o A common problem, increased risk of diarrhea
o Infants and young children are at the highest risk
o Body fluids make up 75% of an infant’s body weight
o Infants/toddlers’ high ratio of surface area to weight equals more body loss through
o Acute diarrhea is typically caused by viruses, like rotavirus, bacteria, and parasites
o Rotavirus is common in infants between 3 and 15 months of age
o Chronic diarrhea can be caused by antibiotic treatment of another condition, poor
absorption of starches and sugars, food allergies, laxative abuse in eating disorders,
hyperthyroidism, or irritable bowel syndrome
o In acute cases, treatment is supportive and includes fluid and electrolyte replacement
and/or antidiarrheals based on age; in chronic cases, treatment is specific to the
o History of present illness (HPI): quantity and frequency of fluid intake, vomiting, and/or
diarrhea, urine output or number of wet diapers in 24 hours, duration or degree of fever,
types of medications, underlying diseases
o Weight is the most essential measure in calculating body fluid loss
o Physical exam (PE): vital signs, color, capillary refill, skin turgor, dryness of lips and
mucous membranes, lack of tears, sunken fontanelles, output, and mental status
Treatment of mild to moderate dehydration:
o Commercially available oral hydration solutions (ORS)
o Continue breastfeeding with ORS supplementation
o Offer young children 20 ml/kg per hour
o Offer older children 100 mL of ORS every 5 minutes
o Combine with IV therapy as needed
o Reassess after 4 hours; repeat if needed
o Avoid juice, soft drinks, and sports drinks
Treatment of severe dehydration:
o Evidence of compromised perfusion and severe dehydration
o Intravenous (IV) therapy of Ringer’s lactate or normal saline if Ringers not available
o under 1 year, 30 ml/kg over the first hour, 70 ml/kg for the following 6 hours, and
100 ml/kg from 6 to 24 hours.
o over 1 year, 30 ml/kg over the first 30 minutes and 70 ml/kg for the following 3
o reassess every 15 to 30 minutes
Dehydration is the loss of water and extracellular fluid. Volume depletion or hypovolemia (loss of
extracellular fluid) and dehydration are used interchangeably. Dehydration is classified as mild (<3%
weight loss when compared with recent current weight in older children and 5% in infants), moderate
(6% in older children and 10% in infants), or severe (9% or greater in older children and 15% or
greater in infants) (Thomas, 2015).
Dehydration is overwhelmingly the result of an infectious process, primarily viral, that often causes
diarrhea. Children are at increased risk due to their higher surface area–to-volume ratios, higher rate
of insensible loss, and in younger children the inability to communicate or actively replenish losses.
The vomiting history should assess the following:
• Symptoms with the onset of vomiting; duration of vomiting, quality and quantity, presence of blood or
bile, odor, precipitating event; pain; relationship of vomiting to meals, activities, or time of day.
Vomiting early in the morning is indicative of increased intracranial pressure.
• Recent exposure to illness, injury, or stress; recent travel (including camping); swimming activities;
possibility of poisoning or contaminated food
• Medications currently being taken (including over-the-counter, herbal, cultural, and homeopathic
• Presence of associated symptoms: Diarrhea, fever, ear pain, UTI symptoms, vision changes, cough,
headache, seizures, high-pitched cry, polydipsia, polyuria, polyphagia, anorexia
• Past history of illnesses, surgeries, or hospitalizations
• Family history of GI disease or fetal or neonatal deaths (metabolic syndrome, congenital anomaly)
The dehydration history should assess the following:
• Mental status and thirst
• Parental concern regarding decreased tearing or urination, or depressed fontanel in infants
• Growth parameters and vital signs
• Neurologic examination: Nuchal rigidity, decreased level of consciousness, and behavioral changes,
which can include irritability or lethargy. Sensorium remains intact until there is greater than 6%
weight loss as a result of dehydration. Hypotension is a late manifestation of dehydration.
• Abdominal examination: Inspect for distention, abdominal scars from previous surgery (may be
associated with obstruction and/or adhesions), or visible peristaltic waves. Auscultate bowel sounds
(i.e., increased with gastroenteritis, decreased with obstruction, absent with ileus or peritonitis).
Palpate the abdomen for pain and/or rebound tenderness. Assess abdominal organs (liver and spleen
size, masses). Perform a rectal examination as indicated.
• Respiratory examination: Tachypnea, decreased oxygen saturation, stridor
• One of the most useful clinical signs of hydration is capillary refill time
Diagnostic studies are performed as indicated by the probable diagnosis:
• Laboratory studies:
• CBC with differential, blood culture
• Electrolytes, including blood urea nitrogen (BUN) and creatinine, glucose, and liver function tests
• Serum sodium less than 130 (hyponatremic) or greater than 150 (hyponatremic)
• CRP and ESR
• Serum lactate, organic acids, ammonia for metabolic disorders (may only be abnormal during
episodes of vomiting)
• UA and urine culture
• Toxicology screen
• Stool for culture and occult blood, leukocytes, parasites, fat, pH, reducing substances
• Rapid strep test and/or throat culture
• Pregnancy test
• Abdominal radiographs (suspected obstruction or FB ingestion, organomegaly, or a palpable mass)
• Chest radiograph (suspected pneumonia)
• Ultrasound (abscesses, masses, stenoses, cysts, appendicitis, pyloric stenosis)
• Barium swallow or enema (malrotation, pyloric stenosis, GER, masses)
• CT scan or MRI to diagnose masses, inflammation, herniations, perforations, and obstructions
• Other studies
• Endoscopy (obstruction, hemorrhage, infection, collect biopsies)
• Esophageal pH probe analysis, scintiscan
• Electroencephalogram (EEG)
Colic (signs, symptoms, treatment, etc): Colic is defined as crying for no apparent reason that
lasts for 3 hours or more per day and occurs 3 days or more per week in an otherwise healthy infant
younger than 3 months of age. The Period of PURPLE Crying Initiative (www.purplecrying.info) is a
resource for parents to assist them during the developmentally normal fussy period. The term
PURPLE – acronym used to describe specific characteristics of an infant’s cry during this period and
provides parents with knowledge that this is indeed normal and will pass in time.
When difficult-to-soothe crying occurs, a careful history and physical examination including a
thorough gastrointestinal and neurological assessment should be performed. The main management
is an acknowledgement by the provider of the tremendous difficulties the parents are dealing with and
an inquiry about the well-being of the parents. There is no evidence to support changing formulas or
using medications to manage crying.
The use of quiet “white noise”—noise that contains many frequencies with equal intensities—can help
calm infants. Many parents realize their infants calm when the vacuum is running or a ceiling fan is
on. Others notice a car ride provides a variety of noise from the engine, street, to calming music in the
car. Discourage parents from putting the infant in a car seat on the dryer or using a blow dryer, in
order to prevent falls and burns. For infants with colic, mothers may wish to reduce or eliminate
allergenic foods (e.g., cow’s milk, eggs, peanuts, tree nuts, soy, fish, and wheat) in her diet; however,
there is little evidence that elimination of foods is protective against colic symptoms.
Appendicitis: inflammation of the appendix that leads to distention and ischemia that can result in
necrosis, perforation, and peritonitis or abscess formation. Process evolves over 12 hours.
• Pain: Initially poorly defined periumbilical pain (earliest sign); acute onset of severe pain is not
typical of acute appendicitis. A shifting of pain to the RLQ may occur after a few hours and becomes
more intense, continuous, and localized.
• Nausea and vomiting: Typically occurs after pain; however, in retrocecal appendicitis, this may be
reversed. In gastroenteritis, vomiting precedes the pain.
• Anorexia occurs (although up to 50% of children state that they are hungry).
• Stool is low volume with mucus; diarrhea is atypical but can occur especially after perforation
(gastroenteritis has high-volume, watery stools).
• Fever is neither sensitive nor specific for appendicitis; many children present as afebrile or with lowgrade fever. High fever may be associated with perforation.
• Presence of involuntary guarding, RLQ rebound tenderness, maximal pain over McBurney point (1.5
to 2 inches in from the right anterior superior iliac crest on a line toward the umbilicus) on abdominal
examination (most reliable finding); percussion is best method for eliciting rebound tenderness.
• Heel-drop jarring test (on toes for 15 seconds, dropping down forcefully on heels); inability to stand
straight or climb stairs; winces when getting off examination table or riding in a car over bumps; child
most comfortable with bent knees.
• Positive psoas sign or obturator sign (or both).
• Rovsing sign or rebound tenderness (pressure deep in left lower quadrant with sudden release
elicits RLQ pain) strongly suggests peritoneal irritation.
• Tenderness and possibly a mass (abscess) on the right side on rectal examination.
• CBC with differential may show an increased WBC count (>10,000) with an increased neutrophil
count. This occurs in 70% to 90% of those with acute appendicitis. However, an elevated WBC count
may be neither sensitive nor specific in the clinical diagnosis of appendicitis; during the first 24 hours
of symptoms it is often within a normal range.
• Amylase, lipase, and liver enzymes help to differentiate liver, gallbladder, or pancreatic issues.
• UA can show small numbers of WBCs (<20) and red blood cells (RBCs) (<20 per high-power field).
Foreign bodies – objects swallowed by child:
Esophageal Foreign Bodies
Esophageal FBs lodge at three spots most commonly—at the thoracic inlet where skeletal muscle
changes to smooth muscle (between the clavicles at about C6) (70%), at the mid-esophagus where
the aortic arch and carina overlap the esophagus (15%), or at the lower esophageal sphincter (LES)
(15%). Pointed objects or small objects, such as pills or small button batteries, may lodge anywhere
along the slightly moist esophageal mucosa. Common symptoms include an initial episode of
choking, gagging, and coughing. Excessive salivation; dysphagia; food refusal; emesis/hematemesis;
or pain in the neck, throat, or sternal notch areas may follow. Respiratory symptoms such as stridor,
wheezing, cyanosis, or dyspnea may occur if the esophageal body impinges on the larynx or tracheal
wall. Cervical swelling, erythema, or subcutaneous crepitations may indicate perforation of the
oropharynx or proximal esophagus. Drooling or pooling of secretions may be related to an
esophageal FB or abrasion of the esophagus as a result of swallowing the object. Disk batteries
cause a liquefactive necrosis, electrical discharge leading to low-voltage burns, and pressure
necrosis. Children who have swallowed lithium batteries greater than or equal to a 20 mm diameter
are at greatest risk of problems due to battery ingestion Some patients have documented severe
erosion or ulceration in as little as 2 hours after ingestion. Emergency endoscopic removal is
Abdominal Foreign Bodies
Most ingested objects that reach the stomach pass through the remainder of the GI tract without
difficulty. Items greater than 5 cm in diameter or 2 cm in thickness tend to lodge in the stomach and
need to be retrieved. Thin objects longer than 10 cm may not make the duodenal sweep turn and also
need to be retrieved. In infants and toddlers, FBs greater than 3 cm in length or 20 mm in diameter
may not pass through the pyloric sphincter. Open safety pins or other pointed objects, such as
needles or thumbtacks, also should be retrieved.
Perforation after ingestion occurs in only 1% of ingestions. Perforation occurs near physiologic
sphincters, areas of angulation, congenital malformations of the gut, or near areas of previous bowel
surgery. Coins made with nickel have been reported to interact with gastric acid to cause stomach
ulceration (Sandoval, 2017). Abdominal distention or pain, vomiting, hematochezia, and unexplained
fever are symptoms related to ingestions lodging in the stomach or intestinal areas. Items that pose a
greater risk include multiple small magnets that may cling together across the bowel wall, leading to
pressure necrosis; items containing lead; and batteries, which usually do not cause problems but
might lead to symptoms if there is leakage of alkali or mercury from battery degradation. Lithium
toxicity has been reported. Nickel in coins can lead to allergic symptoms in children with a nickel
Rectal Foreign Bodies
Children sometimes put items into their rectum. Small blunt objects usually will pass spontaneously,
but large or sharp objects should be retrieved after sedation to relax the anal sphincter.
History, Physical Examination, and Laboratory Studies
Specific physical findings are unusual. Abrasions, streaks of blood, or edema of the hypopharynx may
occasionally indicate an FB. Laboratory studies are usually not helpful, although they may be useful
to identify potential infection.
Most FBs are radiopaque. A single frontal radiograph that includes the neck, chest, and entire
abdomen is usually sufficient to locate the object. Subsequent radiographs may be useful to more
fully evaluate the patient. Esophageal objects should be precisely located with frontal and lateral
chest radiographs and to make sure there are not two objects closely aligned. Coins in the
esophagus are usually seen on the frontal view, whereas tracheal coins are more often seen from the
side view. Having the child ingest a small amount of dilute contrast material may help locate
radiolucent objects. Endoscopy may be needed and also allows removal of the object.
Most children do not require special care. Patients who are drooling may require suction.
Esophageal Foreign Bodies
Objects in the esophagus should generally be considered impacted. Removal is mandatory except for
blunt objects that have been in place less than 24 hours. Disk batteries and sharp objects should be
removed without waiting. Endoscopy is the method of choice for removal except that experienced
gastroenterology practitioners may use a Foley catheter to pull the object up or a bougienage method
to push the object into the stomach. Only experienced clinicians working with healthy children who
ingested an item less than 24 hours previously should try these methods. A radiograph is done
immediately before the procedure to be sure the item has not moved and another radiograph follows
the procedure to be sure there are no retained parts or complications, such as a
Stomach/Lower Gastrointestinal Tract Foreign Bodies
Most FBs that reach the stomach may be left to pass through the system, usually within 2 to 3 days.
Very sharp items may perforate the bowel and should be removed endoscopically from the stomach
or surgically from the intestine. Button batteries in the stomach or intestine may be left to pass but
should be removed if the family has not identified the battery in the stool after 2 to 3 days. It should be
removed endoscopically from the stomach at that time or watched with repeat radiographs to be sure
it is progressing through the tract if it is in the intestine. Items may not pass through the gut if the child
has a bowel abnormality or had bowel surgery. Use of laxatives is not necessary. Inducing vomiting
may lead to aspiration.
Systemic reactions from allergy or toxic response to massive ingestion can occur. Retained FBs may
cause erosion, abrasion, local scarring, obstruction, abscess, FTT, perforation, pneumomediastinum,
pneumonia, or other respiratory disease. Complications from the removal process can occur.
Traumatic epiglottitis can occur from trauma during swallowing or a finger sweep trying to dislodge
Intussusception: Part of the small intestine retracts into itself causing ischemia of the bowel. •
Paroxysmal, episodic abdominal pain with vomiting every 5 to 30 minutes. Vomiting is nonbilious
initially. Some children do not have any pain.
• Screaming with drawing up of the legs with periods of calm, sleeping, or lethargy between episodes.
• Stool, possibly diarrhea in nature, with blood (“currant jelly”).
• A history of a URI is common.
• Lethargy is a common presenting symptom.
• Fever may or may not be present; can be a late sign of transmural gangrene and infarction.
• Severe prostration is possible.
• Observe the infant’s appearance and behavior over a period of time; often the child appears glassyeyed and groggy between episodes, almost as if sedated.
• A sausage-like mass may be felt in the RUQ of the abdomen with emptiness in the RLQ (Dance
sign); observe the infant when quiet between spasms.
• The abdomen is often distended and tender to palpation.
• Grossly bloody or guaiac-positive stools.
Urinary tract infections (assessment, labs/diagnostics, treatment, etc):
History and Clinical Findings
The following information should be obtained:
• Family history of VUR, recurrent UTI, or other kidney problems
• Prenatally diagnosed renal abnormality
• Previous infection: Request records from the past infection evaluation and diagnostic studies
• Risk factors for infants 2 to 24 months old with no other source of infection
• Female—white race, age younger than 12 months old, temperature 39°C or higher, fever for 2 days
• Male—nonblack race, temperature 39°C or higher, fever for more than 24 hours
• Hygiene habits: Wiping front to back
• Voiding patterns: Frequency, abnormal stream, complete emptying, dribbling, enuresis, holding
urine, incomplete emptying, and bathroom avoidance
• Constipation, perianal itching (pinworms)
• Irritants, such as nylon underwear or clothing (spandex, tight pants or shorts that rub); bubble bath
or sitting in soapy bath water
• Sexual activity, masturbation, or sexual abuse
• Other infection: Pinworms, diaper rash
See Table 41.3 for age-related symptoms.
• General appearance (toxic appearing?)
• Vital signs: Temperature, BP
• Growth parameters: Growth may be decreased with chronic UTI or renal insufficiency, especially in
• Flank pain or costovertebral angle tenderness
• Abdominal examination: Suprapubic tenderness, bladder distention or a flank mass (obstructive
signs), mass from fecal impaction
• Genitalia: Vaginal erythema, edema, irritation, or discharge; labial adhesions; uncircumcised male,
urethral ballooning; weak, dribbling, threadlike stream
• Neurologic examination (if voiding is dysfunctional): Perineal sensation, lower extremity reflexes,
sacral dimpling, or cutaneous abnormality
• UA should be used only to raise or lower suspicion. Suspicious findings include foul odor,
cloudiness, nitrites, leukocytes, alkaline pH, proteinuria, hematuria, pyuria, and bacteriuria.
• Leukocyte esterase chemical tests detect pyuria, but pyuria may arise from causes other than UTI.
• Consider obtaining a lab UA with reflexive gram stain and microscopy if dipstick findings are
• Bacterial identification and determination of sensitivities are necessary in patients who appear toxic
or could have pyelonephritis, have relapses or recurrent UTI, or are nonresponsive to medication.
• Complete blood count (CBC) (elevated WBC count), erythrocyte sedimentation rate (ESR), Creactive protein (CRP), BUN, and creatinine should be done if the child is younger than 1 year old,
appears ill, or if pyelonephritis is suspected.
• Blood culture should be done if sepsis is suspected (see Chapter 28).
The differential diagnosis includes urethritis, vaginitis, viral cystitis, foreign body, sexual abuse,
dysfunctional voiding, appendicitis, pelvic abscess, and pelvic inflammatory disease. Any child who
has acute fever without a focus, FTT, chronic diarrhea, or recurrent abdominal pain should be
evaluated for UTI.
If there are no leukocytes on UA, no treatment is indicated.
Use regional antibiotic resistance patterns and culture and sensitivity results when choosing
Children 2 to 24 months old and febrile children should have 7 to 14 days of antibiotics.
• Acute pyelonephritis: Oral therapy is equally as effective as parenteral therapy in treating
pyelonephritis and preventing kidney damage.
• Hospitalization is required if severity of symptoms warrants—dehydrated, vomiting, or not drinking.
Children 1 month old and younger should be admitted and provided a parenteral regimen.
• Infants over 1 month and children with uncomplicated pyelonephritis (well hydrated, no vomiting, no
abdominal pain) can be effectively treated with cefixime, cephalexin, or amoxicillin clavulanate.
• Adolescents with uncomplicated pyelonephritis can be treated with either amoxicillin clavulanate
(875/125 mg twice a day) or ciprofloxacin (500 mg twice a day or extended release 1000 mg once a
Enuresis: voluntary or involuntary urination at an age when toilet training should be complete.
Children who never established control have primary enuresis. Secondary enuresis is present when
children have been dry for more than 6 to 12 months and then begin wetting. Nocturnal enuresis is
incontinence during sleep.
Diagnosis: requires a minimum age of 5 years old, and one episode a month for a duration of 3
• Sleep disorders: Obstructive sleep apnea and disordered sleep patterns result in increased
nocturnal enuresis incidence
• Stress and family disruptions: divorce, move, or a new family member.
• Polyuria: This can be caused by nocturnal drinking as well as caffeine intake
• Inappropriate toilet training: parents are overly demanding or punitive of the child.
History and Clinical Findings
• Voiding characteristics:
• Urgency, dysuria, or dribbling
• Are there voiding or stooling postponement behaviors?
• Number of voids per day: is nocturia present?
• Cluster voiding: for example, is the child waiting until after school?
• Frequency of wetting—day and night
• Type of urinary stream
• These findings warrant referral to a pediatric urologist:
• Weak or interrupted urinary stream
• Need to use abdominal pressure to urinate
• Combined daytime incontinence and nocturnal enuresis
• Fluid intake, including timing, type, and volume
• Family history of enuresis, treatment, and age of resolution, including parents
• Toilet training history: What age was toilet training begun? How was it handled? Was the child ever
dry? For how long?
• The physical examination includes the following:
• Assess the external genitalia for signs of irritation, infection, labial fusion, and/or meatal stenosis.
• Examine the abdomen for masses, especially at the suprapubic midline and in the left lower
• Examine the lower back for dimples and hair tufts.
• Assess for neurologic function and deep tendon reflexes.
A UA is recommended in all children with enuresis. A culture should be done if there are clinical
symptoms to warrant it.
Drug Therapy for Children 6 Years or Older:
Desmopressin acetate (DDAVP)
Oral: 0.2 mg tablet once daily at bedtime; can be adjusted up to maximum of 0.6 mg/day
Oral: 120 mcg Melt (dissolves sublingually) once daily at bedtime; this is the bioequivalent of 0.2 mg
tablet; can be adjusted up to 240 mcg/day
Diabetes (assessment including growth charts, labs/diagnostics, treatment):
Obesity: Endocrine/Immune Responses
early puberty (girls)
delayed puberty (boys)
functional immobility (inability to complete activities of daily living)
gastroesophageal reflux disease (GERD)
joint stress (slipped epiphysis, scoliosis, osteoarthritis)
decreased participation in activities/sports
victim of bullying
lack of relationships
Congenital hypothyroidism: abnormality in development of the thyroid gland during fetal life
(dysgenesis or agenesis) or a problem with the ability of the thyroid to make thyroid hormone. Thyroid
dysgenesis accounts for approximately 85% of cases of CH.
CH is the most common cause of preventable mental retardation. Untreated CH leads to irreversible
brain damage and variable degrees of growth failure, deafness, and neurologic abnormalities. Earlier
detection of CH through improvements in newborn screening combined with more aggressive thyroid
hormone replacement regimens (10 to 15 μg/kg/day) at diagnosis have led to improved
developmental outcomes for newborns with CH.
Signs and Symptoms
Poor feeding and weight gain
Small stature or poor growth
Physical Symptoms and Signs
Course facial features
Mottled, cool and dry skin
Mood & Anxiety Disorders
Unipolar depression: presents in late childhood or early adolescence and can have a longstanding
impact on quality of life. Adolescent depression is strongly associated with recurrent and chronic
depression as well as other psychiatric illnesses in adulthood.
Common comorbid conditions include anxiety disorders and substance use disorders. Adolescent
girls are three times more likely to experience depression than boys, though boys have a higher rate
of depression before puberty.
Early detection of unipolar depression is key to improving outcomes. The GLAD-PC provides different
scoring thresholds to screen for mild, moderate, or moderately severe depression.
Treatment: collab with the client and family.
Safety plan for addressing acute crises or suicidality should be established at the time of diagnosis or
initial treatment, as safety concerns are the highest at this time.
Selective serotonin reuptake inhibitors (SSRIs) should be started at low doses with dose increase or
medication change only after 4 weeks. Symptom severity should be assessed every 1–2 weeks after
initiating medication along with continuous monitoring of suicidality. Although SSRIs are typically well
tolerated in this population, adverse effects can occur including behavioral activation which can
manifest as irritability, agitation, and impulsivity. Referrals should be made to a mental health
specialist for long-term management.
GLAD-PC Toolkit for future reference (192 pages) http://www.gladpc.org/
M e d i c a t i o n Wa r n i n g : Paroxetine is an SSRI that has been associated with increased
suicidal thinking and actions in children and adolescents and should not typically be used to treat
depression in this population.
Bipolar depression: Although bipolar disorder (BPD) was initially described by psychiatrists as early
as 1851, it was not until the 1990s that providers began to fully embrace BPD as a diagnosis affecting
youths. Diagnosis of children before puberty remains controversial. Common comorbidities include
attention deficit hyperactivity disorder (ADHD), anxiety disorders, oppositional defiant disorder,
learning disorders, and substance use.
Although the criteria used to diagnose children with BPD are the same as the criteria used to
diagnose adults, the presentation can look different in children. Children typically experience more
rapidly cycling moods and mixed episodes characterized by symptoms of both mania and depression
together. A challenge with diagnosing BPD is that many clients initially present with depressive
symptoms making it difficult to differentiate it from unipolar depression. Symptoms can also appear as
more extreme versions of common childhood and adolescent behaviors.
BPD diagnosis typically begins with a symptom checklist followed by a clinical interview. The Young
Mania Rating Scale (YMRS) can be used to screen for symptoms of mania.
Treatment for pediatric BPD typically includes a combination of medication and psychotherapy. The
mood stabilizers and antipsychotic medications used in adult treatment are also used to treat
children, though they are less effective for prepubertal children. Clients who screen positive for mania
should be referred to a mental health specialist. SSRIs are not recommended as a monotherapy for
bipolar depression due to the increased risk of triggering manic episodes or rapid cycling.
Generalized anxiety disorder: (GAD) Excessive or unrealistic worry about everyday life events that
are out of proportion to the impact of the events. Diagnostic criteria for GAD in children and teens are
the same as for adults; however, only one physical or cognitive symptom is required for diagnosis
whereas three symptoms are required for adult diagnosis. Treatment is a combination of
psychotherapy and medication. Cognitive-behavioral therapy (CBT) is the most common. First-line
pharmacologic treatment is SSRIs. Benzodiazepines are also used sometimes for short-term
treatment, especially for certain specific phobias such as fear of dental or medical treatments.
Referrals should be made to a mental health specialist for long-term management.
Tool for anxiety screening (SCARED) in children for future reference (5 pages):
Obsessive compulsive disorder: The onset of OCD is gradual with up to 25% of cases emerging
between the ages of 8 to 12 years. Symptoms: persistent, intrusive thoughts (obsessions) and
repetitive behaviors performed to decrease obsession-related anxiety (compulsions). To meet
diagnostic criteria for OCD, the obsessions and compulsions must be time-consuming (greater than 1
hour per day) and disrupt normal routines, functioning, or relationships. Common obsessions and
compulsions in children include washing, checking, ordering, and fear of catastrophe.
Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections
In a small subset of children with OCD, the diagnosis is associated with streptococcal infections. The
acronym PANDAS is used to identify this subset. The strep infection causing PANDAS is treated with
antibiotics while OCD symptoms are treated with a combination of CBT and SSRIs. Children with
PANDAS may be sensitive to the side effects of SSRIs; therefore, it is important to begin treatment
with low doses and increase slowly.
Screening for OCD
Short Obsessive–Compulsive Disorder Screener (SOCS)
Youth who screen positive – refer to mental health specialist. First-line treatment for mild to moderate
OCD is psychotherapy or in combination with SSRI or clomipramine. Atypical antipsychotics in
Disruptive and Neurodevelopmental Disorders
Attention deficit hyperactivity disorder: Developmentally inappropriate levels of inattention,
disorganization, hyperactivity, and impulsivity. Symptoms may be mild or so severe they interfere with
all aspects of a person’s life. Without early identification and proper treatment, ADHD can cause
disruptions in academic performance, family stress, difficulties in social relationships, and accidental
injuries. ADHD is associated with increased rates of depression and substance use disorder.
o Lack of attention to detail
o Careless mistakes
o Not listening
o Losing things
o Diverting attention
o Poor problem solving
o Difficulty completing tasks
o Difficulty sustaining mental effort
o Excessive talking
o Blurting things out
o Not waiting for one’s turn
o Leaving one’s seat
o Running, climbing
o Trouble playing quietly
Over two-thirds of children diagnosed with ADHD have at least one coexisting psychiatric condition ie:
learning disabilities, conduct disorders, tics, anxiety, depression, and language disorders; adolescents
are at increased risk of substance use disorders.
ADHD treatment is multimodal requiring medical, educational, behavioral, and psychological
Stimulant medications are effective for 70-80% of clients.
Nonstimulants are used in cases in which a client does not respond to stimulant medications or where
stimulants are contraindicated. Nonstimulants can help lower distractibility and improve attention,
working memory, and impulsivity. A combination of stimulant and nonstimulant medications is
sometimes used when ADHD includes argumentative or oppositional symptoms.
Providers must consider several factors before prescribing medication for ADHD, including:
Before initiation of any stimulant, obtain a thorough health history. Assess for a personal or
family history of cardiac disease. An electrocardiogram (ECG) is required if cardiac history is
present in a first-degree relative.
Monitor blood pressure, height, and weight regularly during treatment.
Assess all clients for bipolar disorder before treatment. Central nervous system (CNS)
stimulants may cause psychotic or manic symptoms in clients with no prior history or may
exacerbate behavior disturbance symptoms and thought disorders in clients with pre-existing
CNS stimulants may exacerbate comorbid anxiety and substance use disorders.
Treatment efficacy will be noted within the first week of treatment.
Increased irritability and insomnia can be treated with a low dose of nonstimulant medication
which will allow the client to fall asleep.
Abrupt withdrawal after prolonged use can result in irritability and rebound symptoms.
Stimulants can cause or worsen tics; stimulants may unmask the presence of tics.
When switching stimulants, discontinue the current medication and start the new medication at
a starting dose the next day.
Stimulant medications available to treat ADHD are available as immediate-release or
Several stimulant medications are classified as Schedule II indicating that they have a high potential
for abuse. The FNP must adhere to federal and state-specific guidelines for prescribing these
medications. Note: short-acting medications are at higher risk for diversion. Careful monitoring is
required. Occasional urine drug screens should be obtained to verify the presence of amphetamines
and the absence of other substances of abuse.
Nonpharmacologic: Schools can provide educational support, behavioral interventions in the
classroom, and accommodations, which can help children achieve academic success.
Psychotherapy is often used in ADHD treatment.
For younger children under the age of 6, AAP recommends parent training in behavior management
as a first-line intervention.
Know the difference between: Executive function, sensory processing, information
Sensory processing: measures tactile sensitive, taste-smell sensitivity, movement, underresponsiveness, auditory filtering, low energy and weakness, visual and auditory processing.
Information processing: how information is received, processed, and stored, as well as how it then
Autism spectrum disorder: neurological and developmental disorder that impacts individuals’
communication, relationships with others, learning, and behavior. Affects 1-2% of the population and
occurs in all racial, ethnic, and socioeconomic groups.
AAP recommends that all children be screened for ASD at children’s 18-month and 24-month wellchild visits.
avoiding eye contact
showing little interest in peers or caretakers
limited language abilities
frustration with minor changes in routine
Children who demonstrate developmental differences in behavior or functioning require additional
evaluation, typically performed by a team of ASD specialists. Specialists may include a child
psychologist, speech-language pathologist, occupational therapist, developmental pediatrician, or
The Female Reproductive
‣ Common menstrual disorders (PMS, PMDD)
Mittelschmerz (pain during ovulation) often presents with acute lower quadrant pain similar to acute
appendicitis and may lead to misdiagnosis and unnecessary surgery.
Amenorrhea is the absence of a menstrual period and is classified as primary or secondary.
Abnormal Uterine Bleeding (AUB): Abnormal uterine bleeding (AUB) is bleeding that is atypical in
frequency, regularity, duration, and timing.
Frequency: Every 24 – 38 days
Regularity: +/- 2 – 20 days
Duration: 3 – 8 days Quantity: 5 – 80 mL (roughly 3 – 6 pads per day)
Pelvic Inflammatory Disease: PID occurs in the upper female genital tract and includes any
combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.
Toxic Shock Syndrome: TSS is a severe illness with an acute onset characterized by fever, low
blood pressure, a sunburn-like body rash, and end-organ damage. Typically presents with a rapid
onset of fever, hypotension, and rash.
Polycystic ovary syndrome: Disorder that causes enlarged ovaries and ovarian cysts.
‣ Cervical intraepithelial neoplasia (subclassification using an oncology staging system):
Cervical cancer is treated based on the staging of the disease. Treatment is individualized;
clients who wish to preserve fertility may choose less invasive options than those who do not.
Treatment options include:
cold knife cone biopsy
‣ Cervical cancer screening guidelines:
Galactorrhea: Nipple discharge may be benign or pathologic. Milky discharge is
considered normal lactation in the presence of breastfeeding and up to one year after
pregnancy. Non-lactational milk production, or galactorrhea, may occur due to excessive
nipple stimulation or pregnancy or may indicate the presence of a pituitary tumor or
systemic illness. Galactorrhea may occur in women and men.
Mastalgia: also called mastodynia or breast pain, is one of the most commonly reported symptoms in
women with breast concerns. Breast pain is a significant cause of anxiety, even though mastalgia is
benign in 90 percent of cases.
Classified as cyclic or noncyclic, depending on whether its presence is related to the menstrual cycle.
The majority of breast pain is cyclic, occurring 1 to 2 weeks prior to menses.
As many as 70 percent of women experience cyclic mastalgia.
10 to 22 percent of women have moderate to severe breast pain.
Noncyclic mastalgia is less common, with approximately 25 percent of women reporting this
Etiology and Pathophysiology
Mastalgia is considered a normal physiologic condition caused by the hormonal changes of the
menstrual cycle. Can also be caused by certain medications, including combined estrogen and
progestin, contraceptives, hormone therapy, antidepressants, digoxin, methyldopa, cimetidine,
spironolactone, oxymetholone, and chlorpromazine.
Assessment: A woman may present with a breast mass found on self-examination, or a mass may
be discovered on clinical breast examination.
If the woman found the mass, determine when she first noticed it and any changes she has observed
since that time. Ask about other breast symptoms, such as mastalgia or nipple discharge, and
determine whether the woman has a history of any type of breast disease or surgery. Menstrual,
pregnancy, lactation, and general medical histories should be taken. A family history of breast or
ovarian cancer is particularly important, but to be thorough all cancers in the family through a twogeneration pedigree should be obtained.
Perform a comprehensive breast examination, including inspection and palpation with the woman in
both the upright and supine positions, and evaluate the lymph nodes. If a mass is palpable, identify
the size (in centimeters), the shape, and the consistency or texture. Determine whether the mass is
discrete (well-delineated, distinct edges) or poorly differentiated, tender to palpation, and mobile or
fixed. Assess for skin changes, nipple discharge, and lymphadenopathy. When documenting the
location of a mass, draw a sketch of the breast with the site of the mass marked, or, more importantly,
describe the position of the mass on the breast relative to a clock face, such as at seven o’clock.
Women with bilateral milky discharge should be screened initially for pregnancy and
Guidelines for breast cancer screenings vary by organization. Women should discuss
the risks/benefits of screening mammograms with their providers. Women between
ages 40-75 may require annual or biennial screening mammograms. Mammograms are
not routinely recommended for women over 75.
Breast cancer typically presents as firm, non-tender, ill-defined masses; all masses should be
investigated further with a diagnostic mammogram.
Unilateral bloody nipple discharge is a red flag for breast cancer. Diagnostic testing should
initially include a diagnostic mammogram and cytology on the nipple discharge.
‣ Sexually transmitted infections (STI) screening, diagnosis, treatment (HPV including the
vaccine, Genital Herpes, Chlamydia and Gonorrhea, bacterial vaginosis, vulvovaginal
candidiasis, trichomoniasis, Vaginitis
70% of people who contract an STI report being asymptomatic
62% report they always or usually wear a condom
40% of college males and 55% of college females report receiving and completing their HPV
College men have about 14 sexual partners, while college women have 12 sexual partners
The prevalence of STIs increased for the sixth year reaching record-high levels in 2019
Almost half of new STIs are in youth and young adults aged 15-24
Rationale: The most likely diagnosis for Leonora is herpes simplex virus (HSV). HSV is the most
common cause of genital ulcers and is more prevalent in women than men. HSV infection is often
symptomatic, presenting with pain, itching, dysuria, urethral or vaginal discharge, and inguinal
adenopathy. Clients may also have a fever, myalgias, or headaches. Ulcerations may be present on
the genitals, anal region, and cervix. Symptoms can be mistaken for other STIs; therefore, a
polymerase chain reaction (PCR) test is recommended.
Which of the following are the most appropriate management strategies for Leonora?
valacyclovir 1,000 mg tablets orally twice daily (Correct answer)
encourage the use of condoms (Correct answer)
recommend abstaining from sexual activity if symptomatic (Correct answer)
recommend informing sexual partners of HSV status (Correct answer)
Rationale: Antivirals, such as acyclovir, valacyclovir, and famciclovir, are used to treat HSV if the
symptoms appeared less than seven days ago. They can also be used episodically or continuously to
prevent recurrent episodes. Doxycycline and penicillin are not used for viral infections. Client
education is required about HSV transmission and recurrent episodes, condom use, and partner
information about her HSV status, and abstinence from sexual activity if symptomatic.
Which of the following is the most appropriate diagnosis for Shaquille?
herpes simplex virus
syphilis (Correct answer)
Rationale: The most likely diagnosis for Shaquille is syphilis. Syphilis is a bacterium that causes a
lesion, or chancre, at the site of entry. The chancre appears two to three weeks after infection and
progresses from a papule to an ulcer. Men have higher rates than women, while men who have sex
with men have the highest rates of syphilis. The risk for coinfection with human immunodeficiency
virus (HIV) is elevated, therefore all clients who test positive for syphilis should be tested for HIV.
Syphilis can be diagnosed using examination and serologic testing.
Which of the following are the most appropriate management strategies for Shaquille?
benzathine penicillin G 2.4 million units intramuscular single dose (Correct answer)
encourage the use of condoms (Correct answer)
recommend follow-up in six months then yearly for repeat screening (Correct answer)
recommend notifying sex partners from the past three months (Correct answer)
Rationale: Penicillin G is the preferred treatment for syphilis. Azithromycin is effective but not
recommended due to emerging drug-resistant strains. Doxycycline should be used if the client has a
penicillin allergy. STI prevention, including condom use, should be discussed. The client should follow
up in six months to evaluate treatment response. Men who have sex with men should be screened
yearly. Partners from the past 90 days should be notified for evaluation and treatment. Lesions should
not reappear unless the client is reinfected.
Which of the following is the most appropriate diagnosis for Avery?
gonorrhea (Correct answer)
herpes simplex virus
Rationale: The most likely diagnosis for Avery is gonorrhea. Urethritis with purulent drainage is the
most common symptom of gonorrhea in males. Women with gonorrhea may present with pain or
burning with urination, vaginal discharge, or vaginal bleeding between periods. Symptoms emerge
two to five days after exposure. No lesions are present.
Nucleic acid amplification tests (NAATs) are used to diagnose gonorrhea.
Which of the following are the most appropriate management strategies for Avery?
ceftriaxone 500mg to 1 gram intramuscular single dose (Correct answer)
recommend notifying sex partners from the past two months (Correct answer)
encourage the use of condoms (Correct answer)
Rationale: Ceftriaxone is the preferred treatment for gonorrhea. If the client weighs less than 150 kg,
500 mg is recommended; if greater than 150 kg, then 1 gram should be used. Azithromycin is
effective but not recommended due to emerging drug-resistant strains. Doxycycline should be used
with ceftriaxone if chlamydia has not been excluded. Penicillin is not effective. STI prevention and
condom use should be discussed. Clients should notify their partners from the past 60 so they can
receive evaluation and treatment. The client should follow up in three months to evaluate response to
treatment, determine any reinfection, and test for other STIs. Routine screening is recommended for
sexually active women under 25 and men who have sex with men.
Which of the following is the most appropriate diagnosis for Lexi?
pelvic inflammatory disease
chlamydia (Correct answer)
Rationale: The most likely diagnosis for Lexi is chlamydia. Chlamydia is the most commonly reported
STI in the U. S. with women having the highest rates. Chlamydia can cause a range of symptoms,
including urethritis and cervicitis, that appear 7 to 21 days after exposure. Nearly all women with a
urethral chlamydial infection will also have cervicitis. If left untreated, chlamydia can lead to pelvic
inflammatory disease. No lesions are present.
Nucleic acid amplification tests (NAATs) are used to diagnose chlamydia.
Which of the following are the most appropriate management strategies for Lexi?
doxycycline 100 mg orally twice daily for 7 days (Correct answer)
recommend notifying sex partners from the past two months (Correct answer)
encourage the use of condoms (Correct answer)
recommend routine screening (Correct answer)
Rationale: Doxycycline is the preferred treatment for chlamydia. Azithromycin is effective but not
recommended for pregnant women with chlamydia. Ceftriaxone is not effective. STI prevention
should be discussed. Clients should notify partners from the past 60 days so they can receive
evaluation and treatment. The client should follow up in three months to evaluate response to
treatment, determine any reinfection, and test for other STIs. Routine screening is recommended for
sexually active women under 25 and men who have sex with men.
‣ Contraceptive methods:
Tier 1 Contraceptives: 1% Failure Rate
Tier 1 methods include:
o progestin implants
o intrauterine device (IUD)
o tubal ligation
o depot medroxyprogesterone acetate (DMPA): Depo-Provera
Tier 2 Contraceptives: 2-3% Failure Rate
Tier 2 methods include hormonal options:
o combined oral contraceptive (COC) pills: estrogen and progesterone
o monophasic oral contraceptive pill: progestin-only “Minipill”
o emergency contraception transdermal patch
o cervical ring
Tier 3 Contraceptives: 20% Failure Rate
Tier 3 methods include:
o barrier methods
o cervical cap
o spermicidal foam, film, sponge
o natural family planning
o coitus interruptus (withdrawal)
Amenorrhea and a positive pregnancy test are required to confirm a diagnosis.
Pregnancy should be considered in the differential diagnosis for women of childbearing
age and is not ruled out by history alone. For example, pregnancy may be a differential
diagnosis for a 16-year-old who presents with lower abdominal pain, despite denying
sexual activity, or for a 48-year-old perimenopausal client who states she has stopped
menstruating but developed new breast tenderness.
A history and physical exam may reveal signs that increase the probability of pregnancy.
Signs may be classified as:
‣ Presumptive: Changes that are experienced by the client that leads to suspicion
‣ Probable: Changes are seen on physical exam that leads to suspicion of
‣ Positive: Signs that are only explained by pregnancy
Prenatal vitamins are recommended during pregnancy, including 400mg/day of folic acid.
Women who cannot tolerate prenatal vitamins due to nausea may require folic acid
Avoid cleaning cat litter boxes
Avoid eating raw/undercooked meat, shellfish, or oysters
Avoid smoking, alcohol, and illicit drug consumption
Limit caffeine intake (less than 8 ounces per day)
Avoid hot tubs, saunas, or excessive heat
Do not receive live vaccines during pregnancy
Teaching for low breast milk production:
Make sure your baby is latched on and positioned well.
Breastfeed often and let your baby decide when to end the feeding.
Offer both breasts at each feeding. Have your baby stay at the first breast as long
as he or she is still sucking and swallowing. Offer the second breast when the baby
slows down or stops.
Avoid giving your baby formula or cereal in addition to your breastmilk, especially
in the first 6 months of life. Your baby may lose interest in your breastmilk, and
your milk supply will decrease. If you need to supplement your baby’s feedings
with more milk, try using a spoon, cup, or a dropper filled with pumped breastmilk.
Maternal Mental Health
Crying without reason
Drastic hormonal changes
Fatigue after giving birth and breastfeeding
Sudden changes in routine caring for baby
Lack of support from partner or family
Transition to being a mother
Self-care during the Baby Blues
Ask for help
Sleep when possible
Get social support
Up to 1 in 5 women will suffer from a maternal mental health disorder like postpartum
Less than 15% of women receive treatment
1 in 7 will experience depression during pregnancy.
Up to 50% of women living in poverty will suffer from a maternal mental health disorder
Maternal mental health disorders impact the whole family, not just moms
More than 600,000 women will suffer from a maternal mental health disorder in the U.S. every
Anxiety and depression have risen by 37% in teen girls. This will increase the number of
women suffering postpartum depression in the future
Rates of depression are more than doubled in Black moms due to cumulative effects of stress
Contributing factors for maternal mental health disorders among Black women
Exposure to violence
Gaps in medical insurance
Adverse childhood experiences (ACEs)
Lack of access to high-quality medical and mental health care
Lack of representation in the medical system
Higher risk of pregnancy and childbirth complications
Risk Factors for MMHDs
Lack of social support
Poor relationship quality
Personal or family history of depression
History of physical or sexual abuse
Chronic physical conditions
Prior pregnancy with fetal/infant loss
History of mental illness
Current recommendations from ACOG include screening at least once during the
perinatal period using a validated instrument, increasing the frequency of visits when
symptoms are identified, and referring clients for appropriate pharmacotherapy and
AAP recommends incorporating the Edinburgh Postnatal Depression Scale (EPDS) into
infants’ 1, 2, 4, and 6-month well check visits using a cutoff score of 10 as an indicator
that maternal depression may be present.
Mastitis: (assessment and management/treatment)
The pain in such cases is attributed to the proliferation of breast tissue and hormonal influences on
that tissue. Mastitis is the most likely diagnosis when breast pain in a lactating woman is
accompanied by inflammation, erythema, chills, myalgia, and, in more advanced cases, fever.
Plugged ducts or milk stasis is most often related to noninfective mastitis. Infective mastitis can occur
secondary to entry of bacteria from nipple trauma/cracking, stress and fatigue, milk stasis, or
sometimes without explanation. Staphylococcus aureus, Escherichia coli, Enterobacteriaceae,
Mycobacterium tuberculosis, and Candida albicans.
Risk factors: stress and fatigue, cracked or fissured nipples, milk stasis/engorgement, breast trauma
or restriction (too-tight bra), oversupply of milk, use of nipple shields, and attachment difficulties.
Treatment includes continuation of breastfeeding, increased rest, fluids, nutrition, application of moist
heat, anti-inflammatory medications, and possible use of antibiotics. Standard treatment for lactation
mastitis includes a penicillinase-resistant penicillin or cephalosporin 10 to 14 days. Symptoms should
resolve by 48 hours; if they do not, consider the possibility of methicillin-resistant S. aureus infection
and obtain a milk culture.
Women with mastitis should be encouraged to empty the breasts and maintain frequency of feedings.
Altering the feeding schedule can increase the risk of milk stasis and subsequent mastitis. Likewise,
proper latch will ensure nipple integrity.
Practice Questions (chapters: 40, 41, 45, 30, 6, 17, 21, 25, 26, 22, 32, 33, 35)
Chapter 40. Gastrointestinal Disorders Questions
1. The parent of an infant asks about using a probiotic medication. What will the primary care
pediatric nurse practitioner tell this parent?
A. Probiotic medications have demonstrated efficacy in treating colic.
B. Probiotics are not safe to use to treat infants who have colic.
C. There are no studies showing usefulness of probiotics to manage colic.
D. There is no conclusive evidence about using probiotics to treat colic. Correct
2. A toddler who was born prematurely refuses most solid foods and has poor weight gain. A barium
swallow study reveals a normal esophagus. What will the primary care pediatric nurse practitioner
consider next to manage this child’s nutritional needs?
A. Consultation with a dietician
B. Fiberoptic endoscopy evaluation
C. Magnetic resonance imaging
D. Video fluoroscopy swallowing study Correct
3. A toddler is seen in the clinic after a 2 day history of intermittent vomiting and diarrhea. An
assessment reveals an irritable child with dry mucous membranes, 3 second capillary refill, 2 second
recoil of skin, mild tachycardia and tachypnea, and cool hands and feet. The child has had two wet
diapers in the past 24 hours. What will the primary care pediatric nurse practitioner recommend?
A. Antidiarrheal medication and clear fluids for 24 hours
B. Bolus of IV normal saline in the clinic until improvement
C. Hospital admission for IV rehydration and oral fluids
D. Oral rehydration solution with follow-up in 24 hours Correct
4. A 9 year old girl has a history of frequent vomiting and her mother has frequent migraine
headaches. The child has recently begun having more frequent and prolonged episodes
accompanied by headaches. An exam reveals abnormal eye movements and mild ataxia. What is the
A. Begin using an antimigraine medication to prevent headaches.
B. Prescribe ondansetron and lorazepam to help manage symptoms.
C. Reassure the parent that this is expected with cyclic vomiting syndrome.
D. Refer to a pediatric gastroenterologist for further workup. Correct
5. The parent of a 3 month old reports that the infant arches and gags while feeding and spits up
undigested formula frequently. The infant’s weight gain has dropped to the 5th percentile from the 12th
percentile. What is the best course of treatment for this infant?
A. Begin a trial of extensively hydrolyzed protein formula for 2 to 4 weeks. Correct
B. Institute an empiric trial of acid suppression with a proton pump inhibitor (PPI).
C. Perform esophageal pH monitoring to determine the degree of reflux.
D. Reassure the parent that these symptoms will likely resolve by 12 to 24 months.
6. A school age child has a 3 month history of dull, aching epigastric pain that worsens with eating
and awakens the child from sleep. A complete blood count shows a hemoglobin of 8 mg/dL. What is
the next step in management?
A. Administration of H2RA or PPI medications
B. Empiric therapy for H. pylori (HP)
C. Ordering an upper GI series
D. Referral for esophagogastroduodenoscopy (EGD) Correct
7. A 2 month old infant cries up to 4 hours each day and, according to the parents, is inconsolable
during crying episodes with fists and legs noted to be tense and stiff. The infant is breastfeeding
frequently but is often fussy during feedings. The physical exam is normal and the infant is gaining
weight normally. What will the primary care pediatric nurse practitioner recommend?
A. A complete workup, including laboratory and radiologic tests
B. Eliminating certain foods from the mother’s diet Correct
C. Empiric treatment with a proton pump inhibitor medication
D. Stopping breastfeeding and beginning a hydrolyzed formula
8. A child is in the clinic after swallowing a metal bead. A radiograph of the GI tract shows a 6 mm
cylindrical object in the child’s stomach. The child is able to swallow without difficulty and is not
experiencing pain. What is the correct course of treatment?
A. Administer ipecac to induce vomiting.
B. Have the parents watch for the object in the child’s stool. Correct
C. Insert a nasogastric tube to flush out the object.
D. Refer the child for endoscopic removal of the object.
9. A 10 year old child has had abdominal pain for 2 days, which began in the periumbilical area and
then localized to the right lower quadrant. The child vomited once today and then experienced relief
from pain followed by an increased fever. What is the likely diagnosis?
A. Appendicitis with perforation Correct
C. Pelvic inflammatory disease (PID)
D. Urinary tract infection (UTI)
10. An 18 month old child has a 1 day history of intermittent, cramping abdominal pain with nonbilious
vomiting. The child is observed to scream and draw up his legs during pain episodes and becomes
lethargic in between. The primary care pediatric nurse practitioner notes a small amount of bloody,
mucous stool in the diaper. What is the most likely diagnosis?
C. Intussusception Correct
D. Testicular torsion
11. A school age child has had abdominal pain for 3 months that occurs once or twice weekly and is
associated with a headache and occasional difficulty sleeping, often causing the child to stay home
from school. The child does not have vomiting or diarrhea and is gaining weight normally. The
physical exam is normal. According to Bishop, what is included in the initial diagnostic workup
for this child?
A. CBC, ESR, amylase, lipase, UA, and abdominal ultrasound Correct
B. CBC, ESR, CRP, and fecal calprotectin
C. CBC, ESR, CRP, UA, stool for ova, parasites, and culture
D. Stool for H. pylori antigen and serum IgA, IgG, tTg
12. An adolescent is diagnosed with functional abdominal pain (FAP). The child’s symptoms worsen
during stressful events, especially with school anxiety. What will be an important part of treatment for
A. Informing the parents that the pain is most likely not real
B. Instituting a lactose free diet along with lactobacillus supplements
C. Teaching about the brain gut interaction causing symptoms Correct
D. Using histamine 2 blockers to help alleviate symptoms
13. A school age child has recurrent diarrhea with foul smelling stools, excessive flatus, abdominal
distension, and failure to thrive. A 2 week lactose free trial failed to reduce symptoms. What is the
next step in diagnosing this condition?
A. Lactose hydrogen breath test
B. Serologic testing for celiac disease Correct
C. Stool for ova and parasites
D. Sweat chloride test for cystic fibrosis
14. A child is diagnosed with Crohn disease. What are likely complications for this
A. Cancer of the colon and possible colectomy
B. Intestinal obstruction with scarring and strictures Correct
C. Intestinal perforation and hemorrhage RRR. Liver disease and sepsis
15. A 12monthold infant exhibits poor weight gain after previously normal growth patterns. There is no
history of vomiting, diarrhea, or irregular bowel movements, and the physical exam is normal. What is
the next step in evaluating these findings?
A. Complete blood count and electrolytes
B. Feeding and stooling history and 3day diet history Correct
C. Stool cultures for ova and parasites
D. Swallow study with video fluoroscopy
16. A 2yearold
child has an acute diarrheal illness. The child is afebrile and, with oral rehydration measures, has
remained well hydrated. The parent asks what can be done to help shorten the course of this illness.
What will the primary care pediatric nurse practitioner recommend?
A. Clear liquids only
B. Lactobacillus Correct
D. Peppermint oil
Chapter 41. Genitourinary Disorders Questions
1. A 30monthold girl who has been toilet trained for 6 months has daytime enuresis and dysuria and a
low-grade fever. A dipstick urinalysis is negative for leukocyte esterase and nitrites. What is the next
A. Begin empiric treatment with trimethoprim sulfamethoxazole.
B. Discuss behavioral interventions for toilet training.
C. Reassure the child’s parents that the child does not have a urinary tract infection.
D. Send the urine to the lab for culture. Correct
2. The clean catch urine specimen of a child with dysuria, frequency, and fever has a colony count
between 50,000 and 100,000 of E. coli. What is the treatment for this child?
A. Obtain a complete blood count and C-reactive protein.
B. Perform sensitivity testing before treating with antibiotics.
C. Repeat the culture if symptoms persist or worsen.
D. Treat with antibiotics for urinary tract infection. Correct
3. A dipstick urinalysis is positive for leukocyte esterase and nitrites in a school age child with dysuria
and foul smelling urine but no fever who has not had previous urinary tract infections. A culture is
pending. What will the pediatric nurse practitioner do to treat this child?
A. Order ciprofloxacin ER once daily for 3 days if the culture is positive.
B. Prescribe trimethoprim sulfamethoxazole (TMP) twice daily for 3 to 5 days. Correct
C. Reassure the child’s parents that this is likely an asymptomatic bacteriuria.
D. Wait for urine culture results to determine the correct course of treatment.
4. A preschool age child with no previous history ha s mild flank pain and fever but no abdominal pain
or vomiting. A urinalysis is positive for leukocyte esterase and nitrites. A culture is pending. Which is
the correct course of treatment for this child?
A. Hospitalize for intravenous antibiotics.
B. Order amoxicillin clavulanate. Correct
C. Prescribe trimethoprim sulfamethoxazole.
D. Refer for a voiding cystourethrogram.
5. A 3yearold child has just completed a 7day course of amoxicillin for a second febrile urinary tract
infection and currently has a negative urine culture. What is the next course of action?
A. Obtain a renal and bladder ultrasound. Correct .
B. Prescribe prophylactic antibiotics to prevent recurrence.
C. Refer the child for a voiding cystourethrogram.
D. Screen urine regularly for leukocyte esterase and nitrites.
6. A 9monthold infant with a history of three urinary tract infections is diagnosed with grade II
vesicoureteral reflux. Which medication will be prescribed?
A. Amoxicillin 10 mg/kg as a single daily dose
B. Ceftriaxone IM 50 mg/kg as a single daily dose
C. Nitrofurantoin 12 mg/kg as a single daily dose
D. TMPSMX; TMP 2 mg/kg as a single daily dose Correct
7. The parent of a toddler diagnosed with grade V vesicoureteral reflux asks the primary care
pediatric nurse practitioner how the disease will be treated. What will the nurse practitioner tell this
A. That long-term antibiotic prophylaxis will prevent scarring
B. That surgery to correct the condition is possible Correct
C. that the child will most likely require kidney transplant
D. that the condition will probably resolve spontaneously
8. A healthy 14yearold female has a dipstick urinalysis that is positive for 56 RBCs per hpf but
otherwise normal. What is the first question the primary care pediatric nurse practitioner will ask this
A. “Are you sexually active?”
B. “Are you taking any medications?”
C. “Have you had a recent fever?”
D. “When was your last menstrual period (LMP)?” Correct
9. A child has gross hematuria, abdominal pain, and arthralgia as well as a rash. What diagnosis is
A. Henoch Schönlein purpura Correct
C. Sickle cell disease
D. Systemic lupus erythematosus
10. An adolescent has 2+ proteinuria in a random dipstick urinalysis. A subsequent first morning
voided specimen is negative. What will the primary care pediatric nurse practitioner do to manage this
A. Monitor for proteinuria at each annual well child examination. Correct
B. Order a 24hour timed urine collection for creatinine and protein excretion.
C. Reassure the parents that this is a benign condition with no followup needed.
S. Refer the child to a pediatric nephrologist for further evaluation.
11. A child is diagnosed with nephrotic syndrome, and the pediatric nurse practitioner provides
primary care in consultation with a pediatric nephrologist. The child was treated with steroids and
responded well to this treatment. What will the nurse practitioner tell the child’s parents about this
A. “Future episodes are likely to have worse outcomes.”
B. “Steroids will be used when relapses occur.” Correct
C. “This represents a cure from this disease.”
S. “Your child will need to take steroids indefinitely.”
12. A child who has nephrotic syndrome is on a steroids and a salt restricted diet for a relapse of
symptoms. A dipstick urinalysis shows 1+ protein, down from 3+ at the beginning of the episode. In
consultation with the child’s nephrologist, what is the correct course of treatment considering this
A. Begin a taper of the steroid medication while continuing salt restrictions.
B. Continue with steroids and salt restrictions until the urine is negative for protein. Correct
C. Discontinue the steroids and salt restrictions now that improvement has occurred.
D. Relax salt restrictions and continue administration of steroids until proteinuria is gone.
13. A child who had GABHS 2 weeks prior is in the clinic with periorbital edema, dyspnea, and
elevated blood pressure. A urinalysis reveals tea colored urine with hematuria and mild proteinuria.
What will the primary care pediatric nurse practitioner do to manage this condition?
A. Prescribe a 10 to 14day course of high dose amoxicillin.
B. Prescribe high dose steroids in consultation with a nephrologist.
C. Reassure the parents that this condition will resolve spontaneously.
D. Refer the child to a pediatric nephrologist for hospitalization. Correct
14. An adolescent has right sided flank pain without fever. A dipstick urinalysis reveals gross
hematuria without signs of infection or bacteriuria, and the primary care pediatric nurse
practitioner diagnoses possible nephrolithiasis. What is the initial treatment for this condition?
A. Extracorporeal shockwave lithotripsy (ESWL)
B. Increasing fluid intake up to 2 L daily Correct
C. Percutaneous removal of renal calculi
D. Referral to a pediatric nephrologist
15. During a well child examination of a 2yearold child, the primary care pediatric nurse practitioner
palpates a unilateral, smooth, firm abdominal mass which does not cross the midline. What is the
next course of action that?
A. Order a CT scan of the chest, abdomen, and pelvis.
B. Perform urinalysis, CBC, and renal function tests.
C. Reevaluate the mass in 1 to 2 weeks.
D. Refer the child to an oncologist immediately. Correct
16. A 6monthold infant has a retractile testis that was noted at the 2month well baby exam. What will
the primary care pediatric nurse practitioner do to manage this condition?
A. Reassure the parent that the testis will most likely descend into place on its own.
B. Refer the infant to a pediatric urologist or surgeon for possible orchiopexy. Correct
C. Teach the parent to manipulate the testis into the scrotum during diaper changes.
D. Tell the parent that hormonal therapy may be needed to correct the condition.
17. A 9monthold infant is brought to the clinic with scrotal swelling and fussiness. The primary care
pediatric nurse practitioner notes a tender mass in the affected scrotum that is difficult to reduce.
What is the correct action?
A. Obtain an abdominal radiograph.
B. Refer immediately to a pediatric surgeon. Correct
C. Schedule an appointment with a pediatric urologist.
D. Teach the parents signs of incarceration.
18. The mother of a 12monthold uncircumcised male infant reports that the child seems to have pain
associated with voiding. A physical examination reveals a tight, pinpoint opening of the foreskin,
which thickened and inflamed. What will the primary care pediatric nurse practitioner do?
A. Attempt to retract the foreskin to visualize the penis.
B. Order corticosteroid cream 3 times daily for 4 weeks.
C. Refer the child to a pediatric urologist. Correct
D. Teach the mother to gently stretch the foreskin with cleaning.
19. An adolescent male comes to the clinic reporting unilateral scrotal pain, nausea, and vomiting that
began that morning. The primary care pediatric nurse practitioner palpates a painful, swollen testis
and elicits increased pain with slight elevation of the testis (a negative Phren’s sign). What will the
nurse practitioner do?
A. Administer IM ceftriaxone and prescribe doxycycline twice daily for 10 days.
B. Encourage bed rest, scrotal support, and ice packs to the scrotum as tolerated.
C. Prescribe NSAIDs, limited activities, and warm compresses to the scrotum.
D. Refer the adolescent immediately to a pediatric urologist or surgeon. Correct
Chapter 45. Endocrine and Metabolic Disorders Questions
1. The primary care pediatric nurse practitioner evaluates children’s growth to
screen for endocrine and metabolic disorders. Which is a critical component of this screening?
A. Measuring supine length in children over the age of 2 years
B. Obtaining serial measurements to assess patterns over time Correct
C. Using the CDC growth chart for children under age 2 years
D. Using the WHO growth chart for children over age 2 years
2. The primary care pediatric nurse practitioner is performing a well child examination on a 5yearold
girl. The parents ask if the child s adult height can be predicted. The nurse practitioner learns that the
mother is 5’8″ tall and the father is 5’11” tall. The nurse practitioner will estimate which expected adult
height for this child?
A. 5’11” tall
B. 5’7″ tall Correct
C. 5’8″ tall
D. 6′ tall
3. The primary care pediatric nurse practitioner is performing a well child examination on a 2yearold
child with a history of intrauterine growth retardation (IUGR) whose height remains less than the 3rd
percentile on a WHO growth chart. What will the nurse practitioner do?
A. Consider prescribing growth hormone therapy.
B. Reassure the parent that this is normal for this child.
C. Refer the child to a dietician for dietary supplementation.
D. Refer the child to a pediatric endocrinologist. Correct
4. The primary care pediatric nurse practitioner is evaluating a child who has short
stature. Although bone age studies reveal a delay in bone age, the child’s growth is consistent with
bone age. Which diagnosis is most likely?
A. Constitutional growth delay Correct
B. Growth hormone deficiency
C. Idiopathic short stature
D. Klinefelter syndrome
5. The mother of a female infant is concerned that her daughter is developing
breasts. The primary care pediatric nurse practitioner notes mild breast development but no pubic
or axillary hair. What is the likely diagnosis?
A. Congenital adrenal hyperplasia causing breast development
B. Precocious puberty needing endocrinology management
C. Premature adrenarche which will lead to pubic hair onset
D. Premature thelarche which will resolve over time Correct
6. A 7yearold female has recently developed pubic and axillary hair without breast development. Her
bone age is consistent with her chronological age, and a pediatric endocrinologist has diagnosed
idiopathic premature adrenarche. The primary care pediatric nurse practitioner will monitor this child
for which condition?
A. Adrenal tumor
B. Congenital adrenal hyperplasia
C. Polycystic ovary syndrome Correct
D. Type 1 diabetes mellitus
7. A 6yearold female has had a recent growth spurt and an exam reveals breast and pubic hair
development. Her bone age is determined to be 8 years. What will the primary care pediatric nurse
practitioner do next?
A. Order LH and FSH levels and a long acting GnRH agonist.
B. Order thyroid function tests to exclude primary hypothyroidism.
C. Reassure the parent that this is most likely idiopathic.
D. Refer the child to a pediatric endocrinologist for management. Correct
8. An infant has congenital adrenal hyperplasia. At a routine well baby checkup, the primary care
pediatric nurse practitioner notes vomiting, poor feeding, lethargy, and dehydration. Which action is
A Administer an intramuscular stress dose of hydrocortisone succinate.
B. Administer intravenous fluids in the clinic and reassess hydration status.
C. Prescribe an oral hydrocortisone in a replacement dose of 8 to 10 mg/M2.
D. Refer the infant to the emergency department for fluids, dextrose, and steroids. Correct
9. The primary care pediatric nurse practitioner performs a physical examination on a 9monthold
infant with congenital hypothyroidism who takes daily levothyroxine sodium and notes a recent
slowing of the infant’s growth rate. What will the nurse practitioner order?
A. Free serum T4 and TSH levels Correct
10. A 12 year old child has a recent history of increased thirst and frequent urination. The child’s
weight has been in the 95th percentile for several years. A dipstick UA is positive for glucose, and
random plasma glucose is 350 mg/dL. Which test will the primary care pediatric nurse practitioner
order to determine the type of diabetes in this child?
A. Fasting plasma glucose
B. Hemoglobin A1C levels
C. Pancreatic antibodies Correct
D. Thyroid function tests
11. The primary care pediatric nurse practitioner diagnoses an 8 year old child with type 1 diabetes
after a routine urine screen is positive for glucose and negative for ketones and plasma glucose is
350 mg/dL. The child’s weight is normal and the parents report a mild increase in thirst and urine
output in the past few days. Which course of action is correct?
A. Admit the child to the hospital for initial insulin management.
B. Begin insulin and refer the child to a children’s diabetes center. Correct
C. Order a fasting serum glucose and a dipstick UA in the morning.
D. Send the child to the emergency department for fluids and IV insulin.
12. The primary care pediatric nurse practitioner is reviewing lab work and diabetes
management with a school-age child whose HbA1C is 7.6% who reports usual blood sugars before
meals as being 80 to 90 mg/dL. The nurse practitioner will consult with the child’s endocrinologist
to consider which therapy?
A. Continuous glucose monitoring Correct
B. Continuous subcutaneous insulin infusion
C. Self-monitoring of blood glucose
D. Use of a long-acting insulin analogue
13. The primary care pediatric nurse practitioner is performing a well child examination on a
child who was diagnosed with type 1 diabetes at age 9. The child had a lipid screen at age 10 with an
LDL cholesterol <100 mg/dL. What will the nurse practitioner recommend as part of ongoing
management for this child?
A. Annual lipid profile evaluation
B. Annual screening for microalbuminuria
C. Comprehensive ophthalmologic exam Correct
D. Hypothyroidism screening every 5 years
14. A 13yearold Native American female has a BMI at the 90th percentile for age. The primary care
pediatric nurse practitioner notes the presence of a hyperpigmented velvetlike rash in skin folds. The
child denies polydipsia, polyphagia, and polyuria. The nurse practitioner will
A. counsel the child to lose weight to prevent type 2 diabetes.
B. diagnose type 2 diabetes if the child has a random glucose of 180 mg/dL.
C. order a fasting blood sample for a metabolic screen for type 2 diabetes.
D. refer the child to a pediatric endocrinologist.
15. The primary care pediatric nurse practitioner prescribes metformin for a 15yearold adolescent
newly diagnosed with type 2 diabetes. What will the nurse practitioner include when teaching the
adolescent about this drug?
A. That insulin therapy will be necessary in the future
B. The importance of checking blood glucose 3 or 4 times daily Correct
LL. To consume a diet with foods that are high in vitamin B12
MM. To use a stool softener to prevent gastrointestinal side effects
16. A 16yearold adolescent female whose BMI is at the 90th percentile reports irregular periods. The
primary care pediatric nurse practitioner notes widespread acne on her face and back and an
abnormal distribution of facial hair. The nurse practitioner will evaluate her further based on a
suspicion of which diagnosis?
HH. Nonalcoholic steatohepatitis
D. Polycystic ovary syndrome Correct
17. The primary care pediatric nurse practitioner is providing nutritional counseling for a 9yearold
female whose weight is at the 95th percentile for her age. What is the goal for this patient?
X. A loss of 10 to 15 pounds in 6 months
Y. An average weight loss of 2 pounds per month
C. Maintenance of her current weight Correct
D. Weight loss of 5% of her current body weight
18. The primary care pediatric nurse practitioner notes a musty odor when examining a newborn at a
2 week checkup. What will the nurse practitioner suspect?
B. Glucose phosphatase deficiency
C. Phenylketonuria Correct
D. Urea cycle disorder
19. An initial key part of management of a child suspected of having an inborn error of metabolism is
A. consulting a metabolic specialist. Correct
B. obtaining a complete family history.
C. ordering metabolic screening tests.
D. referring the family to a dietician.
Chapter 30. Mental Health Disorders Questions
1. During a well child examination on a 4 month old infant, the primary care pediatric nurse
practitioner evaluates mental health issues. Which statement by the parent indicates a potential
problem with the parent/infant relationship?
A. “I can sense a difference in my baby’s cries.”
B. “I let my baby cry a while to learn to be patient.” Correct
C. “My baby prefers to nurse in a darkened room.”
D. “My baby seems very sensitive to loud noises.”
2. A child has a difficult temperament. What will the primary care pediatric nurse practitioner tell the
parent about managing this child’s behavior?
A. A difficult temperament is its own risk factor for maladjustment disorders.
B. Children with difficult temperaments need strict adherence to rules.
C. Having a difficult temperament limits intelligence and emotional maturity
D. It is important for the parent to learn to manage criticism and power struggles. Correct
3. During a well child assessment of a preschool age child, the parent voices concerns that, because
the child has behavior problems at school, the child may have a mental health disorder. Which initial
approach will provide the best information?
A. Ask the parent whether other caregivers have voiced similar concerns.
B. Interview the child separately from the parent to encourage sharing of feelings.
C. Take time to actively listen to the parent’s and child’s perceptions of the problem. Correct
D. Use a validated screening tool to ensure that all aspects of behaviors are evaluated.
4. The primary care pediatric nurse practitioner attempts to learn more about the emotional health of
an 18 month old child through which assessment strategy?
A. Asking the child to tell a story using dolls and other props
B. Asking the child to draw a picture of him or herself and other family members
C. Interviewing the child separately from caretakers and parents
D. Observation of the child with caretakers in structured and unstructured situations. Correct
5. A middle school age child is skipping school frequently and getting poor grades since the child’s
father was killed while deployed in the military. How will the primary care pediatric nurse practitioner
manage this situation?
A. Prescribe short-term antidepressants for this situational depression.
B. Refer the child to a mental health specialist for evaluation and treatment. Correct
C. Schedule extended appointments for counseling and mental health intervention.
D. Suggest that the child have close follow-up by a school counselor.
6. The parent of a 4 year old child reports that the child seems to be having trouble adjusting to a new
day care and reportedly is always engaging in solitary play when the parent arrives to pick up the
child. What will the primary care pediatric nurse practitioner do?
A. Ask the parent if the child is slow to warm up to other new situations. Correct
B. Reassure the parent that parallel play is common among preschool age children.
C. Recommend that the parent spend time encouraging the child to play with others.
D. Suggest that the day care center may be neglecting the child.
7. The parent of a school age child is concerned because the child has started to express anger
about a grandparent’s death even though this occurred when the child was a toddler. What will the
primary care pediatric nurse practitioner tell the parent?
A. Anger is an abnormal reaction to bereavement and loss in this age child.
B. Counseling is needed since the child has had sufficient time to resolve this issue.
C. Grief and bereavement lasting longer than a year may require medication.
D. The significance of this loss must be reworked at each developmental level. Correct
8. The parent of a school age child reports that the child doesn’t like being alone in rooms because of
a fear of aliens hiding in closets. What will the primary care pediatric nurse practitioner tell the parent?
A. “Fear of imaginary creatures does not usually occur at this age.” Correct
B. “I may need to refer your child to a pediatric mental health specialist.”
C. “Your child is expressing normal fears for a school age child.”
D. “Your child may be watching too much violence on television.”
9. The parent of a preschool age child reports that the child often appears anxious and nervous and
that this is associated occasionally with a rapid heart rate and tremors. What is the best type of
referral that the primary care pediatric nurse practitioner could recommend?
A. Cognitive behavioral therapy
B. Family therapy
C. Medication therapy
D. Play therapy Correct
10. A 9 year old child exhibits school refusal and a reluctance to attend sleepovers with classmates.
The parent is concerned because the child has recently begun sleeping in the parents’ bed. Which
initial action by the primary care pediatric nurse practitioner is appropriate?
A. Assess for environmental stress, parental dysfunction, and maternal depression. Correct
B. Ask about recent traumatic events that may have precipitated this behavior.
C. Consider a possible pediatric autoimmune neuropsychiatric disorder cause.
D. Recommend firm insistence on school and activity attendance.
11. The parent of a school age child reports that the child becomes frustrated when unable to perform
tasks well and often has temper tantrums and difficulty sleeping. Which disorder may be considered
in this child?
A. Generalized anxiety disorder (GAD) Correct
B. Obsessive compulsive disorder (OCD)
C. Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS)
D. Separation anxiety disorder (SAD)
12. The parent of a school age girl reports that the child has difficulty getting ready for school and is
often late because of a need to check and recheck whether her teeth are clean and her room light
has been turned off. What will the primary care pediatric nurse practitioner recommend to this parent?
A. Cognitive behavioral therapy Correct
B. Deferral of treatment until symptoms worsen
C. Medication management with an SSRI
D. Referral to a child psychiatrist
13. The parents of a 4 year old boy are concerned because he has begun twisting and pulling out his
hair, especially when he is tired or stressed. What will the primary care pediatric nurse practitioner
recommend as part of an initial approach to treat this behavior?
A. Consultation with a pediatric behavioral specialist
B. Cutting his hair so that it is too short to pull Correct
C. Long-term antistreptococcal prophylaxis
D. Medication with Risperdal or clonidine
14. A newly divorced mother of a toddler reports that the child began having difficulty sleeping and
nightmares along with exhibiting angry outbursts and tantrums 2 months prior. The primary care
pediatric nurse practitioner learns that the child refuses to play with usual playmates and often
spends time sitting quietly. What will the nurse practitioner do initially?
A. Ask the mother about the child’s relationship with the father. Correct
B. Consult with a child psychiatrist to prescribe medications.
C. Recommend cognitive behavioral or psychodynamic therapy.
D. Refer the family to a child behavioral specialist for counseling.
15. An adolescent has recently begun doing poorly in school and has stopped participating in sports
and other extracurricular activities. During the history interview, the adolescent reports feeling tired,
having difficulty concentrating, and experiencing a loss of appetite for the past few weeks but cannot
attribute these changes to any major life event. Which is an important next step in managing this
A. Administering a diagnostic rating scale for depression
B. Considering a short-term trial of an antidepressant medication
C. Determining suicidal ideation and risk of suicide Correct
D. Referring the adolescent to a mental health specialist
16. An adolescent is diagnosed with major depression, and the mental health specialist has
prescribed fluoxetine. What other treatment is important to protect against suicide risk?
A. Addition of risperidone therapy
B. Cognitive behavioral therapy Correct
C. Family therapy Hospitalization
17. A 13 year old child has exhibited symptoms of mild depression for several weeks. The parent
reports feeling relieved that the symptoms have passed but concerned that the child now seems to
have boundless energy and an inability to sit still. What will the primary care pediatric nurse
A. Administer an ADHD diagnostic scale and consider an ADHD medication.
B. Consult with a child psychiatrist to prescribe an antidepressant medication.
C. Reassure the parent that this behavior is common after mild depressive symptoms.
D. Refer the child to a child psychiatrist for evaluation of bipolar disorder. Correct
18. A toddler has begun hitting and biting other children at a day care center and is exhibiting temper
tantrums and bad language at home. The parent reports that these behaviors began shortly after a
sibling was born. What will the primary care pediatric nurse practitioner do?
A. Advise the parent that the child is exhibiting early symptoms of ADHD.
B. Engage the parent in positive parenting strategies to facilitate appropriate child coping.
C. Recommend evaluating the child for conduct or oppositional defiant disorder.
D. Suggest putting the child in another day care center to ameliorate the problems.
19. A 14 year old female comes to the clinic with amenorrhea for 3 months. A pregnancy test is
negative. The adolescent’s body weight is at 82% of expected for height and age. The mother reports
that her daughter often throws up and refuses to eat most foods. Which condition does the primary
care pediatric nurse practitioner suspect?
A. Anorexia nervosa Correct
B. Bulimia nervosa
D. Substance abuse
CHAPTER 6 Gynecologic Anatomy and Physiology
A major contributor to pelvic stability is
the ilium and its ligaments.
The sheet made up of dense fibrous tissue that spans the opening of the anterior pelvic outlet is/are
deep perineal space.
How many different fiber sections subdivide the levator ani muscular sheet?
•2 •3 •4 •6
What is the function of the Bartholin’s gland?
To help prevent infection of the introitus
To secrete lubricating mucus into the introitus during sexual excitement
To assist in keeping the vaginal introitus closed
To secrete estrogen and regulate its levels
Which arteries supply blood to the clitoris?
Dorsal and clitoral cavernosal arteries
Two ovarian arteries
What is the approximate number of ovarian follicles at the initiation of puberty?
The four segments of a fallopian tube are the pars interstitialis, the isthus, the ampulla, and the
What causes the epithelium to thicken, differentiate, and accumulate glycogen?
About how many openings are in the nipple?
1 to 5
5 to 10
10 to 15
15 to 20
What is one of the most frequent reasons women visit their clinician?
Changes in menstruation
Prevention and wellness
What is the objective of the endometrial cycle?
To emulate the activities of the ovaries
To produce an ovum
To reach the menstruation phase
To prepare a site to nourish and maintain the ovum
Ovulation is dependent on an increased level of _
estrogen and the LH surge.
What initiates contractions of the uterine muscle leading to menstruation?
Rupture of the basal arterioles
Why does the cervical mucus become thick, viscous and opaque after ovulation?
To make an hospitable environment for the sperm
To promote stromal vascularization
To relax the myometrial fibers that supply the cervix
To reduce the risk of ascending infection at the time of implantation
CHAPTER 17 Breast Conditions
more likely causes unilateral, localized pain that is sharp or burning in nature.
has an increased risk of occurrence in women whose diets are low in fat.
occurs most frequently in women who are 18 to 30 years old.
is caused by hormonal changes associated with menstruation.
The possibility of cancer is associated with mastalgia when the pain
occurs in perimenopausal women who are receiving HT.
is accompanied by skin changes or palpable abnormality.
is felt in both breasts equally and is related to a cyclic pattern.
is reproducible with palpation of the chest wall.
Effective for 85% of women who have mild or moderate symptoms of mastalgia, the first line of
isoflavones, or naturally occurring phytoestrogens.
2% lidocaine injection and 40 mg of methyl prednisone.
Mammary duct ectasia
is one of the most common causes of milky nipple discharge.
like intraductal papilloma, is typically unilateral and uniductal.
usually occurs in women 20 to 35 years of age.
discharge may be green, brown, or black in color.
If a woman is complaining of bilateral, milky nipple discharge, the clinician is to first
perform a pregnancy test.
perform a mammogram and an ultrasound of the breasts.
assess the sella turcica with magnetic resonance imaging (MRI).
obtain a serum prolactin level and a thyroid- stimulating hormone (TSH) measurement.
The most common benign breast masses are
fibroadenomas and cysts.
lipomas and phyllodes tumors.
Which breast tissue sampling procedure is best to use when density or calcification is seen on a
mammogram in a location that cannot be effectively assessed with a core biopsy?
MRI-guided needle biopsy
Needle-localized breast biopsy
Excisional breast biopsy
Among women aged 55 years and older
macromastia is the most common cause of breast masses.
breast masses are presumed malignant until proven otherwise.
most breast masses decrease in size over time and many resolve completely.
diagnostic imaging of a breast mass and tissue sampling should be deferred.
A woman’s lifetime risk of being diagnosed with breast cancer is
d. 1 in 233.
No risk factors other than age are identifiable in of women with breast cancer.
The genetic counselor has a significant role in the care of women because BRCA1 and BRCA2
genetic mutations account for 5% to 10% of all cancer cases
The most common sites of metastatic spread of invasive breast cancer include all of the following
CHAPTER 21 Gynecologic Infections
What is the major source of normal vaginal secretions?
What is the term for the inflammation of the vagina characterized by an increased vaginal discharge
containing numerous white blood cells?
• Vaginal mucosa
How does vaginosis differ from vaginitis?
It must be treated with metronidazole.
The discharge does not contain white blood cells.
The discharge does not have an odor.
It causes itching and/or burning.
What is the most important step in preventing vaginal infections?
Good personal hygiene
Scented sanitary products
What can bacterial vaginosis lead to?
Pelvic inflammatory disease
Toxic shock syndrome
Approximately what percentage of women with bacterial vaginosis are asymptomatic?
What is the most common symptom of bacterial vaginosis?
Vaginal itching and/or burning
Cottage cheese-like discharge
Vulvovaginal candidiasis accounts for what percentage of all vaginal infections?
Which organism causes 90% of vulvovaginal candidiasis episodes in women?
What is the most common symptom of vulvovaginal candidiasis?
Thin, grayish-white discharge
What percentage of Toxic Shock Syndrome cases are related to menses?
Women who have had Toxic Shock Syndrome should be instructed not to use tampons or
a. barrier contraception methods.
b. hormonal contraception methods.
c. intravaginal antibiotic cream.
d. oral antibiotics.
What is generally the cause of Bartholin’s cyst?
Complications from gonorrhea
Cystic fluid in Bartholin’s gland becomes infected
A fungal infection in Bartholin’s gland
Obstruction of a duct in Bartholin’s gland
Chapter 25 Menstrual-Cycle Pain and Premenstrual Conditions
What term refers to the period from about 7 to 10 days before menstrual flow begins until the first or
second day of menstrual flow?
Approximately what percentage of women experience severe recurring symptoms associated with
their menstrual cycle?
Why shouldn’t symptoms such as bloating and breast tenderness be considered disordered
Because only a small minority of women have these symptoms
Because these symptoms affect the majority of women
Because these symptoms do not affect women’s moods
Because it is not possible to quantify these symptoms
Of the four symptom clusters of perimenstrual symptoms identified by Woods, Mitchell & Lentz
(1999), which was the dominant one in terms of explaining variance in premenstrual symptoms?
How is secondary dysmenorrhea defined?
Absence of menstruation due to an underlying pathology
Painful menstruation in the absence of pathology
An underlying pathology causing pain symptoms during menstrual flow
Painful menstruation that occurs in women after the age of 35
What is the term for the exacerbation of somatic or mood symptoms in the late luteal or menstrual
phase of the cycle?
• Premenstrual magnification
• Perimenstrual dysmenorrhea
• Premenstrual syndrome
• Premenstrual dysphoric disorder
Which of the following is a diagnostic label that is listed in the Diagnostic and Statistical Manual IVTR?
Premenstrual dysphoric disorder
Women who report experiencing the most severe symptoms of PMS tend to be
in their late 40s.
in their early 20s.
in their late teens.
in their late 30s.
Which of the following is one of the key criteria for a diagnosis of PMS?
The symptoms markedly interfere with occupational functioning
One of the symptoms is depressed mood, anxiety, or irritability
Exclusion of other diagnoses that may better explain the symptoms
The symptoms are confirmed by prospective daily ratings over at least two menstrual
All menstruating women report that which type of symptoms is highest during menses?
What hormone has been shown to help with relieving the mood discomfort cluster of symptoms of
Which dietary supplement has been shown to help treat PMS?
The only botanical treatment with Level I evidence to support its use in PMS is
chaste tree berry.
Research suggests a link between PMS and
seasonal affective disorder.
high blood pressure.
Chapter 26 Normal and Abnormal Uterine Bleeding
What is the best definition of abnormal uterine bleeding (AUB)?
Uterine bleeding for which no pelvic pathology is found
Uterine bleeding that is irregular during a woman’s menstrual cycle
Uterine bleeding that is irregular in amount or frequency
Uterine bleeding that is related to systemic conditions
What is a good first question to ask women who present with a concern about abnormal bleeding?
What is a normal pattern for you?
How long has this persisted?
What was your last menstrual cycle like?
How many times has this occurred?
In women of reproductive age, the most common cause of a bleeding pattern that is suddenly
• an increase in estrogen.
• a reaction to a change in eating or exercise habits.
• adrenal hyperplasia.
• a complication of pregnancy.
Progesterone breakthrough bleeding is sometimes seen in women who
have polycystic ovary syndrome.
use progesterone-only contraception.
have ceased progesterone therapy.
The least variation in menses occurs during the ages of
How can liver and renal diseases result in abnormal uterine bleeding?
They cause an imbalance in platelet aggregation.
They result in an inability to adequately clear estrogen from the body.
They cause thyroid dysfunction, which leads to bleeding abnormalities.
They result in elevated prolactin levels, which leads to bleeding abnormalities.
Signs of endometrial or cervical cancer may present abnormal uterine bleeding, often as heavy,
prolonged bleeding or
Products from which of the following herbs have been associated with alterations in estrogen levels,
resulting in AUB?
Chaste tree berry
Exercise-induced amenorrhea is probably due to the combination of low body fat and decreased
When is a pelvic examination unnecessary for a woman who is experiencing AUB?
If she is not sexually active
If she has recently begun menstruating
If her bleeding is extremely heavy
If she also has anemia
What test should be ordered for a woman who is experiencing AUB as well as headaches and
peripheral vision changes?
Thyroid-stimulating hormone test
Nucleic acid amplification test
Complete blood count
Prolactin level test
Gonadotropin hormone-releasing agonists are recommended for only short-term use to treat heavy
bleeding due to
their many side effects, such as hot flashes.
the fact that they cause amenorrhea.
the fact that they are poorly understood.
their poor interaction with hormonal contraception.
What treatment was introduced in the 1990s as a less invasive alternative to hysterectomy?
What is the definition of primary amenorrhea?
The cessation of menses for an interval of 6 months
The failure to begin menses by age 14
The cessation of menses due to outflow tract obstruction
The failure to begin menses by age 16
CHAPTER 22 Sexually Transmitted Infections
Approximately how many Americans will contract one or more sexually transmitted infections during
Why is it often more difficult to detect STIs in women than in men?
Men are two times more likely to transmit STIs to women than the reverse.
The risk of a woman contracting an STI is much higher than a man’s risk.
The anatomy of women’s genital tracts makes examination more difficult.
Women tend to have fewer sexual partners than men do.
Who should be screened regularly for STIs?
Women who have more than one sexual partner
Women over the age of 21
Women who are sexually active
Women over the age of 15
Of the more than 100 known serotypes of human papillomavirus (HPV), approximately how many can
infect the genital tract?
Routine HPV vaccination is recommended for girls of what age?
An initial or primary genital herpes infection characteristically lasts about
How do systemic antiviral drugs treat genital herpes?
They can control the symptoms.
They can reduce the frequency of recurrences after discontinuation.
They can prevent transmission to sexual partners.
They can prevent secondary infection.
Which of the following is caused by an anaerobic one-celled protozoan that commonly lives in the
The prevalence of chlamydia is how many times higher in black women than in white women?
The second most commonly reported STI after chlamydia is
pelvic inflammatory disease.
Why do adolescents have the highest risk of developing pelvic inflammatory disease (PID)?
They have the highest risk for bacterial vaginosis.
They are the least at risk for developing other STIs.
They are the most sexually active.
They have decreased immunity to infectious organisms.
What is different about syphilis as compared to other bacterial STIs?
The incidence in women is much higher than in men.
The rates are higher for white women than for black women.
It cannot be spread by kissing.
It persists past age 25, into the 30s and 40s.
What has contributed to the decreased incidence of Hepatitis B over the past 20 years?
The decrease in PID
The HBV vaccination
The increase in condom use
More precise screening methods
Patients presenting for STI treatment should be screened for HIV
at each visit.
at the end of treatment.
at the beginning of treatment.
• each year.
Chapter 32 Anatomic and Physiologic Adaptations of Normal Pregnancy
A pregnant clients mother is worried that her daughter is not big enough at 20 weeks of gestation.
The nurse palpates and measures the fundal height at 20 cm, which is even with the woman’s
umbilicus. Which should the nurse report to the client and her mother?
a. You’re right. We’ll inform the practitioner immediately.
b. Lightening has occurred, so the fundal height is lower than expected.
c. The body of the uterus is at the belly button level, just where it should be at
d. When you come for next month’s appointment, well check you again to make sure
that the baby is growing.
While the vital signs of a pregnant client in her third trimester are being assessed, the client
complains of feeling faint, dizzy, and agitated. Which nursing intervention is appropriate?
a. Have the client stand up and retake her blood pressure.
b. Have the client sit down and hold her arm in a dependent position.
c. Have the client turn to her left side and recheck her blood pressure in 5 minutes.
d. Have the client lie supine for 5 minutes and recheck her blood pressure on both arms.
A pregnant client has come to the emergency department with complaints of nasal congestion and
epistaxis. Which is the correct interpretation of these symptoms by the health care provider?
a. Nasal stuffiness and nosebleeds are caused by a decrease in progesterone.
b. These conditions are abnormal. Refer the client to an ear, nose, and throat specialist.
c. Estrogen relaxes the smooth muscles in the respiratory tract, so congestion and epistaxis
are within normal limits.
d. Estrogen causes increased blood supply to the mucous membranes and can result in
congestion and nosebleeds.
While providing education to a primiparous client regarding the normal changes of pregnancy, what is
important for the nurse to explain about Braxton Hicks contractions?
a. These contractions may indicate preterm labor.
b. These are contractions that never cause any discomfort.
c. Braxton Hicks contractions only start during the third trimester.
d. These occur throughout pregnancy, but you may not feel them until the third
Why should a woman in her first trimester of pregnancy expect to visit her health care provider every
a. Problems can be eliminated.
b. She develops trust in the health care team.
c. Her questions about labor can be answered.
d. The conditions of the expectant mother and fetus can be monitored.
A client in her first trimester complains of nausea and vomiting. She asks, Why does this happen?
What is the nurses best response?
a. It is due to an increase in gastric motility.
b. It may be due to changes in hormones.
c. It is related to an increase in glucose levels.
d. It is caused by a decrease in gastric secretions.
Which advice to the client is one of the most effective methods for preventing venous stasis?
a. Sit with the legs crossed.
b. Rest often with the feet elevated.
c. Sleep with the foot of the bed elevated.
d. Wear elastic stockings in the afternoon.
To relieve a leg cramp, what should the client be instructed to perform?
a. Dorsiflex the foot.
b. Apply a warm pack.
c. Stretch and point the toe.
d. Massage the affected muscle.
Which complaint made by a client at 35 weeks of gestation requires additional assessment?
a. Abdominal pain
b. Ankle edema in the afternoon
c. Backache with prolonged standing
d. Shortness of breath when climbing stairs
Which laboratory result would be a cause for concern if exhibited by a client at her first prenatal visit
during the second month of her pregnancy?
a. Rubella titer, 1:6
b. Platelets, 300,000/mm3
c. White blood cell count, 6000/mm3
d. Hematocrit 38%, hemoglobin 13 g/dL
A client in her third trimester of pregnancy is asking about safe travel. Which statement should the
nurse give about safe travel during pregnancy?
a. Only travel by car during pregnancy.
b. Avoid use of the seat belt during the third trimester.
c. You can travel by plane until your 38th week of gestation.
d. If you are traveling by car stop to walk every 1 to 2 hours.
The client has just learned she is pregnant and overhears the
gynecologist saying that she has a positive Chadwick’s sign. When the client asks the nurse what this
means, how should the nurse respond?
a. Chadwick’s sign signifies an increased risk of blood clots in pregnant women because
of a congestion of blood.
b. That sign means the cervix has softened as the result of tissue changes that naturally
occur with pregnancy.
c. This means that a mucous plug has formed in the cervical canal to help protect you
from uterine infection.
d. This sign occurs normally in pregnancy, when estrogen causes increased blood
flow in the area of the cervix.
Chapter 33 Diagnosis of Pregnancy and Overview of Prenatal Care
A pregnant clients biophysical profile score is 8. She asks the nurse to explain the results. What is the
nurses best response?
a. The test results are within normal limits.
b. Immediate birth by cesarean birth is being considered.
c. Further testing will be performed to determine the meaning of this score.
d. An obstetric specialist will evaluate the results of this profile and, within the next week, will inform
you of your options regarding birth.
The primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to determine
whether the fetus has which?
b. Sickle cell anemia
c. A neural tube defect
d. A normal lecithin-to-sphingomyelin ratio
Which should be considered a contraindication for transcervical chorionic villus sampling?
a. Rh-negative mother
b. Gestation less than 15 weeks
c. Maternal age younger than 35 years
d. Positive for group B Streptococcus
Which nursing intervention is necessary prior to a second-trimester transabdominal ultrasound?
a. Perform an abdominal prep.
b. Administer a soap suds enema.
c. Ensure the client is NPO for 12 hours.
d. Instruct the client to drink 1 to 2 quarts of water.
What is the term for a nonstress test in which there are two or more fetal heart rate accelerations of
15 or more bpm with fetal movement in a 20- minute period?
In preparing a pregnant client for a nonstress test (NST), which of the following should be included in
the plan of care?
a. Have the client void prior to being placed on the fetal monitor because a full bladder will interfere
b. Maintain NPO status prior to testing.
c. Position the client for comfort, adjusting the tocotransducer belt to locate fetal heart rate.
d. Have an infusion pump prepared with oxytocin per protocol for evaluation.
The results of a contraction stress test (CST) are positive. Which intervention is necessary based on
this test result?
a. Repeat the test in 1 week so that results can be trended based on this baseline result.
b. Contact the health care provider to discuss birth options for the client.
c. Send the client out for a meal and repeat the test to confirm that the results are valid.
d. Ask the client to perform a fetal kick count assessment for the next 30 minutes and then reassess
A pregnant client has received the results of her triple-screen testing and it is positive. She provides
you with a copy of the test results that she obtained from the lab. What would the nurse anticipate as
being implemented in the clients plan of care?
a. No further testing is indicated at this time because results are normal.
b. Refer to the physician for additional testing.
c. Validate the results with the lab facility.
d. Repeat the test in 2 weeks and have the client return for her regularly scheduled
A newly pregnant patient tells the nurse that she has irregular periods and is unsure of when she got
pregnant. Scheduling an ultrasound is a standing prescription for the patients’ health care provider.
When is the best time for the nurse to schedule the patient’s ultrasound?
b. In 2 weeks
c. In 4 weeks
d. In 6 weeks
Chapter 35 Overview of Postpartum Care
A multiparous client is admitted to the postpartum unit after a rapid
labor and birth of a 4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged.
The nurse has the client void and massages her fundus, but the fundus remains difficult to find and
the rubra lochia remains heavy. Which action should the nurse take next?
a. keep my legs elevated with pillows.
b. sit in my rocking chair most of the time
c. stay in bed for the first 3 days after my baby is born
d. put my support stockings on every morning before rising.
A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests:
a. uterine atony.
b. perineal hematoma.
c. infection of the uterus.
d. lacerations of the genital tract.
A postpartum client would be at increased risk for postpartum
hemorrhage if she delivered a(n):
a. 5-lb, 2-oz infant with outlet forceps.
b. 6.5-lb infant after a 2-hour labor.
c. 7- lb infant after an 8-hour labor.
d. 8- lb infant after a 12-hour labor.
If nonsurgical treatment for subinvolution is ineffective, which surgical procedure is appropriate to
correct the cause of this condition?
d. Dilation and curettage (D&C)
Which nursing measure would be appropriate to prevent thrombophlebitis in the recovery period
following a cesarean birth?
a. Limit the client’s oral intake of fluids for the first 24 hours.
b. Assist the client in performing leg exercises every 2 hours.
c. Ambulate the client as soon as her vital signs are stable.
d. Roll a bath blanket and place it firmly behind the client’s knees.
A white blood cell (WBC) count of 35,000 cells/mm3 on the morning of the first postpartum day
a. possible infection.
b. normal WBC limit.
c. serious infection.
d. suspicion of a sexually transmitted disease.
The client who is being treated for endometritis is placed in the Fowler position because it:
a. promotes comfort and rest.
b. facilitates drainage of lochia.
c. prevents spread of infection to the urinary tract.
d. decreases tension on the reproductive organs.
Following a difficult vaginal birth of a singleton pregnancy, the client starts bleeding heavily. Clots are
expressed and a Foley catheter is inserted to empty the bladder because the uterine fundus is soft
and displaced laterally from midline. Vital signs are 99.8 F, pulse 90 beats/min, respirations 20
breaths/min, and BP 130/90 mm Hg. Which pharmacologic intervention is indicated?
a. Oxytocin (Pitocin) to be administered in a piggyback solution
b. Administration of methylergonovine (Methergine)
c. Administration of prostaglandin analogue
d. Increase in parenteral fluids
Following a vaginal birth, a client has lost a significant amount of blood and is starting to experience
signs of hypovolemic shock. Which clinical signs would be consistent with this clinical diagnosis?
a. Decrease in blood pressure, with an increase in pulse pressure
b. Compensatory response of tachycardia and decreased pulse pressure
c. Decrease in heart rate and an increase in respiratory effort
d. Flushed skin
The nurse recognizes that infection may be present in her postpartum
client when the client exhibits a temperature of:
a. 100.0 F during the first 36 hours postpartum.
b. 100.8 F twice in the first 24 hours postpartum.
c. 99.6 F on the first postpartum day and 100.4 on the second.
d. 100.4 F on the second postpartum day and 100.8 F on the fourth.
To determine an adverse response to carboprost tromethamine (Hemabate), the nurse should
b. lochial flow.
c. fundal height.
d. breath sounds.
What data in the client’s history should the nurse recognize as being pertinent to a possible diagnosis
of postpartum depression?
a. Teenage depression episode
b. Unexpected operative birth
c. Ambivalence during the first trimester
d. Second pregnancy in a 3-year period
The nurse notes that the fundus of a postpartum patient is boggy, shifted to the left of the midline, and
2 cm above the umbilicus. What is the nurse’s priority action?
a. Massage the fundus of the uterus.
b. Assist the patient out of bed to void. I
c. Increase the infusion of oxytocin (Pitocin).
d. Ask another nurse to bring in a straight catheter tray.
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