concern that the baby has become less interested in his feedings over the past 2 or 3 days, taking in only about half the normal amount of formula before becoming tired and falling asleep. His birth history is normal and he has normal development and weight gain. His temperature is 100.2 °F (axillary) now. He has no respiratory symptoms and your physical examination reveals no identifiable source of fever. Which of the following questions/observations would be MOST helpful in establishing a diagnosis?
- "Is anyone else at home ill at this time?"
- "How sick do you think he is?"
- "Has he ever had a temperature before?"
- "Did you have any infection or rash when you were pregnant?"
1. "Is anyone else at home ill at this time?"
The child’s symptoms are consistent with the prodromal phase of a viral or bacterial infection. Asking if there are sick contacts would provide the most valuable information at this point in time.
Which of the following infants are susceptible to respiratory syncytial virus (RSV) and bronchitis in the first year of life?
- Term infant with chronic rhinitis
- Very low birth weight infants
- Term infant with hypospadias
- 38-week gestation infant with feeding problems
2. Very low birth weight infants
Although all infants are at risk for RSV, low birth weight infants, infants younger than 6 months of age, premature infants, and infants with an underlying condition such as heart or lung disease are at highest risk. By two years of age, almost all children will have had RSV.
A 4-week-old infant presents to the office in mid-January with a one-week history of nasal congestion and occasional cough. On the evening prior to this visit, she developed a temperature of 102 °F, refused to breast feed, had paroxysmal coughing, and noisy, labored breathing. Patient is an ill-appearing infant who is lethargic with tachypnea and intercostal retractions. She has a 4-year-old sibling who is in day care and who recently had a "cold." Considering the clinical presentation, what is the most likely cause of this infant’s illness?
- Mycoplasma pneumonia
- RSV bronchiolitis
- Aspiration pneumonia
- Streptococcal infection of the pharynx
2. RSV bronchiolitis
The child has many risk factors associated with RSV, including a sibling in day care, along with the time of year. The child’s clinical presentation is consistent with RSV bronchiolitis.
A 9-year-old child’s symptoms occur four times a week during the day and three times during the night, with an FEV1 of 80%. What would be the severity classification per the National Asthma Education and Prevention Program?
- Severe persistent
- Moderate persistent
- Mild persistent
- Mild intermittent
2. Moderate persistent
The child’s symptoms are consistent with the diagnosis of moderate persistent asthma per the GINA (Global Initiative for Asthma) guidelines.
An 8-year-old male has mild persistent asthma. Appropriate daily medication should include which of the following?
- An inhaled low-dose corticosteroid
- Short-acting beta2-agonists
- An oral systemic corticosteroid
- A cough suppressant
1. An inhaled low-dose corticosteroid
A child with mild persistent asthma should be using the stepwise approach to management. Per GINA guidelines, the child with mild persistent asthma should be using an inhaled low-dose corticosteroid to control symptoms.
A 3-month-old female is brought to the office for a routine examination and numerous bruises in varying stages are noted on the infant’s back and legs. The mother gets very upset when asked about the bruises and starts to cry. She refuses to talk any more about the bruises or how this may have happened. A necessary next step for this scenario is which of the following?
- Explain to the mother that she has to leave the baby with the office staff for Department of Children and Families to come and get her.
- Discuss with the mother that sometimes congenital bleeding issues can cause these types of bruises and make an appointment for her to return with the baby in 2 days for bloodwork.
- Explain to the mother that bruises such as these are uncommon in a 4-month-old, and further assessment, including a skeletal body scan, is required.
- Ask the mother to call the baby’s father to come to the office so that the family can be interviewed regarding child abuse.
3. Explain to the mother that bruises such as these are uncommon in a 4-month-old, and further assessment, including a skeletal body scan, is required.
Any child with unexplained bruises (especially in children who are not yet mobile) is required to have a full skeletal body scan.
According to the developmental theory of Erikson, if the needs of the infant are met in a consistent manner, the infant will develop which of the following?
According to the developmental theorist, Erikson, it is essential for an infant’s needs to be met so they may develop trust in the world around them (Trust vs. Mistrust stage).
The ability of an infant to turn his head to the side when lying prone occurs during the _______ month of life.
A neonate’s normal gross motor skill development should include the ability to turn his/her head during the first month of life when placed in a prone position.
According to the vaccination schedule recommendations, the IPV (polio) vaccine, the DTaP (diptheria—tetanus-acellular pertussis), Haemophilis influenzae type B (HIB), Rotavirus (RSV1) pneumoccal vaccine (Prevnar-13), and second hepatitis B vaccine are given at _______ month(s) of age.
This is in accordance with the recommended vaccination schedule for children, as defined by the CDC.
An infant would be expected to begin babbling and laughing by what age?
- 0–3 months of age
- 3–6 months of age
- 6–9 months of age
- 8 months of age
2. 3–6 months of age
Normal social development includes the ability for the infant to laugh and babble between the ages of 3 and 6 months. Infants that are not performing this behavior should be evaluated for further developmental delays.
Most infants will begin to crawl around at ___________.
- 4–6 months
- 7–9 months
- 8–10 months
- 10–12 months
2. 7–9 months
This is the most common age for development of this gross motor skill.
The first solid food item that should be introduced into an infant’s diet is ____________.
Rice cereal is the least likely food to cause an allergic reaction in an infant and is generally considered to be the first recommended solid food.
The initial MMR (measles, mumps, rubella) vaccine is recommended at _____________.
- 12 to 15 months of age
- 6 months of age
- 9 months of age
1. 12 to 15 months of age
Per CDC guidelines for childhood vaccinations.
An infant develops increased coordination between his index finger and thumb and is now able to pick up small objects. This is known as what?
- Grasp reflex
- Moro reflex
- Pincer reflex
- Palmar reflex
3. Pincer reflex
Infants typically develop the pincer reflex at approximately 12 months of age. Anticipatory guidance includes teaching the parents that the child is at higher risk for choking/poisoning and putting foreign objects in their nares, mouth, or ears.
The fine motor developmental ability that would be demonstrated first in the infant would be the ability to ____________.
- pinch with the fingers
- grasp with the hands
- throw an object
- intentionally release an object
2. grasp with the hands
Grasping with the hands precedes the ability to perform more higher-level fine motor tasks such as throwing an object or intentionally releasing an object.
An infant’s birth weight is 7 pounds 5 ounces. What would the nurse practitioner expect the infant to weigh at 6 months of age?
- 12 pounds
- 15 pounds
- 18 pounds
- 22 pounds
2. 15 pounds
An infant is expected to double his/her body weight at 6 months of age.
A father brings his 2-year-old to the clinic. He verbalizes frustration with the child’s willfulness and states that he would like to know what the best form of discipline would be for his child. The nurse practitioner responds that:
- A gentle spanking works best because it is the most effective.
- A 5-minute time-out is most effective.
- A 2-minute time-out is most effective.
- Discipline should be individualized to the child and family and based on social and cultural preferences.
3. A 2-minute time-out is most effective.
The recommended form of discipline for a child is to use the "timeout" strategy. Most young children can sit in "timeout" for the same amount of minutes that is equal to what their age is in years.
One indication that the toddler is ready to toilet train is:
- The child has the ability to climb up on the toilet.
- The child has the ability to stay dry for one hour.
- The child is able to communicate that he or she is wet or needs to urinate or defecate.
- The child is willing to sit on the potty for at least 5 minutes.
3. The child is able to communicate that he or she is wet or needs to urinate or defecate.
Children are ready to toilet train when they are able to communicate their need and interest in doing so to their parents.
Which type of play do 2-year-old toddlers most commonly exhibit?
- Associative play
- Team play
- Solitary play
- Parallel play
4. Parallel play
Young toddlers will often prefer to sit near other children when playing but typically their play is not associated with the other children.
The nurse practitioner provides anticipatory guidance to the parents/guardians at every well-child visit. The NP is aware that the leading cause of death in infants and children is _________.
- child abuse
Per U.S. national statistics, accidents remain the number one cause of death in children.
A parent is frustrated with her 2-year-old’s inability to share her toys with siblings or playmates. The NP explains to the parent that a toddler has difficulty seeing anyone else’s point of view and that this is a normal part of development and is referred to as ________________.
- egocentric thinking
3. egocentric thinking
Egocentricity is commonly seen in toddlers as they develop a sense of self that is separate from their primary caregivers.