Chapter 4: Exam and Assessment of the Neonatal and Pediatric Patient Test Bank

Multiple Choice

1. What measures can the therapist take to prevent heat loss and cold stress before performing resuscitation on a preterm neonate?

I. Dry the infant’s skin.

II. Wrap the infant in pre-warmed blankets.

III. Remove wet linens from around the infant.

IV. Measure the neonate’s body temperature.a. IV only b. I and II only c. I, II, and III only d. I, II, and IV only

ANS: C

Preventing heat loss is critical when caring for a newborn because cold stress increases oxygen consumption and impedes effective resuscitation. If possible, deliver the infant in a warm, draft-free area. Heat loss can be greatly reduced by rapidly drying the infant's skin, immediately removing wet linens, and wrapping the infant in pre-warmed blankets.

REF: p. 41

2. What should the therapist do to avert injury and atelectasis, and to avoid interfering with the infant's ability to establish adequate ventilation, while stabilizing a preterm neonate before resuscitation?

I. Use a bulb syringe.

II. Avoid excessive suctioning of clear fluid from the nasopharynx.

III. Use a suction catheter clearing the mouth first and then the nose.IV. Suction using direct laryngoscopy. a. IV only b. I and II only c. I, II, and III only d. I, II, and IV only

ANS: C

To avert injury and atelectasis, and to avoid interfering with the infant's ability to establish adequate ventilation, avoid excessive suctioning of clear fluid from the nasopharynx.

REF: p. 41 b. Perform pharyngeal and tracheal suctioning immediately. c. Perform tracheal suctioning only at this time.

3. As the head of a neonate contaminated with meconium emerges at birth, the heart rate monitor indicates 120 beats/minute, and the physician notices that the infant has good muscle tone and a strong respiratory effort. What should the physician do at this time to provide airway care? a. Intubate the infant immediately.

ANS:

Only routine monitoring of respiratory vital signs is needed at this time.

Attempts to suction meconium from the pharynx or trachea before birth, during birth, or postpartum increase the likelihood of severe aspiration pneumonia. Some obstetricians perform oral and nasal suctioning on meconium-stained infants after delivery of the head but before delivery of the shoulders. However, a large, multicenter, randomized trial showed no benefit from this practice. Therefore, current recommendations for infants with meconium are that (1) no intrapartum suctioning should occur; (2) infants who are vigorous at birth (strong respiratory effort, a heart rate of greater than 100 beats/min, good muscle tone) should not receive tracheal suctioning; and (3) infants who are not vigorous (no or poor respiratory effort, a heart rate of less than 100 beats/min, poor muscle tone) may receive direct laryngotracheal suctioning.

REF: p. 42 a. Hold the newborn upside down. b. Rub over the sternal area. c. Suction the nasopharynx. d. Gently rub the back.

4. A newborn does not appear to respond to the extrauterine environment. Cry is weak and the respiratory effort is not strong. Which of the following methods should the therapist use to stimulate the newborn?

ANS: D

If the newborn does not respond to the extrauterine environment with a strong cry, good respiratory effort, and the movement of all extremities, the infant requires stimulation. Flicking the bottoms of the feet, gently rubbing the back, and drying with a towel are all acceptable methods of stimulation. Slapping, shaking, spanking, and holding the newborn upside down are contraindicated and potentially dangerous to the infant.

REF: p. 42

5. The therapist has completed a 1-minute Apgar score. The following evaluations were obtained:

(1) the infant is pale;

(2) the heart rate is 90 beats/minute;

(3) the respiratory effort is irregular;

(4) some muscle tone is noted; and a. 1 b. 2 c. 3 d. 5

(5) no response to nasal suctioning is found.

On the basis of these findings, what Apgar score should be assigned to this neonate?

ANS: C

The Apgar scoring system is depicted on Table 4-1. The infant evaluated in this question earned 1 point each for the heart rate, respiratory effort, and muscle tone. Scores for color and reflex irritability were both 0. The total Apgar score is therefore 3. Apgar scores are generally used to ascertain the need for resuscitation and are obtained at 1 minute and 5 minutes after birth. A score below 7 indicates the need for resuscitative efforts.

REF: p. 42 a. Heart rate b. Respiratory rate c. Skin color d. Muscle tone

6. Which of the following parameters of the Apgar score provides the most important prognostic value?

ANS: A

The most important of the signs is heart rate, which indicates life or death. Failure of the heart rate to respond to resuscitation is an ominous prognostic sign. Heart rate appears to be least affected by developmental maturity but may still be inadequate because of developmental difficulties in establishing cardiorespiratory function at birth.

REF: p. 43

7. Which of the following factors are taken into consideration when assessing the gestational age of a neonate?

I. Previous maternal pregnancies

II. Prenatal ultrasound evaluations

III. Postnatal findings based on physical and neurologic examinationsIV. Gestational duration based on the last menstrual cycle a. I and III only b. I, II, and III only c. I, II, and IV only d. II, III, and IV only

ANS: D

Ideally, gestational age assessment is performed before the neonate is 12 hours old to allow the greatest reliability for infants less than 26 weeks of gestational age. Evaluating gestational age requires consideration of several factors. The three main factors are as follows:

• Gestational duration based on the last menstrual cycle

• Prenatal ultrasound evaluation

• Postnatal findings based on physical and neurologic examinations

REF: p. 43

8. The gestational age of a newborn has been evaluated to be 34 weeks. The newborn’s birth weight is greater than the 90th percentile. How should the therapist classify this infant? a. Small for gestational age b. Average for gestational age c. Large for gestational age

Very large for gestational age

Once gestational age is determined, weight, length, and head circumference are plotted on a standard newborn grid. Any infant whose birth weight is less than the 10th percentile for gestational age is classified as small for gestational age. Similarly, an infant whose birth weight is more than the 90th percentile is large for gestational age. When using intrauterine growth curves, considering specific charts that are race and gender specific may be necessary. Along with prematurity, abnormal gestational age and size for gestational age are associated with many neonatal disease processes.

REF: p. 43 b. The infant was swaddled in numerous blankets. c. The delivery room temperature was low. d. The newborn has protracted diarrhea.

9. An infant arrives in the newborn nursery with an axillary body temperature of 95.6° F. Which of the following events may be responsible for this infant’s temperature? a. The neonate was in an infant warmer in the delivery room.

ANS: C

Normal values for temperature are 97.6° F ± 1° F axillary and 99.6° F ± 1° F rectally; however, temperature on arrival in the nursery may be lower if the delivery room was cold or may be higher if the radiant warmer was operating at a higher temperature because of incorrect probe position or warmer malfunction.

REF: p. 43 a. An injury to the infant’s brachial plexus may have occurred during birth. b. The infant may have been born breach. c. The baby was born via cesarean section. d. The infant experienced nuchal cords during birth.

10. A physical examination is being performed on a newborn, and the therapist notices that the infant’s arms do not move symmetrically. Which of the following situations could account for this problem?

ANS: A

Observing the infant’s overall appearance is an important aspect of the physical examination. Ideally, examine the infant lying quietly and unclothed in a neutral thermal environment. Body position and symmetry, both at rest and during muscular activity, provide valuable information regarding possible birth trauma. For example, an infant who does not move the arms symmetrically could have a broken clavicle or an injury to the brachial plexus.

ANS: a. b. c.

11. The therapist notices that an infant presents with irregular areas of dusky skin alternating with areas of pale skin. On the basis of this observation, which of the following conditions should the therapist anticipate this patient having?

Polycythemia

Hypotension

Situs inversus with dextrocardia

ANS:

Renal insufficiency B

Observing skin and color often provides diagnostic clues. Mottling refers to irregular areas of dusky skin alternating with areas of pale skin. An extremely pale or mottled infant suggests hypotension or anemia.

REF: p. 44

12. Which of the following neonatal skin presentations at birth is associated with a high hematocrit value or polycythemia and neonatal hyperviscosity syndrome? a. Mottling b. Lanugo c. Reddish blue appearance d. Vernix

ANS: C

A ruddy, reddish blue appearance is frequently associated with a high hematocrit value, or polycythemia (hematocrit > 65%), and neonatal hyperviscosity syndrome. The yellow color associated with mild to moderate jaundice is common among newborns after the first day of life. Jaundice on the first day of life, however, is always an indication for an immediate evaluation. Mottling refers to irregular areas of dusky skin alternating with areas of pale skin. An extremely pale or mottled infant suggests hypotension or anemia. The presence of lanugo, the fine hair that covers premature infants mostly over the shoulders, back, forehead, and cheeks, indicates an even younger gestational age than one presenting with vernix. Often a grayish white cheese-like substance, called vernix caseosa, is present in the skin folds of a term infant. However, vernix is even more abundant on a preterm infant and suggests an earlier gestational age.

REF: p. 44 a. Because neonates generate a greater subatmospheric intrapleural pressure b. Because newborns have relatively thin and weak musculature and a less rigid thorax c. Because neonates have a much higher respiratory rate d. Because airway resistance through the smaller caliber airways is higher

13. Why are chest retractions more prominent among neonates than among older children and adults?

ANS: B

Chest wall retractions are more prominent and easily observed among neonates than in an older children or adults. The newborn musculature is relatively thin and weak, and the thoracic cage is less rigid. The flexible chest wall and thoracic cage of the newborn exhibit noticeable retractions as lung compliance worsens.

REF: p. 46

14. Why is it difficult to localize auscultation findings of the thorax of a newborn?

Because the neonate’s chest is small and sounds are difficult to differentiate a. b. c.

ANS: Because the newborn infant is frequently crying Because the neonate’s tidal volume is so small Because the newborn’s pulmonary compliance is low

Auscultation of the newborn can sometimes be difficult. The newborn’s chest wall is small, and sounds easily transmit from one lung region to another. Abdominal sounds may even transmit to the lungs, although bowel sounds heard from the chest in place of absent breath sounds may indicate a diaphragmatic hernia. Localizing auscultation findings in a preterm infant is frequently difficult or impossible with single-head stethoscopes. Auscultation with a double-head stethoscope has proved useful in some situations.

REF: p. 48

15. While performing a physical examination on a newborn infant, the therapist notices that the point of maximal cardiac impulse is to the left of the sternal border. Which of the following conditions can cause this situation? a. Atelectasis of the right lung b. Bilateral pulmonary consolidation c. Right-sided pneumothorax d. Left main stem bronchus intubation

ANS: C

The point of maximal cardiac impulse (PMI) is the position on the chest wall at which the cardiac impulse can be maximally seen. The PMI is usually seen in newborns because of the relatively thin and flexible chest wall. Typically, the PMI is relatively close to the sternal border because of the predominance of the right ventricle in the fetal period. A mediastinal shift due to a pneumothorax will move the PMI away from the affected side of the chest.

REF: p. 48 a. Place a light source between the surface of the bed and the patient’s back, and orient the patient in a supine position. b. Direct a light source toward the ipsilateral surface of the patient’s thorax. c. Position a beam of light against a patient’s chest wall in a well-lit room. d. Insert a fiberoptic light source down a patient’s endotracheal tube and beyond the tube’s distal tip.

16. Which of the following statements refers to the diagnostic procedure called transillumination?

ANS: B

With suspected pneumothorax, perform transillumination of the chest wall, using a highenergy flashlight or fiberoptic device in a darkened room. Direct the light source on the chest wall of the suspected (ipsilateral) side. A large pneumothorax will reveal an excessively pink and illuminated, usually irregular, area of light, or “glowing” area, through the chest wall when compared with the contralateral side.

REF: p. 48

ANS:

17. A neonate is found to have a bounding pulse. Which of the following conditions may contribute to this finding?

Low cardiac output

Coarctation of the aorta

Left-to-right shunt

Patent foramen ovale

Weak pulses suggest low cardiac output states such as shock and hypoplastic left-sided heart syndrome. Bounding pulses are seen in infants with patent ductus arteriosus and left-to-right shunt. The bounding characteristic of the pulse results from rapid runoff of the blood into the low-resistance pulmonary circulation. This lowers the systolic blood pressure and produces a wider pulse pressure. Brachial and femoral pulses should be equal in intensity and felt simultaneously. A delayed or weak femoral pulse can indicate coarctation of the aorta.

REF: p. 48 a. Volume depletion with compensatory peripheral vasoconstriction b. Hypoplastic left-sided heart syndrome c. Hypervolemia with compensatory peripheral vasodilation d. Hypoplastic right-sided heart syndrome

18. What condition would be responsible for the therapist observing a pulse oximeter indicating decreased perfusion while central blood pressure remains normal?

ANS: A

A pulse oximeter will display a low pulse rate and perfusion signal as peripheral pulses and perfusion decrease. The cause of this poor perfusion status must be determined. However, if the pulse oximeter suggests decreased perfusion while central blood pressure remains normal, the cause may be volume depletion with compensatory peripheral vasoconstriction.

REF: p. 49

19. For the purpose of assessing right-to-left shunting, as in the case of persistent pulmonary hypertension, which of the following sites would render postductal blood?

I. Right arm

II. Left arm

III. Right legIV. Left leg a. I only b. II only c. I, III, and IV only d. II, III, and IV only

ANS: D

In addition, placing pulse oximeters on preductal and postductal sites allows for assessing right-to-left ductal level shunting, as seen with persistent pulmonary hypertension of the newborn. In this case the right arm, or preductal site, will have a higher saturation, while the

ANS: postductal site, or left arm and lower extremities, will have a lower saturation due to venous admixture occurring postductally.

REF: p. 49 a. Enterocolitis b. Ascites c. Congenital diaphragmatic hernia d. Omphalocele

20. The therapist is evaluating a newborn with an abdominal defect consisting of protrusion of the membranous sac that encloses abdominal contents through an opening in the abdominal wall into the umbilical cord. Which of the following conditions is consistent with this description?

ANS: D

Successful abdominal examination requires a calm and quiet infant. Observe the contour of the abdomen and determine whether it is scaphoid (sunken anterior wall), flat, or distended. Distention is a significant finding characterized by tightly drawn skin through which engorged subcutaneous vessels can easily be seen. More noticeable abnormalities of the abdomen include prune belly syndrome, which is a congenital lack of abdominal musculature; omphalocele, a protrusion of the membranous sac that encloses abdominal contents through an opening in the abdominal wall into the umbilical cord; and gastroschisis, a defect in the abdominal wall lateral to the midline with protrusion of the intestines.

REF: p. 49

21. After the umbilical cord has been cut in the delivery room during the delivery of an infant who is large for gestational age, the therapist notices that the umbilical cord is large and fat. Which of the following maternal conditions is likely present? a. Congestive heart failure b. Renal insufficiency c. Diabetes mellitus d. Hypertension

ANS: C

The umbilical cord of an infant who is large for gestational age and born to a diabetic mother is frequently large and fat.

REF: p. 49

22. The therapist notices that a preterm newborn has a grunting cry. Which of the following conditions is most consistent with this description? a. Hypothyroidism b. Neurologic injury c. Respiratory distress syndrome d. Laryngeal edema

ANS: A

A loud and vigorous cry is usually a sign of a healthy infant. A moaning, weak, or faint cry suggests illness. Frequently, an infant with respiratory distress syndrome strains with a grunting cry. An infant with a piercing, high-pitched cry often has a neurologic injury, drug withdrawal, or increased intracranial pressure. Hoarse crying can be associated with laryngeal edema, as in recently extubated infants. However, a hoarse cry may also be heard with congenital hypothyroidism, cretinism, or hypocalcemia with laryngospasm.

REF: p. 51

23. Which of the following pieces of information represent components of patient history for a new pediatric patient?

I. Chief complaint

II. History of present illness

III. Past medical historyIV. Occupational history a. I and II only b. III and IV only c. I, II, and III only d. I, II, III, and IV

ANS: C

The history for a new patient can be divided into the chief complaint, or primary concern, history of the present illness (HPI), past medical history (PMH), review of symptoms (ROS), family history (FH), and social and environmental histories. The history for a follow-up or for an established patient can be modified to include an interim health history and a review of key components of the PMH, ROS, and social and environmental histories. An occupational history is inappropriate for a pediatric patient.

REF: p. 52

24. Which of the following components compose the history of present illness section of a patient’s medical history? a. Immunizations b. Symptoms exhibited by parents c. Aggravating or alleviating factors d. Symptoms resulting in hospitalizations

ANS: C

Components of the history of present illness include the following:

Duration

Intensity or severity

Improvement or deterioration

Triggers

Aggravating or alleviating factors

Medications (past and current)

Chronicity

Seasonality

REF: p. 53

25. Which of the following components compose the past medical history section of the patient’s medical history?

I. Birth weight

II. Previous mechanical ventilation

III. Recurrence of symptoms based on seasonIV. Emergency department visits a. II only b. II and IV only c. I, II, and IV only d. I, II, III, and IV

ANS: C

Components of past medical history include the following:

History of prematurity

Birth weight

Need for and duration of oxygen therapy, assisted ventilation, or both in the neonatal period Previous emergency room visits, hospitalizations, or both for respiratory disturbances (including intensive care unit admissions and any need for assisted ventilation)

Previous surgeries

Immunization history

REF: p. 53 a. Chief complaint b. Past medical history c. Review of systems d. History of present illness

26. Which of the following components of a patient’s medical history is intended to determine the presence of symptoms not identified in the history of present illness and may be related or contribute to the child’s underlying condition?

ANS: C

The review of symptoms (ROS) attempts to identify symptoms that were not identified in the HPI and that may be related or contribute to the child's underlying respiratory condition. A systematic review of symptoms related to atopic diseases, gastroesophageal reflux, immunodeficiency, as well as thoracic cage, neurologic, and neuromuscular disorders, may suggest previously unidentified contributions to the presenting pulmonary complaint.

REF: p. 53 a. respiratory distress b. hypoxemia c. hypercapnia d. acidemia

27. A child who demonstrates head bobbing, nasal flaring, and grunting is exhibiting signs of ____________________.

ANS: A

Head bobbing, nasal flaring, and grunting are common signs of respiratory distress in infants and young children and are compensatory mechanisms to decrease the work of breathing. Head bobbing occurs when the sternocleidomastoids (neck muscles that serve to flex and rotate the head), in an attempt to overcome decreased lung compliance, increased airway resistance, or both, contract during inspiration, pulling the head down and the clavicles and rib cage up (see Figure 4-9 in the textbook). This results in the head bobbing forward in synchrony with each inspiration. Nasal flaring and grunting can be present in the pediatric patient as well. The presence of one or more of these signs typically indicates significant airway obstruction and/or lung disease.

REF: p. 55 a. Pectus excavatum b. Interstitial pulmonary disease c. Pneumonia d. Cystic fibrosis

28. Which of the following pulmonary diseases are not chest wall deformities but are characterized by an increased anteroposterior diameter?

ANS: D

Inspection of the chest wall may reveal increased anteroposterior diameter, abnormal shape, muscular weakness, or obesity. Chest wall inspection should include anterior, posterior, and lateral examination. Chronic obstructive lung diseases such as severe asthma, advanced CF, and severe bronchopulmonary dysplasia may be associated with increased anteroposterior diameter of the chest due to increased air trapping. The chest wall may be abnormally shaped such as in pectus carinatum ("pigeon breast"), pectus excavatum ("sunken chest"), kyphosis ("hunchback" appearance), and scoliosis (abnormal "sideways" spinal curvature).

REF: p. 55 a. Pulmonary consolidation b. Pneumothorax c. Mucous plug d. Aspirated foreign object

29. During a physical examination of a child’s chest, the therapist perceives increased tactile fremitus over the patient’s right lower lobe. Which of the following conditions may cause this physical sign?

ANS: A

Palpation of the chest wall and neck may be helpful in the physical examination of a child with respiratory disease. In infants and young children, palpation of the chest during quiet breathing may elicit rhonchal or bronchial fremitus, which are vibrations of the chest resulting from movement of air through airways partially obstructed by mucus. In an older child, palpation of the chest during normal speech may elicit tactile fremitus, vibrations of the chest produced by the spoken voice. Tactile fremitus may be increased over areas of the chest wall corresponding to underlying pulmonary consolidation.

REF: p. 56

30. While percussing the thorax of a child during a physical examination, the therapist hears a dull percussion note over the child’s right lung. Which of the following conditions may cause this physical finding?

I. Atelectasis

II. Pneumothorax

III. Pleural effusionIV. Consolidation a. I and II only b. I, III, and IV only c. II, III, and IV only d. I, II, III, and IV

ANS: B

Chest percussion is performed by tapping the finger of one hand with a finger of the other hand over corresponding areas of the patient’s chest, usually while the patient is sitting upright. A relatively high-pitched percussion note, or hyperresonance, suggests focal or generalized air trapping or pneumothorax. A relatively dull percussion note indicates atelectasis, consolidation, or pleural effusion.

REF: p. 56

31. After placing a stethoscope over a small child’s trachea, the therapist hears expiratory stridor. Which of the following conditions is consistent with this finding? a. Laryngotracheobronchitis b. Adenotonsillar hypertrophy c. Asthma episode d. Tracheomalacia

ANS: D

Stridor is a high-pitched, monophonic, audible noise that may occur during inspiration or expiration, or may be biphasic. Inspiratory stridor suggests extrathoracic airway obstruction, such as occurs in laryngomalacia, subglottic stenosis, and croup. Expiratory stridor suggests intrathoracic central airway obstruction, such as occurs in mass or vascular compression of the trachea, tracheomalacia, and bronchomalacia. Biphasic stridor typically indicates a more severe degree of laryngeal or central airway obstruction and may be associated with signs of respiratory distress.

REF: p. 57 a. Pulmonary edema b. Bronchitis c. Croup d. Asthma

32. While auscultating a young child’s thorax, the therapist hears bilateral fine crackles. Which of the following conditions can produce these adventitious sounds?

ANS: A

Crackles can be further described as inspiratory, expiratory, fine, and coarse. Fine crackles are less loud crackles with high-frequency components and short duration; they are usually associated with distal small airway and/or alveolar diseases such as pneumonia or pulmonary edema. Coarse crackles are louder crackles with lower frequency and longer duration; they are usually associated with medium and/or large airway disease such as bronchitis.

REF: p. 57 a. Less than or equal to 3500/mm3 b. 5000 to 10,000/mm3 c. 10,000 to 20,000/mm3 d. Greater than or equal to 25,000/mm3

33. Which of the following white blood cell counts constitutes the condition leukopenia?

ANS: A

The white blood cell (WBC) count of the newborn is usually significantly higher than pediatric or adult values. Leukopenia, WBCs less than 3500/mm3, and leukocytosis, WBCs greater than 25,000/mm3, suggest infection. WBCs greater than 25,000/mm3, however, are not unusual in the immediate newborn period.

REF: p. 58