Free CPEN Practice Test: 60 Questions With Rationales

Answer: C. Abnormal appearance with normal breathing and circulation: possible brain dysfunction or a systemic or metabolic problem that needs immediate evaluation

Appearance (tone, interactiveness, consolability, look or gaze, speech or cry) is the triangle component most tied to how well the brain is perfused and oxygenated. When appearance alone is abnormal and work of breathing and skin circulation are normal, the pattern points toward a primary brain problem or a systemic or metabolic cause, such as hypoglycemia, a toxic ingestion, sepsis or head injury. An abnormal component requires prompt further assessment; the triangle is a first impression, not a diagnosis.

Why the other answers do not fit

• A: The triangle isn't scored by majority. One abnormal component requires further assessment.
• B: Respiratory distress shows up as abnormal work of breathing, and this child's breathing is quiet and unlabored.
• D: That is not the PAT pattern shown: circulation to the skin is described as normal. A full assessment must still evaluate perfusion; pink skin alone does not rule out circulatory illness.

Review topic: Triage Process · Visual assessment / Pediatric Assessment Triangle · Outline 1.A.1

Sources: Horeczko and colleagues, Pediatric Assessment Triangle study — Table 1 and PAT categorization discussion; Royal Children’s Hospital Melbourne: Dehydration — Key points; clinical assessment and shock signs.

Answer: A. A 4-year-old with known asthma who can speak only one or two words at a time, SpO2 89% on room air after two home albuterol treatments

The child with asthma is failing home treatment: hypoxemia, speech limited to one or two words and a known reactive airway history put breathing at immediate risk. This respiratory presentation takes priority over the other presentations described.

Why the other answers do not fit

• B: A controlled scalp laceration in an alert child has lower priority on the facts given, with reassessment while waiting.
• C: A deformity with intact distal circulation needs pain control and imaging, but it isn't threatening airway, breathing or perfusion.
• D: A playful, well-appearing child with fever and ear pain is low acuity.

Review topic: Triage Process · Triage priority based on acuity · Outline 1.A.2

Sources: Royal Children’s Hospital Melbourne: Acute asthma — Assessment of severity and acute management.

Answer: D. DTaP and tetanus immune globulin (TIG)

A soil-contaminated puncture wound is a dirty or major wound in CDC guidance. With fewer than three documented doses (or an unknown history), both a tetanus toxoid-containing vaccine and TIG are indicated. DTaP is the vaccine used for children younger than 7. TIG gives immediate passive protection; the vaccine starts the child's own immunity.

Why the other answers do not fit

• A: Wound care matters, but it doesn't replace prophylaxis in an unvaccinated child with a tetanus-prone wound.
• B: Vaccine alone is enough for a clean, minor wound in an under-vaccinated child, not for a contaminated puncture wound.
• C: TIG protects only temporarily; the child also needs the vaccine.

Review topic: Triage Process · Immunization status · Outline 1.A.3

Sources: CDC: Tetanus wound management — Dirty or major wounds; vaccination; TIG indications; CDC: Tetanus vaccination recommendations — Routine vaccination; DTaP for children younger than 7.

Answer: B. Mask the child if tolerated and take the family directly to an airborne infection isolation room

Fever, cough, coryza and conjunctivitis followed by a rash that starts at the hairline is a classic measles picture in an unvaccinated child. Measles spreads through the air and can linger in a room for up to 2 hours, so public health guidance is to mask the patient and move them directly into an airborne infection isolation room. Staff entering the room use a fit-tested, NIOSH-approved N95 respirator or more protective respiratory protection.

Why the other answers do not fit

• A: A suspected measles patient shouldn't stay in a shared waiting area, even masked.
• C: Droplet precautions don't cover airborne spread.
• D: Contact precautions and a hallway exam expose everyone who passes.

Review topic: Triage Process · Isolation concerns · Outline 1.A.4

Sources: CDC: Measles infection prevention in healthcare — Patient placement; transport; respiratory protection; airborne persistence.

Answer: B. Ask directly and privately, "Are you having thoughts of killing yourself?" as part of a validated suicide risk screen

The statement is a possible warning sign and needs a direct, private follow-up with a validated screening tool such as the NIMH Ask Suicide-Screening Questions (ASQ). A positive screen leads to further safety assessment; current suicidal thoughts require immediate safety precautions and urgent evaluation.

Why the other answers do not fit

• A: Reassurance dismisses a possible warning sign without assessing it.
• C: Screening the adolescent privately comes first; involving the parent before asking can make an honest answer less likely.
• D: Delaying the screen leaves a possibly at-risk patient without safety measures.

Review topic: Triage Process · Behavioral status and risk for harm · Outline 1.A.5

Sources: NIMH Ask Suicide-Screening Questions toolkit — Youth screening; private screening; positive-screen pathway; NIMH Youth brief suicide safety assessment guide — Current thoughts and urgent safety assessment.

Answer: C. Use a qualified medical interpreter in person, by phone or by video

Under the federal Section 1557 rule, a covered health program must offer a qualified interpreter and must not rely on a minor child to interpret, except briefly in an emergency involving an imminent threat when no qualified interpreter is immediately available. A vomiting but alert toddler isn't that kind of emergency. If the narrow emergency exception is used, a qualified interpreter must confirm or supplement the initial communication as soon as one becomes available.

Why the other answers do not fit

• A: Fluency isn't the standard. A minor child may interpret only in an imminent-threat emergency with no qualified interpreter available.
• B: Being bilingual alone does not establish that the officer is qualified to interpret. The rule also recognizes appropriately qualified bilingual or multilingual staff.
• D: Instructions the parent can't read don't provide meaningful access, and it still relies on a child.

Review topic: Triage Process · Cultural and language considerations · Outline 1.A.7

Sources: 45 CFR 92.201: Meaningful language access — Paragraphs (c)–(e), including minor-child exception and qualified staff.

Answer: A. Immediate (red)

The immediate (red) category identifies children with compromised airway, breathing or circulation who need intervention within minutes. This child is breathing but needs immediate airway and breathing care, so delayed or minor categories do not fit.

Why the other answers do not fit

• B: Delayed patients can tolerate a delay of hours; that is not the condition described.
• C: Minor patients generally have minor injuries and can walk; this child has severe respiratory compromise.
• D: The facts do not establish injuries so severe that survival is unlikely with the available resources. Severe but potentially treatable breathing compromise belongs in the immediate category.

Review topic: Triage Process · Mass casualty triage · Outline 1.B.2

Sources: HHS Radiation Emergency Medical Management: JumpSTART text alternative — Category definitions, especially III Immediate/Red.

Answer: D. Remove the children's contaminated clothing promptly and follow the incident team's agent-appropriate decontamination procedure

Removing contaminated clothing is the fastest way to remove much of the chemical. Further decontamination depends on the contaminant: PRISM guidance uses dry decontamination for noncaustic contamination and agent-appropriate wet decontamination when indicated. The team should avoid spreading contamination and protect the children from cold exposure.

Why the other answers do not fit

• A: Waiting for identification prolongs skin contact.
• B: Separating people into age groups does not remove the wet, contaminated clothing. Exposure reduction comes first.
• C: Cold water raises the risk of hypothermia; closing pores isn't a decontamination goal.

Review topic: Triage Process · Decontamination · Outline 1.B.1

Sources: HHS PRISM: Tactical Guidance, second edition — PDF p. 22, dry versus wet decontamination; p. 37 wet-decontamination temperature.

Answer: D. Compensated shock: tachycardia and poor perfusion with a blood pressure still normal for age

For a 3-year-old, hypotension is a systolic BP below 76 mm Hg (70 + 2 × 3), so 96 isn't hypotensive. But the tachycardia, prolonged capillary refill, cool mottled extremities and decreased alertness show the body is compensating for poor perfusion. Children maintain blood pressure until late, so a normal BP doesn't rule out shock.

Why the other answers do not fit

• A: Poor perfusion with decreased alertness is beyond mild dehydration.
• B: Normal BP with signs of poor perfusion is exactly how compensated shock looks.
• C: The BP is above the hypotension threshold for age, so this isn't hypotensive shock yet.

Review topic: Assessment · Primary survey: recognizing shock · Outline 2.A.1

Sources: Children’s Health: Pediatric low blood pressure — What is low blood pressure? Age-based table, children 1–10; Royal Children’s Hospital Melbourne: Dehydration — Key points; clinical assessment and shock signs.

Answer: B. Hypotensive, because it is below 82 mm Hg (70 + 2 × 6)

For children 1 to 10 years old, hypotension is a systolic BP below 70 + (2 × age in years) mm Hg. For a 6-year-old that's 82 mm Hg, so 80 is hypotensive, a late and serious sign in an injured child.

Why the other answers do not fit

• A: 80 mm Hg is below the threshold for a 6-year-old.
• C: Hypotension in an injured child calls for immediate action, not a recheck in an hour.
• D: The definition doesn't depend on heart rate; tachycardia is actually expected with hypovolemia.

Review topic: Assessment · Primary survey: age-based hypotension · Outline 2.A.1

Sources: Children’s Health: Pediatric low blood pressure — What is low blood pressure? Age-based table, children 1–10; Royal Children’s Hospital Melbourne: Dehydration — Key points; clinical assessment and shock signs.

Answer: C. Wariness of strangers is expected at this age; examine the infant on the parent's lap

Being shy, clingy or fearful around strangers is a typical social-emotional milestone around 9 months. Keeping the infant with the caregiver supports comfort during the exam; begin with the least distressing parts when the clinical situation permits.

Why the other answers do not fit

• A: Calming with the parent is consistent with stranger wariness. This behavior alone does not establish significant pain or justify analgesia before any exam.
• B: This behavior is expected at 9 months, not a sign of delay.
• D: Separation removes the comfort the caregiver is providing and is not the best approach to the behavior described.

Review topic: Assessment · Developmental milestones · Outline 2.A.2

Sources: CDC: Milestones by 9 months — Social and emotional milestones; AAP: Patient- and family-centered care — Family knowledge, collaboration and participation.

Answer: A. Suction the tracheostomy tube

Mucus plugging is a common cause of acute distress in a child with a tracheostomy. With emergency help and oxygen already in place, attempt suctioning with the correct-size catheter to clear secretions and assess tube patency. Inability to pass the catheter suggests a blocked tube: do not force it, and proceed with the emergency tracheostomy algorithm, including urgent tube change by trained staff when indicated. Reassess ventilation and oxygenation throughout.

Why the other answers do not fit

• B: Oxygen is already being given. Observation alone does not address a possible tube obstruction.
• C: Albuterol doesn't clear an obstructed tracheostomy tube.
• D: Imaging delays relief of a likely obstruction.

Review topic: Assessment · Children with special needs: tracheostomy · Outline 2.A.3

Sources: Royal Children’s Hospital Melbourne: Tracheostomy management — Suction indications; emergency airway management; inability to pass suction catheter.

Answer: A. Treat the mother's report as a meaningful change from baseline, document his usual baseline and escalate for prompt evaluation

For a child with medical complexity, the caregiver usually knows the baseline better than anyone on the team. A change she describes, plus fever and a heart rate well above his normal, is a signal to act. Family-centered care means treating the caregiver's observations as clinical information.

Why the other answers do not fit

• B: The mother is describing a change from his baseline, not his usual state.
• C: Vital signs alone miss subtle neurologic changes that only someone who knows the child can see.
• D: Waiting for obvious signs can mean missing early deterioration.

Review topic: Assessment · Caregivers' perception of baseline · Outline 2.A.4

Sources: AAP: Patient- and family-centered care — Family knowledge, collaboration and participation.

Answer: D. Offer them the option to stay, with a staff member assigned to support them and explain what is happening

The 2025 AHA/AAP pediatric guidelines recommend that family members be offered the option of being present during resuscitation. Assigning a staff member to stay with them, explain what's happening and watch for distress lets the family be present without interrupting care.

Why the other answers do not fit

• A: Automatically removing the family denies them an option the guidelines say should be offered.
• B: There's no drug-timing rule for family presence.
• C: Leaving the family without support is hard on them and can disrupt the team.

Review topic: Assessment · Family functioning and dynamics · Outline 2.A.5

Sources: AHA/AAP 2025 pediatric advanced life support — Family presence; bradycardia; SVT; post-cardiac-arrest oxygen and temperature management.

Answer: B. FLACC (Face, Legs, Activity, Cry, Consolability)

An 18-month-old can't reliably self-report pain. FLACC is a behavioral observation scale developed and validated for young children, including toddlers, so the nurse scores what they see rather than what the child says.

Why the other answers do not fit

• A: Numeric scales need an understanding of numbers that toddlers don't have.
• C: FACES is a self-report tool for children old enough to point to the face that matches how they feel, generally about 3 and older.
• D: A visual analog scale also needs abstract self-report.

Review topic: Assessment · Developmentally appropriate pain assessment · Outline 2.B.1

Sources: Royal Children’s Hospital Melbourne: Pain assessment and measurement — Pain-scale table; FLACC; age-appropriate self-report.

Answer: C. Oral sucrose combined with non-nutritive sucking or skin-to-skin contact with the parent

The AAP recommends preventing procedural pain in neonates, using measures such as oral sucrose, non-nutritive sucking, skin-to-skin contact or breastfeeding for minor procedures like heel sticks.

Why the other answers do not fit

• A: Neonates feel pain, and unmanaged procedural pain has consequences.
• B: A cream applied just before the stick hasn't had time to work, and topical anesthetics aren't the recommended approach for heel sticks.
• D: An IV opioid is disproportionate to a heel stick and carries risk.

Review topic: Assessment · Non-pharmacological pain interventions · Outline 2.B.2

Sources: AAP: Prevention and management of procedural pain in the neonate — Minor procedures; sucrose, sucking, skin-to-skin and breastfeeding.

Answer: C. Give intranasal fentanyl now, as ordered

Intranasal fentanyl works quickly, avoids a needle and treats severe acute pain without waiting for IV access. Early, effective analgesia is part of emergency care for children.

Why the other answers do not fit

• A: Waiting 20 minutes leaves severe pain untreated.
• B: Ibuprofen alone is unlikely to control 9/10 fracture pain quickly.
• D: A painful injection is avoidable when an effective intranasal route is available.

Review topic: Assessment · Pharmacological pain interventions · Outline 2.B.2

Sources: Royal Children’s Hospital Melbourne: Intranasal fentanyl — Indications, contraindications and monitoring.

Answer: A. Pain score and sedation level with respiratory rate and effort

Reassessment after an opioid checks two things: whether the pain is controlled and whether the drug is causing oversedation or respiratory depression. Sedation usually shows up before respiratory depression, so both are checked together. Monitoring begins after administration and continues according to the opioid protocol; the expected peak is not the first or only reassessment.

Why the other answers do not fit

• B: Pain alone misses opioid-related sedation and hypoventilation.
• C: Blood pressure doesn't show whether pain is controlled or breathing is adequate.
• D: Waiting 4 hours misses the window when adverse effects peak.

Review topic: Assessment · Pain reassessment · Outline 2.B.1

Sources: Royal Children’s Hospital Melbourne: Pediatric opioid monitoring — Sedation and respiratory assessment; monitoring after boluses.

Answer: D. Keep the child calm and NPO (nothing by mouth), and anticipate bronchoscopy

A choking episode followed by one-sided wheezing and decreased breath sounds points to an aspirated foreign body in a lower airway. The child is moving air, crying and oxygenating, so this isn't a severe obstruction. Keeping the child calm and NPO and preparing for bronchoscopic removal is the priority.

Why the other answers do not fit

• A: Back blows and thrusts are for severe obstruction, when the child can't cough, cry or speak.
• B: Blind finger sweeps can push an object deeper and injure the airway.
• C: Improving wheeze doesn't remove the object, and missed aspiration causes later complications.

Review topic: System-Focused Emergencies · Respiratory: foreign body · Outline 3.A.1

Sources: AHA/AAP 2025 pediatric basic life support — Sections 6.1–6.3, breathing support, CPR indications and foreign-body obstruction; Royal Children’s Hospital Melbourne: Inhaled foreign bodies — Assessment; referral and bronchoscopy.

Answer: B. Keep the child in the parent's arms in a position of comfort, avoid upsetting procedures and call the airway team

Drooling, tripod-style positioning, muffled voice and toxic appearance in an unvaccinated child suggest epiglottitis, which can lead to sudden complete airway obstruction. Keeping the child calm and upright, avoiding anything that causes crying or struggling, and getting airway experts to the bedside is the priority.

Why the other answers do not fit

• A: An upsetting throat examination can precipitate complete obstruction.
• C: Lying flat can worsen the obstruction.
• D: Painful procedures can agitate the child and precipitate airway loss.

Review topic: System-Focused Emergencies · Upper airway infection · Outline 3.A.3

Sources: Royal Children’s Hospital Melbourne: Acute upper airway obstruction — Key points; epiglottitis; minimal handling and escalation.

Answer: B. Gently suction superficial nasal secretions, especially before feeds, and monitor hydration

Bronchiolitis care is supportive. Young infants breathe mostly through the nose, so clearing nasal secretions can improve both breathing and feeding. Supportive-care guidance recommends against routine bronchodilators, corticosteroids and antibiotics without a bacterial infection in this presentation.

Why the other answers do not fit

• A: Routine albuterol is not recommended for the bronchiolitis presentation described.
• C: Systemic corticosteroids are not recommended for routine bronchiolitis care in this infant.
• D: Bronchiolitis is viral; antibiotics are only for a coexisting bacterial infection.

Review topic: System-Focused Emergencies · Lower airway infection: bronchiolitis · Outline 3.A.4

Sources: Royal Children’s Hospital Melbourne: Bronchiolitis — Supportive care; superficial suction; treatments not routinely recommended.

Answer: C. Impending respiratory failure; escalate care now

Quieter wheezing with diminished breath sounds, drowsiness and falling saturation means less air is moving, not less bronchospasm. These are signs of imminent respiratory arrest in asthma and call for immediate escalation.

Why the other answers do not fit

• A: A 'silent chest' is an ominous sign, not improvement.
• B: Drowsiness here suggests hypercapnia and fatigue, not relaxation.
• D: Spacing treatments now would be dangerous.

Review topic: System-Focused Emergencies · Reactive airway disease / asthma · Outline 3.A.4

Sources: Royal Children’s Hospital Melbourne: Acute asthma — Assessment of severity and acute management.

Answer: A. A vagal maneuver, such as ice applied to the face, while adenosine is prepared

This is a stable infant with supraventricular tachycardia (SVT). For hemodynamically stable SVT, vagal maneuvers are first-line; in infants, ice applied to the face is a common approach. If that fails, IV adenosine given as a rapid push with a flush is next.

Why the other answers do not fit

• B: Synchronized cardioversion is used when SVT causes cardiopulmonary compromise, which this infant doesn't have.
• C: Other antiarrhythmics require expert-guided management of refractory SVT; they are not the first treatment for this stable infant.
• D: Defibrillation is for pulseless rhythms such as VF or pulseless VT.

Review topic: System-Focused Emergencies · Rhythm disturbances: SVT · Outline 3.B.3

Sources: AHA/AAP 2025 pediatric advanced life support — Family presence; bradycardia; SVT; post-cardiac-arrest oxygen and temperature management.

Answer: D. Start chest compressions

In infants and children, a heart rate below 60 beats/min with signs of poor perfusion that persists despite effective oxygenation and ventilation calls for CPR. Epinephrine is the first drug if bradycardia persists; atropine is reserved for increased vagal tone or primary AV block.

Why the other answers do not fit

• A: Atropine isn't the first step for hypoxic bradycardia with poor perfusion.
• B: Observation isn't enough when perfusion is failing despite ventilation.
• C: Pacing is a later option for specific causes, not the first response.

Review topic: System-Focused Emergencies · Rhythm disturbances: bradycardia · Outline 3.B.3

Sources: AHA/AAP 2025 pediatric basic life support — Sections 6.1–6.3, breathing support, CPR indications and foreign-body obstruction; AHA/AAP 2025 pediatric advanced life support — Family presence; bradycardia; SVT; post-cardiac-arrest oxygen and temperature management.

Answer: D. An alprostadil (prostaglandin E1) infusion, with equipment for assisted ventilation at the bedside

Shock in the first weeks of life with weak femoral pulses and an enlarged liver suggests a ductal-dependent heart lesion as the ductus arteriosus closes. Alprostadil keeps the ductus open as a temporary measure until definitive treatment. Its label carries a boxed warning: apnea occurs in about 10 to 12% of treated neonates, usually in the first hour, so ventilatory support must be immediately available.

Why the other answers do not fit

• A: Hepatomegaly and no response to fluid suggest a cardiac cause; more volume can worsen it.
• B: A diuretic doesn't address the ductal closure driving the shock.
• C: An infant in shock needs resuscitation, not feeding.

Review topic: System-Focused Emergencies · Congenital heart defects · Outline 3.B.2

Sources: PROSTIN VR PEDIATRIC prescribing information — Boxed warning and indications; Royal Children’s Hospital Melbourne: Seriously unwell neonate and young infant — Assessment; cardiac causes; apnea and admission.

Answer: B. Possible shunt malfunction with rising intracranial pressure; arrange urgent evaluation, including neurosurgery

Headache, vomiting and decreasing alertness in a child with a VP shunt are classic signs of shunt malfunction and rising intracranial pressure until proven otherwise. The drowsiness is especially concerning.

Why the other answers do not fit

• A: Assuming gastroenteritis can miss a life-threatening shunt failure.
• C: Do not attribute these symptoms to migraine before urgently evaluating possible shunt dysfunction.
• D: Treating the symptom and discharging leaves the cause unaddressed.

Review topic: System-Focused Emergencies · Shunt dysfunction · Outline 3.C.4

Sources: Perth Children’s Hospital: Ventriculoperitoneal shunt problems — Symptoms; urgent neurosurgical referral.

Answer: C. A benzodiazepine by an available non-IV route, such as IM midazolam

A seizure lasting 5 minutes or more needs a benzodiazepine now. The American Epilepsy Society treatment algorithm includes IM midazolam as initial therapy. With stabilization underway and no earlier benzodiazepine given, treatment should not wait for IV access.

Why the other answers do not fit

• A: Waiting for IV access delays first-line treatment.
• B: Second-line antiseizure drugs come after a benzodiazepine.
• D: Treatment begins at 5 minutes; delay makes seizures harder to stop.

Review topic: System-Focused Emergencies · Seizure: status epilepticus · Outline 3.C.5

Sources: American Epilepsy Society: Prolonged-seizure treatment guideline — Stabilization 0–5 minutes; initial treatment 5–20 minutes.

Answer: A. "Fever medicine can make her more comfortable, but it does not reliably prevent febrile seizures in future illnesses."

Antipyretics can improve comfort but do not reliably prevent febrile seizures in future illnesses. Continuous antiseizure medication is not routinely recommended for simple febrile seizures, and a lumbar puncture isn't routinely needed for a well-appearing, fully vaccinated child with a simple febrile seizure.

Why the other answers do not fit

• B: Around-the-clock antipyretics do not guarantee that another febrile seizure will be prevented.
• C: Daily antiseizure medication isn't recommended for simple febrile seizures.
• D: A lumbar puncture is based on clinical findings, not done routinely.

Review topic: System-Focused Emergencies · Seizure: simple febrile seizure education · Outline 3.C.5

Sources: Royal Children’s Hospital Melbourne: Febrile seizure — Simple seizure criteria; investigations; parent advice.

Answer: A. Come to the ED now; on the way, give 2 teaspoons (10 mL) of honey every 10 minutes, up to 6 doses; don't make her vomit

A lithium coin cell lodged in the esophagus can cause serious burns within hours. The National Capital Poison Center guideline says to go to the ED immediately and, if the child is 12 months or older, can swallow and swallowed the battery within the past 12 hours, give 10 mL of honey every 10 minutes for up to 6 doses on the way. Don't induce vomiting. Honey must not delay departure or definitive removal; it does not make home observation safe.

Why the other answers do not fit

• B: Inducing vomiting is specifically not recommended.
• C: Waiting for symptoms can mean the injury is already severe.
• D: Delaying care until morning allows time for esophageal injury.

Review topic: System-Focused Emergencies · GI foreign body: button battery · Outline 3.D.1

Sources: National Capital Poison Center: Button-battery triage and treatment — Initial triage and prehospital honey criteria.

Answer: D. Intussusception; anticipate an abdominal ultrasound and possible enema reduction

Intermittent, severe, colicky pain with drawn-up legs and calm periods, followed by vomiting and lethargy, is a classic intussusception picture in an infant. Ultrasound is used to diagnose it, and an air or contrast enema can reduce it. Stabilization and analgesia come first. Enema reduction is not appropriate with shock, peritonitis or perforation; the surgical team determines the next step.

Why the other answers do not fit

• A: This episodic pain pattern with new lethargy should not be dismissed as colic.
• B: A home enema delays diagnosis of a surgical emergency.
• C: The paroxysmal pain and lethargy require evaluation for intussusception rather than assuming gastroenteritis.

Review topic: System-Focused Emergencies · GI obstruction: intussusception · Outline 3.D.3

Sources: Royal Children’s Hospital Melbourne: Intussusception — Presentation; resuscitation; ultrasound; enema contraindications.

Answer: B. Hypochloremic, hypokalemic metabolic alkalosis

Repeated vomiting of stomach contents loses hydrochloric acid, which causes hypochloremia and metabolic alkalosis; potassium is lost as well. These abnormalities are corrected with IV fluids before pyloromyotomy. Electrolytes can be normal early, so the classic pattern is not required to suspect pyloric stenosis.

Why the other answers do not fit

• A: Losing gastric acid causes alkalosis, not acidosis.
• C: Potassium falls with ongoing losses.
• D: Electrolytes can be normal early, but nonbilious vomiting does not protect against chloride, acid and potassium losses.

Review topic: System-Focused Emergencies · GI obstruction: pyloric stenosis · Outline 3.D.3

Sources: Royal Children’s Hospital Melbourne: Pyloric stenosis — Electrolytes; early presentation; correction before surgery.

Answer: C. Emergent urology evaluation, because saving the testis is time-critical

Sudden onset, vomiting, a high-riding horizontal testis and an absent cremasteric reflex strongly suggest torsion. Testicular salvage depends on how quickly blood flow is restored, so urology is called immediately.

Why the other answers do not fit

• A: Epididymitis usually has a more gradual onset; treating for it delays surgery.
• B: Outpatient follow-up risks losing the testis.
• D: Lab results shouldn't delay surgical evaluation.

Review topic: System-Focused Emergencies · Genitourinary emergencies: testicular torsion · Outline 3.E.2

Sources: Royal Children’s Hospital Melbourne: Acute scrotal pain or swelling — Suspected testicular torsion and urgent surgical evaluation.

Answer: C. Two large-bore IVs, type and crossmatch, and emergent gynecology evaluation for a possible ruptured ectopic pregnancy

Pelvic pain, syncope, tachycardia and hypotension with a positive pregnancy test suggest a ruptured ectopic pregnancy with hemorrhage. Resuscitation and emergent surgical evaluation come first.

Why the other answers do not fit

• A: The exam can wait; hemorrhagic shock can't.
• B: Oral fluids don't treat ongoing bleeding.
• D: Serial hCG is for stable patients, not a hypotensive one.

Review topic: System-Focused Emergencies · OB emergencies: ectopic pregnancy · Outline 3.E.3

Sources: ACOG Practice Bulletin 193: Tubal ectopic pregnancy, abstract — Published abstract.

Answer: A. Don't replant a primary tooth; arrange dental follow-up

Pediatric dental-trauma guidance advises against replanting avulsed primary teeth; injuries to primary teeth can also affect the developing permanent teeth. Permanent teeth are the ones that should be replanted quickly.

Why the other answers do not fit

• B: Immediate replantation is for permanent teeth, not primary teeth.
• C: Milk storage matters for permanent teeth waiting to be replanted.
• D: A primary tooth isn't replanted, so splinting for replantation doesn't apply.

Review topic: System-Focused Emergencies · Maxillofacial trauma: dental avulsion · Outline 3.F.4

Sources: Royal Children’s Hospital Melbourne: Dental trauma — Primary versus permanent teeth; avulsion.

Answer: D. Orbital (postseptal) cellulitis; anticipate IV antibiotics, imaging and urgent evaluation

Pain with eye movement and proptosis signal infection behind the orbital septum. Orbital cellulitis can threaten vision and spread intracranially, so it needs IV antibiotics, imaging and urgent specialist evaluation.

Why the other answers do not fit

• A: Preseptal cellulitis doesn't cause pain with eye movement or proptosis.
• B: Fever, proptosis and painful eye movement aren't allergic findings.
• C: Conjunctivitis doesn't cause proptosis.

Review topic: System-Focused Emergencies · Ocular infection: orbital cellulitis · Outline 3.F.2

Sources: Royal Children’s Hospital Melbourne: Periorbital and orbital cellulitis — Red flags; orbital cellulitis management.

Answer: B. Suspected septic arthritis; keep NPO and prepare for joint aspiration and orthopedic evaluation

Fever, refusal to bear weight, painful restricted hip movement and inflammatory laboratory findings raise concern for bacterial arthritis. These findings support urgent evaluation but do not establish the diagnosis by themselves. Joint aspiration and orthopedic assessment help establish the cause and guide treatment; an ill-appearing child should not have antibiotics delayed for diagnostic procedures.

Why the other answers do not fit

• A: The fever, marked hip findings and inability to bear weight require urgent evaluation for infection rather than discharge with presumed transient synovitis.
• C: Fever and inflammatory labs don't fit a sprain.
• D: Growing pains don't cause fever or refusal to bear weight.

Review topic: System-Focused Emergencies · Musculoskeletal infection: septic arthritis · Outline 3.G.1

Sources: PIDS/IDSA guideline: Acute bacterial arthritis in pediatrics — Diagnosis, aspiration and timing of antibiotics.

Answer: B. Standard plus Droplet Precautions and immediate sepsis care, including vascular access and antibiotics without waiting for a lumbar puncture

Fever with spreading petechiae and purpura and signs of shock suggest meningococcemia. Neisseria meningitidis calls for Standard plus Droplet Precautions until 24 hours of effective therapy. For suspected septic shock, the Surviving Sepsis Campaign recommends antimicrobials as soon as possible, ideally within 1 hour.

Why the other answers do not fit

• A: Waiting for labs delays life-saving treatment, and contact precautions don't cover droplet spread.
• C: Spreading purpura with tachycardia and delayed capillary refill isn't a benign rash.
• D: Culture results take too long; antibiotics must not wait.

Review topic: System-Focused Emergencies · Rash: petechiae with fever · Outline 3.H.2

Sources: CDC isolation precautions: Appendix A — Neisseria meningitidis and pertussis rows; Surviving Sepsis Campaign: Pediatric sepsis and septic shock — Antimicrobial timing; cultures; fluid resuscitation with intensive-care availability.

Answer: C. Rapid evaluation with CBC, reticulocyte count and blood culture, and prompt parenteral antibiotics without waiting for results

Children with sickle cell disease can have impaired spleen function and are at high risk for overwhelming bacterial infection. The NHLBI expert panel recommends that a temperature of 101.3 °F (38.5 °C) or higher prompt evaluation (CBC, reticulocyte count, blood culture) and empiric parenteral antibiotics.

Why the other answers do not fit

• A: Looking well doesn't rule out bacteremia in sickle cell disease.
• B: Antibiotics shouldn't wait for lab results.
• D: Fever in sickle cell disease is an emergency, not a routine complaint.

Review topic: System-Focused Emergencies · Hematology: sickle cell disease with fever · Outline 3.I.1

Sources: NHLBI: Evidence-based management of sickle cell disease — PDF p. 24, printed p. 18, fever recommendations.

Answer: A. Obtain blood cultures and give empiric IV antipseudomonal antibiotics promptly

Fever with severe neutropenia is an oncologic emergency, even in a well-appearing child. Guidelines call for prompt empiric antipseudomonal beta-lactam therapy after cultures are drawn.

Why the other answers do not fit

• B: The documented fever and severe neutropenia already require prompt evaluation and treatment; waiting an hour adds delay.
• C: This high-risk child is not a candidate for routine oral outpatient treatment.
• D: Waiting for cultures delays treatment of a possible life-threatening infection.

Review topic: System-Focused Emergencies · Oncology: fever and neutropenia · Outline 3.I.2

Sources: Royal Children’s Hospital Melbourne: Fever and neutropenia — Risk stratification; AML induction; initial cultures and antibiotics.

Answer: D. Suspected cerebral edema: elevate the head of the bed, notify the provider immediately and prepare mannitol or hypertonic saline, with protocol-directed fluid adjustment

Headache with a relative drop in heart rate and rising blood pressure during DKA treatment are warning signs of cerebral injury (cerebral edema). Treat suspected cerebral injury immediately under the pediatric DKA protocol rather than waiting for brain imaging: elevate the head and prepare mannitol or hypertonic saline. Fluid adjustment is protocol-directed and must maintain adequate perfusion.

Why the other answers do not fit

• A: Insulin boluses aren't recommended in pediatric DKA and don't treat cerebral edema.
• B: Simply increasing fluids does not treat these neurologic warning signs. Fluid adjustment must follow the cerebral-injury protocol while maintaining perfusion.
• C: Bradycardia with rising BP and headache is a warning sign, not improvement.

Review topic: System-Focused Emergencies · Acquired endocrine disorder: DKA · Outline 3.J.2

Sources: Royal Children’s Hospital Melbourne: Diabetic ketoacidosis — Cerebral injury warning signs and immediate management.

Answer: D. Begin assisted ventilation by face mask, starting with 21% oxygen

A newborn who is apneic or has a heart rate below 100/min after the initial steps needs ventilation, started within 60 seconds of birth. For babies born at 35 weeks or later, starting with 21% oxygen is reasonable, then titrating to pulse-oximetry targets. A rising heart rate is the main sign ventilation is working.

Why the other answers do not fit

• A: Compressions start only if the heart rate stays below 60/min after 30 seconds of ventilation that moves the chest.
• B: Prolonged stimulation should never delay ventilation in an apneic newborn.
• C: Epinephrine is indicated only if the heart rate stays below 60/min after 60 seconds of compressions with adequate ventilation.

Review topic: Special Considerations · Newborn resuscitation · Outline 4.A.5

Sources: AHA/AAP 2025 neonatal resuscitation — Ventilation; initial oxygen; compressions and epinephrine.

Answer: B. A full sepsis evaluation, including urine, blood culture and cerebrospinal fluid, with parenteral antibiotics and admission

The UCSF consensus guideline recommends blood, urine and cerebrospinal fluid evaluation, empiric parenteral antibiotics and hospital monitoring for febrile infants younger than 21 days, even when they look well. This infant is in that youngest age group.

Why the other answers do not fit

• A: Looking well doesn't lower the risk enough to skip evaluation at this age.
• C: A urine test alone misses bacteremia and meningitis.
• D: Treating the fever doesn't address its cause.

Review topic: Special Considerations · Neonatal infection · Outline 4.A.1

Sources: UCSF: Consensus guidelines for febrile infants 0–90 days — Infants younger than 21 days; exclusion criteria.

Answer: C. Recognize medical instability and anticipate admission with cardiac monitoring

An awake heart rate below 50 beats/min in an adolescent with a restrictive eating disorder is a medical instability criterion that supports hospitalization for stabilization and cardiac monitoring.

Why the other answers do not fit

• A: Bradycardia with symptoms in a restricting adolescent shouldn't be attributed to fitness.
• B: Oral fluids don't address the risk of arrhythmia or refeeding complications.
• D: Exercise testing is inappropriate for a medically unstable patient.

Review topic: Special Considerations · Self-injury: restrictive eating disorder · Outline 4.B.2

Sources: SAHM: Medical management of restrictive eating disorders — Table 4, PDF p. 4.

Answer: A. Use verbal de-escalation: a calm voice, space, reduced stimulation and simple choices

Agitation management in children starts with the least restrictive approach: verbal de-escalation and a calmer environment. Medication may be needed alongside de-escalation after assessment. Physical restraint is a last resort when necessary for immediate safety.

Why the other answers do not fit

• B: Restraint is a last resort, not a first response.
• C: In the situation described, immediate IM medication before assessment and de-escalation is not the least restrictive appropriate first step.
• D: Locking an agitated child alone is unsafe seclusion without monitoring.

Review topic: Special Considerations · Aggressive behavior · Outline 4.B.4

Sources: Pediatric BETA emergency-department agitation consensus — Nonpharmacologic strategies; concurrent treatment; restraint.

Answer: A. Recognize the bruise as a sentinel finding in a non-mobile infant, notify the provider for an abuse evaluation and initiate the reporting process under applicable state law

Bruising anywhere on an infant 4.99 months old or younger is a red flag in the validated TEN-4-FACESp screening rule. A positive screen calls for further evaluation; it does not diagnose abuse. Document the findings and explanation objectively, protect the child and follow applicable reporting requirements rather than waiting for proof.

Why the other answers do not fit

• B: A plausible-sounding explanation doesn't remove the need for an abuse evaluation and consideration of reporting requirements.
• C: The nurse should initiate evaluation and the applicable reporting process rather than conduct an investigation to prove abuse.
• D: Confrontation can put the child at risk and isn't the nurse's investigative role.

Review topic: Special Considerations · Physical abuse · Outline 4.C.2

Sources: Pierce and colleagues: TEN-4-FACESp validation — Rule definition and conclusions; Child Welfare Information Gateway: Mandatory reporting overview — Reporting standards and jurisdictional variation.

Answer: D. Arrange to interview the patient alone, such as during a private exam, using a trauma-informed approach

A controlling companion, repeated STI visits and an older partner are potential indicators of trafficking or exploitation. The first step is a safe, private conversation with the patient using a trauma-informed approach. Explain the limits of confidentiality rather than promising secrecy.

Why the other answers do not fit

• A: Confronting the companion can escalate danger to the patient.
• B: Involving police in front of the companion can endanger her and close off disclosure.
• C: A patient can't speak freely with a possible trafficker present.

Review topic: Special Considerations · Human trafficking · Outline 4.C.4

Sources: AAP: Child sex trafficking and commercial sexual exploitation — Private interview; confidentiality limits; safety.

Answer: B. Begin rapid whole-body cooling immediately, such as cold-water immersion, while monitoring rectal temperature

Exertional heat stroke is core hyperthermia with central nervous system dysfunction. Cold-water immersion is preferred when feasible, with airway protection and other resuscitation measures performed at the same time. Monitor core temperature and stop active cooling at the protocol target to avoid overcooling.

Why the other answers do not fit

• A: Antipyretics don't work in heat stroke because the hypothalamic set point isn't raised.
• C: Cooling can't wait for labs.
• D: Ice packs to the groin alone cool far more slowly, and a confused patient shouldn't drink.

Review topic: Special Considerations · Temperature-related emergency: heat stroke · Outline 4.D.1

Sources: AHA 2025 special circumstances of resuscitation — Drowning; section 16.3, children with life-threatening hyperthermia.

Answer: C. Obtain a level 4 hours after ingestion and plot it on the nomogram to decide whether acetylcysteine is needed

The acetaminophen treatment nomogram starts at 4 hours after an acute ingestion with a reliable time; earlier levels cannot be plotted on it. The 2023 US and Canadian consensus guideline recommends drawing the level at 4 hours (or as soon as possible if the patient arrives later) and plotting it to decide on acetylcysteine. An uncertain time, delayed absorption or delayed laboratory results requires a different assessment and may require treatment before a definitive plotted result.

Why the other answers do not fit

• A: A level drawn before 4 hours can't be interpreted on the nomogram.
• B: Early acetaminophen toxicity is often symptom-free, so no symptoms doesn't mean safe.
• D: Ipecac isn't part of acetaminophen management.

Review topic: Special Considerations · Ingestion: acetaminophen · Outline 4.E.1

Sources: US/Canada acetaminophen poisoning consensus statement — Acute ingestion; 4-hour level; history reliability; delayed absorption.

Answer: C. Give 100% oxygen by non-rebreather mask and obtain co-oximetry for carboxyhemoglobin

Standard pulse oximetry can't distinguish carboxyhemoglobin from oxyhemoglobin, so a normal SpO2 doesn't rule out carbon monoxide poisoning. High-flow 100% oxygen shortens carboxyhemoglobin's half-life, and co-oximetry measures the actual level.

Why the other answers do not fit

• A: A normal SpO2 is falsely reassuring in CO poisoning.
• B: Headache and vomiting after generator exposure need evaluation, not symptom treatment alone.
• D: Low-flow oxygen doesn't provide the high concentration needed.

Review topic: Special Considerations · Carbon monoxide poisoning · Outline 4.E.2

Sources: CDC: Carbon monoxide clinical guidance — Diagnosis; pulse oximetry limitations; oxygen treatment.

Answer: A. Standard plus Droplet Precautions and admission with cardiorespiratory monitoring for apnea

Pertussis in young infants can cause apnea and is most dangerous in the first months of life. Pertussis requires Standard plus Droplet Precautions, and an infant with apnea or cyanotic spells needs admission and monitoring.

Why the other answers do not fit

• B: Pertussis is spread by droplets, and a young infant with apnea shouldn't go home.
• C: Contact precautions don't cover droplet spread, and cough suppressants aren't a treatment.
• D: Discharging a 6-week-old with apneic spells is unsafe.

Review topic: Special Considerations · Childhood disease: pertussis · Outline 4.F.1

Sources: CDC isolation precautions: Appendix A — Neisseria meningitidis and pertussis rows; CDC: Clinical features of pertussis — Infant apnea; clinical stages; Royal Children’s Hospital Melbourne: Seriously unwell neonate and young infant — Assessment; cardiac causes; apnea and admission.

Answer: D. Open the airway and begin rescue breaths or bag-mask ventilation

Drowning injures the body through hypoxia, so restoring oxygenation and ventilation is the priority. This child is apneic with a heart rate of 100 beats/min and needs ventilation right away, with continued reassessment of pulse and perfusion.

Why the other answers do not fit

• A: Abdominal thrusts delay ventilation and risk vomiting and aspiration.
• B: This child has a pulse, and ventilation is essential in drowning.
• C: Routine spinal immobilization isn't indicated without signs of trauma and shouldn't delay breaths.

Review topic: Multi-System Considerations · Submersion injury · Outline 5.A

Sources: AHA/AAP 2025 pediatric basic life support — Sections 6.1–6.3, breathing support, CPR indications and foreign-body obstruction; AHA 2025 special circumstances of resuscitation — Drowning; section 16.3, children with life-threatening hyperthermia.

Answer: B. Obtain a blood culture if it won't delay treatment, give broad-spectrum antibiotics within the first hour and give 10 to 20 mL/kg (200 to 400 mL) crystalloid boluses, reassessing after each

For suspected septic shock, the Surviving Sepsis Campaign pediatric guidelines recommend antimicrobials as soon as possible, ideally within 1 hour, with blood cultures drawn first only if that doesn't delay treatment. Where intensive care is available, fluid is given in 10 to 20 mL/kg boluses, up to 40 to 60 mL/kg in the first hour, with reassessment after every bolus and stopping if fluid overload develops. For 20 kg, 10 to 20 mL/kg is 200 to 400 mL.

Why the other answers do not fit

• A: Antibiotics shouldn't wait for a lumbar puncture in septic shock.
• C: A 60 mL/kg total without reassessment ignores the bolus-and-reassess approach and the risk of fluid overload.
• D: Septic shock needs IV resuscitation and IV antimicrobials.

Review topic: Multi-System Considerations · Sepsis · Outline 5.B

Sources: Surviving Sepsis Campaign: Pediatric sepsis and septic shock — Antimicrobial timing; cultures; fluid resuscitation with intensive-care availability.

Answer: B. Epinephrine 1 mg/mL, 0.22 mg IM in the anterolateral thigh

IM epinephrine in the anterolateral thigh is first-line for anaphylaxis. For this 22-kg child, 0.01 mg/kg of the 1 mg/mL solution gives 0.01 × 22 kg = 0.22 mg, which is 0.22 mL.

Why the other answers do not fit

• A: Antihistamines don't reverse airway or circulatory compromise and shouldn't come before epinephrine.
• C: The thigh (IM) is the preferred site and route; subcutaneous deltoid absorption is slower.
• D: IV bolus epinephrine isn't the first-line route for anaphylaxis with a pulse and risks dangerous effects.

Review topic: Multi-System Considerations · Anaphylaxis · Outline 5.C

Sources: CDC: Managing adverse reactions, pediatric anaphylaxis table — Table 5-1, emergency anaphylaxis management in children.

Answer: C. Wean oxygen to a saturation of 94% to 99% and begin protocol-directed temperature control to prevent core temperature above 37.5 °C

After pediatric cardiac arrest, the 2025 guidelines suggest weaning oxygen to a saturation of 94% to 99%, because 100% can hide a very high PaO2. Fever after arrest is associated with worse neurologic outcomes, and the guidelines recommend avoiding central temperatures above 37.5 °C in children who remain comatose.

Why the other answers do not fit

• A: The goal after return of circulation is normal oxygen levels, not maximum oxygen.
• B: Post-arrest fever is linked to worse neurologic outcome and should be prevented.
• D: Low PaCO2 constricts cerebral vessels; the guidelines advise limiting both hypocapnia and hypercapnia.

Review topic: Multi-System Considerations · Post-resuscitative care · Outline 5.D

Sources: AHA/AAP 2025 pediatric advanced life support — Family presence; bradycardia; SVT; post-cardiac-arrest oxygen and temperature management.

Answer: A. Continuous capnography (end-tidal CO2)

Capnography shows changes in ventilation breath by breath, often before oxygen saturation falls, especially when supplemental oxygen is running. The AAP/AAPD sedation guideline calls for capnography during deep sedation.

Why the other answers do not fit

• B: Oxygen saturation drops late in hypoventilation, particularly on supplemental oxygen.
• C: Intermittent visual checks miss early changes.
• D: Blood pressure doesn't measure ventilation.

Review topic: Multi-System Considerations · Procedural sedation · Outline 5.E

Sources: AAP/AAPD: Pediatric sedation monitoring guideline — Deep sedation and capnography; PDF p. 11.

Answer: D. Provide emergency evaluation and time-critical treatment needed to prevent harm while continuing attempts to contact the parents

Emergency evaluation and care needed to prevent serious harm should not be delayed solely because a parent cannot be reached. An open fracture needs timely care, and staff continue efforts to contact the parents.

Why the other answers do not fit

• A: Delaying needed emergency care for consent isn't appropriate.
• B: A school nurse generally isn't a legal guardian able to consent for the child.
• C: Analgesia alone leaves an open fracture untreated.

Review topic: Professional Issues · Consent for treatment · Outline 6.A.1

Sources: AAP: Consent for emergency medical services, abstract — Published abstract: prevent imminent significant harm without delay.

Answer: D. The child gets a medical screening exam; registration may collect information but can't delay screening to ask about payment

EMTALA requires a covered hospital with an emergency department to provide an appropriate medical screening examination regardless of ability to pay, and the regulation says screening can't be delayed to ask about payment method or insurance status.

Why the other answers do not fit

• A: Screening can't be conditioned on coverage.
• B: Steering a patient away before screening because of payment concerns conflicts with EMTALA.
• C: Prior authorization can't delay the medical screening exam.

Review topic: Professional Issues · Government regulations: EMTALA · Outline 6.A.3

Sources: 42 CFR 489.24: Emergency medical screening and stabilization — Medical screening obligation and (d)(4), delay for payment/insurance.

Answer: B. Obtaining vital signs on a stable 8-year-old with an ankle sprain

Routine, predictable tasks for a stable patient, like taking vital signs, can be delegated when the worker is competent and the task is permitted. Initial assessment, initial teaching and evaluation of treatment response require nursing judgment and stay with the RN. The RN remains accountable for the delegation decision, supervision and follow-up; the worker is responsible for performing the accepted task correctly.

Why the other answers do not fit

• A: Initial assessment requires RN judgment.
• C: Initial teaching about a new inhaler requires nursing assessment and judgment.
• D: Evaluating response to an opioid requires nursing assessment.

Review topic: Professional Issues · Delegation to assistive personnel · Outline 6.B.4

Sources: NCSBN/ANA: National guidelines for nursing delegation — Responsibilities and rights of delegation; PDF pp. 1 and 4.

Answer: C. Report the near miss through the event reporting system according to policy

Near misses reveal system weaknesses before anyone is hurt. A culture of safety depends on reporting them through the event reporting system so the process can be fixed, without a blame-first response.

Why the other answers do not fit

• A: Near misses should be reported even when no harm occurred.
• B: A verbal mention doesn't create the record needed for learning and system fixes.
• D: An automatic board referral is not a substitute for reporting and reviewing this near miss under policy. Separate reporting duties depend on the facts and applicable rules.

Review topic: Professional Issues · Culture of safety · Outline 6.B.3

Sources: AHRQ PSNet: Reporting patient safety events — Near misses; reporting systems and learning.

Answer: A. Keep the seat rear-facing until your child reaches the seat's highest rear-facing weight or height limit

NHTSA recommends keeping a child rear-facing as long as possible, until the child reaches the highest rear-facing weight or height allowed by the car seat manufacturer. The manufacturer's limit, not the second birthday alone, determines when to move to a forward-facing seat with a harness and tether.

Why the other answers do not fit

• B: The second birthday alone is not the recommended switch point.
• C: A weight of 20 lb does not establish this seat's rear-facing limit; follow its weight and height limits.
• D: Legs touching the seat back isn't a reason to turn the seat forward.

Review topic: Professional Issues · Injury prevention · Outline 6.C.3

Sources: NHTSA: Car seats and booster seats — Rear-facing recommendations, ages 1–3 and manufacturer limits.