PNCB CPNP-PC Exam Questions

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81.

Which of the following is NOT a likely cause of childhood nocturnal enuresis? 

  • Infrequent voiding during the day

  • Familial disposition

  • Behavioral comorbidities

  • Constipation

Correct answer: Infrequent voiding during the day

Nocturnal enuresis is a common complaint in children, defined as incontinence during sleep. Primary enuresis occurs in children who have never attained dryness at night, whereas secondary enuresis occurs in children who have previously been potty trained. The diagnosis of secondary enuresis requires a minimum age of 5 years old, and one episode a month for a duration of 3 months. The cause of enuresis varies among children and can be difficult to determine. 

A number of factors have been found to be associated with enuresis, including:

  • Constipation
  • Familial disposition
  • Neurologic developmental delay
  • Behavioral comorbidities (strong association between enuresis and ADHD)
  • Functional small bladder capacity
  • Sleep disorders
  • Stress and family disruptions
  • Polyuria
  • Inappropriate toilet training (especially common when parents are overly demanding or punitive of the child)

Infrequent voiding is a clinical finding (symptom) associated with dysfunctional voiding or a problem of bladder emptying.

82.

The rule of Two/Too is a mnemonic for gathering and interpreting:

  • Genetic health data

  • Environmental health issues

  • Developmental milestones

  • Obstetric history

Correct answer: Genetic health data

Genetic red flags indicate the potential for genetic risk. One way to remember the important components to look for or ask about when taking a health history is the rule of Two/Too, a mnemonic for gathering and interpreting genetic health data. 

The rule of Two/Too is as follows: Too many of something: a person is too tall, too short, too early, too young, too different, etc., or Two birth defects, two cancers, two in a family, or two generations involved.

83.

In a child with microcephaly caused by primary craniosynostosis, it is important to know in your INITIAL exam that:

  • Sagittal suture involvement is most common, but posterior plagiocephaly is usually benign

  • There is a male to female ratio of 1:2 in Caucasian children

  • Synostosis which requires surgery should be done as soon as possible

  • Computed tomography (CT) will give you the best idea of whether or not a suture is closed, and is considered the standard in evaluation of bradycephaly

Correct answer: Sagittal suture involvement is most common, but posterior plagiocephaly is usually benign

Primary or "true" craniosynostosis involves premature closure or absence of one or more cranial sutures. Primary craniosynostosis occurs in 1 per 2,000 to 2,500 births, is ethnically neutral, and can vary in type and prominence between genders. Early fusion of the sagittal suture is the most common craniosynostosis, accounting for about half of all cases. 

In posterior plagiocephaly, which is pressure-related, occipital flattening is usually self-limited, benign, and due to positional pressures on the growing cranium (an infant spending more time on his back than on his tummy). Predominant causes of posterior plagiocephaly are craniosynostosis of the lambdoidal sutures, or positional suture molding (vast majority). 

Synostosis treatment is often surgical, though it is not generally done until 6-12 months of age as some other, less invasive measures are tried first. Primary craniosynostosis occurs in one per 2000 to 2500 births, is ethnically neutral, and can vary in type and prominence between genders.

While CT is considered the standard for a skull shape deformity, this is an aspect of management and not part of the initial exam (never neglect to perform a thorough initial exam simply because you suspect you will be ordering a CT). Deformational plagiocephaly does not require imaging studies in most situations when the history and physical examination are diagnostic.

84.

You receive a call from a physician requesting recent blood test results on a patient that is under your care. You should:

  • Verify that the caller has a need to know the information

  • Not give the caller the requested results

  • Give the caller the results, since it is a physician

  • Ask the physician to come to the clinic to access the requested results

Correct answer: Verify that the caller has a need to know the information

You must determine if the caller on the phone is the physician of record or has a need to know the information. Until you have determined this, the results should not be discussed.

Unless you cannot determine the identity of the caller, it is not necessary to ask the physician to come to the clinic to access the requested information.

85.

You are seeing a new patient, a 4-year-old who has recently moved to the United States from India. He is up-to-date on all of his immunizations, and you give him the measles, mumps, rubella, and varicella vaccine (MMRV) today in preparation for school. His parents call your clinic the following week, as the preschool is requesting he receive a TB skin test (PPD) prior to starting school, due to his recent move from India.

When should this be done?

  • In 4 weeks

  • Now

  • In 2 weeks

  • In 8 weeks

Correct answer: In 4 weeks

Measles vaccination may temporarily suppress tuberculin reactivity. The MMR vaccine may be given after (or even on the same day as) the PPD test. However, since MMR was already administered in this scenario, PPD should be postponed for the next 28 days (4 to 6 weeks). The effects of other live vaccines on PPD is unknown.

86.

You are seeing a 12-year-old female who is concerned that she has not yet started developing breasts nor has she started menses. She is worried something might be wrong with her. Her mother reports all of the females in the family started menses by the age of 12. The patient is otherwise healthy, eats a well-balanced diet, and is plotting at the 25th percentile for height and weight. She is at Tanner stage 2 for breast and genitalia development.

What is the BEST next step in management?

  • Reassure her that she has started puberty and closely follow-up

  • Referral to endocrinology for delayed onset of puberty

  • Referral to endocrinology for estrogen therapy

  • Perform a lab workup to assess patient's LH, FSH, estrogen, and progesterone levels

Correct answer: Reassure her that she has started puberty and closely follow-up 

The appearance of pubic hair in girls commences at about 11.5 years old, and the first menstrual period occurs, on average, at 12.5 years old, but age of onset ranges from 9 to 15 years. 

This patient and her mother need reassurance that she is developing normally and has started puberty within the proper time frame, as evidenced by Tanner stage 2 breast and pubic hair development. As long as her growth and physical exam are normal, there are no concerns, and close follow-up is all that is indicated. Referral to endocrinology and/or lab workups are not warranted at this time.

87.

Which of the following is TRUE regarding newborns with developmental dysplasia of the hip (DDH)?

  • Most cases identified by physical examination resolve by 8 weeks of life

  • Surgical repair is required approximately 50% of the time

  • These patients frequently develop a leg-length discrepancy

  • Routine ultrasonography is recommended in screening for DDH

Correct answer: Most cases identified by physical examination resolve by 8 weeks of life

DDH represents a spectrum of anatomic abnormalities in which the femoral head and the acetabulum are in improper alignment and/or grow abnormally. These include dysplastic, subluxated, dislocatable, or dislocated hips. Some 60% to 80% of abnormal hips of newborns identified by physical examination resolve spontaneously by 2 to 8 weeks of life. 

Screening tests for DDH are serial physical examinations of the hip and lower extremities and include the Barlow and Ortolani tests in neonates and the Klisic and Galeazzi tests in older infants. Routine ultrasonography is not recommended; however, an ultrasound should be obtained if there is suspicion of dysplasia based on positive clinical findings.

Patients rarely develop leg-length discrepancies, as generally these cases are diagnosed early in life and treatment is implemented quickly. Surgical repair (either closed manipulation or open reduction) is usually only required in an older infant (6- to 18-months-old) with a dislocated hip or in the case that the Pavlik harness is unsuccessful.

88.

Cardiac syncope in a child that manifests with cyanosis, pallor, and shortness of breath MOST likely originates from:

  • Pulmonary hypertension

  • Mitral stenosis

  • Aortic stenosis

  • Arrhythmias

Correct answer: Pulmonary hypertension 

Syncope is the transient loss of consciousness due to a decrease in cerebral blood flow. Recovery is relatively prompt, and most episodes in children are benign. Approximately 95% of syncope is vasovagal. 

However, syncope associated with cardiac causes, such as primary pulmonary hypertension, is often clinically silent until severe symptoms are present. Pulmonary hypertension is the only etiology that includes cyanosis as a major clinical manifestation, and often syncope associated with pulmonary hypertension accompanies exercise.

89.

A homeless African-American woman brings her 3-year-old daughter in to the Emergency Department. She reports that her daughter has had a fever, cough, and congestion for the past 7 days, which she has been treating with acetaminophen and ibuprofen. After a thorough history and physical examination, including a chest x-ray, you diagnose the child with pneumonia.

The MOST likely factor that caused the mother to delay bringing her daughter in for care sooner is:

  • Poverty

  • Ethnicity

  • Lack of education

  • Neglect

Correct answer: Poverty

Child health is fundamental to overall child development, and children with health insurance are more likely to have a regular source of care and access to preventive healthcare services. 

Lack of health care insurance is the single strongest predictor of quality of care for children in the United States. Poverty is a primary reason why the homeless delay receiving care for themselves or family members. If the homeless person does not qualify for healthcare assistance, this can be a huge barrier to accessing care.

The other answer choices can be reasons for delaying care, but the most likely reason is poverty.

90.

Predictive genetic testing involves:

  • Performing a genetic test on select individuals who are at higher risk of developing a genetic disorder

  • Tracking a particular genetic trait through a family to determine the likelihood of developing a genetic disorder

  • Performing a genetic test to determine differences in drug metabolism to better customize pharmacologic therapy for specific diseases

  • Determining the degree to which a genetic test can accurately predict the presence or absence of a genetic disorder

Correct answer: Performing a genetic test on select individuals who are at higher risk of developing a genetic disorder 

Predictive genetic testing, such as certain prenatal screenings, involves testing healthy people who are at risk of developing a genetic disorder based on factors such as family history, age, and ancestral or ethnic background. Predictive genetic testing should be performed if the results of the test can benefit the medical management of the patient(s).

91.

You refer a 17-year-old female for evaluation by a psychiatrist and a nutritionist for the following reasons: she believes that she is fat, despite weighing approximately 80% of her ideal body weight for her height; she refuses to gain weight, despite urging from her parents; she has also been amenorrheic for nearly 6 months; she admits to using laxatives consistently.

What is the mortality rate of patients with this disorder 5 years after a completed treatment program?

  • 15% to 20%

  • Less than 1%

  • 5% to 10%

  • 30% to 40%

Correct answer: 15% to 20%

The approximate mortality rate 5 years following treatment for anorexia is 15% to 20%. The majority of these deaths are caused by electrolyte imbalances, malnutrition, and suicide.

Due to the complexity of eating disorders, specialty care is needed, and interprofessional collaboration is essential in managing these patients. PCPs play a critical role in detection and early intervention, case coordination, and monitoring for complications.

92.

Which of the following is a major clinical manifestation (Jones criteria) of acute rheumatic fever (ARF)?

  • Carditis

  • Fever

  • Polyarthralgia

  • Elevated acute-phase reactants (ESR or leukocyte count)

Correct answer: Carditis

ARF is a nonsuppurative complication following a sequela of streptococcal infection, typically 2 to 3 weeks after group A streptococcal (GAS) pharyngitis. It results in an autoimmune inflammatory process involving the joints (polyarthritis), heart (rheumatic heart disease), CNS (Sydenham chorea) and subcutaneous tissue (subcutaneous nodules and erythema marginatum). It most commonly presents between the ages of five and 15 years old. Long-term effects on tissues are generally mild except for the damage done to cardiac valves, leaving fibrosis and scarring that results in rheumatic heart disease.

The diagnosis of an initial attack of ARF is based on the following revised Jones criteria:

  • Evidence of documented GAS pharyngeal infection (culture, rapid strep antigen test, or ASO titer)
  • Findings of two major manifestations or one major and one minor manifestation of ARF

Major manifestations include:

  • Carditis (pancarditis, valves, pericardium, myocardium)
  • Polyarthritis (migratory and painful)
  • Chorea (uncoordinated jerking movements of face, hands, feet)
  • Erythema marginatum (nonpruritic rash involving pink rings on torso and limbs)
  • Subcutaneous nodules

Minor manifestations include:

  • Clinical fever, polyarthralgia
  • Laboratory elevated acute phase reactants (ESR or leukocyte count)

93.

What is the MOST common food that causes anaphylaxis in children?

  • Peanuts

  • Cow's milk

  • Eggs

  • Shrimp

Correct answer: Peanuts

Food was found to be the most common cause of anaphylaxis in children seen in an emergency department over a five-year period, with peanuts being the most common cause of food-induced anaphylaxis in children.

The other answer choices are also common food allergies found in children.

94.

Which of the following statements is TRUE regarding growth?

  • Complementary foods should be introduced by 6 months of age because an exclusively breastfed infant requires additional sources of iron, protein, and zinc

  • A child will grow an average of 4 inches per year and gain 5 pounds per year between 4 years of age and puberty

  • When a child is nutritionally deprived, the weight percentile falls first, followed by the head circumference percentile, then finally the height percentile

  • A child with growth delays will have a lower-than-average adult weight and height

Correct answer: Complementary foods should be introduced by 6 months of age because an exclusively breastfed infant requires additional sources of iron, protein, and zinc

Introduction of solid (complementary) foods is recommended when the child is 6 months old, because infants that are exclusively breastfed require additional sources of protein, zinc, and iron. Development in a term infant makes this an appropriate time. Signs of readiness generally occur between 4 and 6 months of age and include: a change in sucking patterns to allow mastery of chewing and swallowing; sitting with some support and being able to purposefully move their head; and being able to grasp, pick up, and bring objects to the mouth. Delaying the introduction of solid foods can lead to nutritional deficiencies and oral sensory issues.

The average annual height increase for a child between 4 years of age and puberty is 2 to 3 inches per year, and the average annual weight gain is 5 pounds between 2 years old and puberty (growth is not always consistent, however, and spurts and plateaus may exist). When a child is nutritionally deprived, weight falls first, then height, and lastly head circumference. Ultimately, a normal or near-normal height and weight is achieved in adulthood despite growth delays in childhood.

95.

Of the following scenarios, which is considered acceptable for breastfeeding? 

  • Invasive breast surgery

  • Illegal maternal drug use

  • HIV-positive mother

  • Galactosemia in infant

Correct answer: Invasive breast surgery

With rare exception, breastmilk is the ideal food for the infant. It is a living food rich in vitamins, minerals, fat, proteins (including antibodies and immunoglobulins), and carbohydrates, particularly lactose. Studies show that breastfed babies have added protection against bacterial, viral, and protozoan illnesses.

However, although rare, contraindications to breastfeeding occur in some unique situations. A small number of infant conditions also preclude breastfeeding. Infants with classic galactosemia (a condition in which the infant is unable to fully break down the simple sugar galactose, which makes up half of lactose, found predominantly in breastmilk), maternal HIV infection, and illegal maternal drug use (cocaine, phencyclidine [PCP], and cannabis) are situations in which breastfeeding would be contraindicated. 

Invasive breast surgery (in particular, breast reduction in which the areola is removed and reattached) is not a contraindication to breastfeeding; however, it is a situation that would require close management by a lactation consultation to ensure proper functionality and milk supply. 

96.

A 72-hour-old male is noted to have jaundice in the face, shoulders, chest, and abdomen. The infant is exclusively breastfeeding, and mom reports he is eating well, approximately 8-10 times per day. He is voiding and stooling well. He was born via spontaneous vaginal delivery at 37 5/7 weeks gestation after an uncomplicated pregnancy. The mother's blood type is B+ with a negative antibody screen. His total serum bilirubin (TSB) is 13 mg/dL.

Which of the following is the MOST appropriate management of this infant's jaundice at this stage?

  • Continue breastfeeding, evaluate for risk factors, and if indicated, initiate phototherapy

  • Continue breastfeeding and supplement with oral dextrose water to prevent dehydration

  • Discontinue breastfeeding and supplement with dextrose water and formula until jaundice resolves

  • Discontinue breastfeeding and supplement with formula and IV fluids until total serum bilirubin begins to decrease

Correct answer: Continue breastfeeding, evaluate for risk factors, and if indicated, initiate phototherapy

Jaundice is observed in the first week of life in approximately 60% of term infants due to various causes. Management of hyperbilirubinemia in infants at 35 or more weeks' gestation includes promotion and support of successful breastfeeding (baby to breast 8 to 12 times per day), systematic assessment of the newborn for the risk of jaundice, early and focused follow-up based on the risk assessment, and treatment when indicated. Phototherapy is not a contraindication to breastfeeding.

The use of routine supplementation of water or dextrose water is not indicated and should be discouraged. IV fluids should be given if feeding is unsuccessful and the infant is dehydrated, but this scenario is rare. Formula supplementation is only indicated in the newborn with inadequate oral intake, excessive weight loss (generally greater than 10% birth weight), or dehydration, as these can worsen hyperbilirubinemia.

97.

The leading cause of sepsis in infants from birth to 3 months old is:

  • Group B streptococcus (GBS)

  • Cytomegalovirus (CMV)

  • Listeriosis

  • Chlamydia

Correct answer: Group B streptococcus (GBS)

GBS, a gram-positive diplococcus, is the leading cause of sepsis in infants from birth to 3 months old, resulting in significant perinatal morbidity and mortality rates. Early-onset disease usually occurs at birth or within the first 24 hours of life but can occur in the first 7 days of life. Late-onset disease occurs during the second week of life through 3 months of age. 

The highest attack rate of early-onset GBS is in high-risk deliveries, premature SGA (small for gestational age) infants, very low birth weight (VLBW) infants, or those with prolonged ruptured membranes. However, full-term infants account for 50% of cases. Management includes hospitalization with IV antibiotics. Consultation with pediatric infectious disease specialists is recommended.

Screening of all pregnant women for GBS at 35 to 37 weeks of gestation is recommended. Antepartum treatment of asymptomatic mothers carrying GBS is not recommended. Chemoprophylaxis of high-risk, colonized pregnant women is effective for preventing early-onset GBS infection. Treatment consists of IV penicillin or ampicillin given to high-risk women at the onset of labor, repeated every 4 hours until the infant is born. 

98.

A 2-week-old female presents with a fever, poor feeding, and increasing irritability. The mother reports that the baby is not breastfeeding as often as usual and has had fewer wet diapers than normal. She denies any nasal congestion or cough. She reports there have been no illnesses in the family and that the infant has not been exposed to an illness. Upon exam, you note a rectal temperature of 102 F (38.9 C), a pulse of 185 beats/min, and tachypnea with nasal flaring and subcostal retractions. You order a sepsis workup and admit her to the hospital.

What is the BEST IV antibiotic regimen for empiric coverage at this point?

  • Ampicillin (Ampi) and gentamicin (Garamycin)

  • Vancomycin (Vancocin)

  • Erythromycin (Erythrocin)

  • Ampicillin (Ampi) and clindamycin (Cleocin)

Correct answer: Ampicillin and gentamicin (Garamycin)

Any infant under 1 month of age with a documented fever should undergo laboratory evaluation for sepsis, including blood for complete blood count (CBC) with differential, platelet count and culture, as well as urine for analysis and culture (if infant >72 hours old). CSF is often obtained for protein, glucose, cell count, and culture. 

The child should also be admitted for observation until culture results are obtained, or the source of the fever is found and treated. GBS (group B streptococcus) is the leading cause of sepsis in infants from birth to 3 months old. Management includes initiation of antibiotic therapy with a penicillin (usually ampicillin) and an aminoglycoside, often gentamicin, until GBS has been differentiated from other pathogens such as E. coli or Listeria sepsis or other organisms. 

Clindamycin and erythromycin are not indicated treatments in this situation. Vancomycin is not recommended as a first-line treatment unless the child has evidence of a soft-tissue infection suspected to be methicillin resistant.

99.

Rifampin (Rifadin) is very useful in combination with other antibiotics, as many pathogenic microorganisms become resistant to it quickly when it is used alone. Which of the following is a scenario in which oral rifampin is used alone?

  • N. meningitis prophylaxis for infants and children

  • Methicillin-resistant Staphylococcus aureus (MRSA) cellulitis in infants and children

  • Extra-ocular gonococcal conjunctivitis in infants

  • Streptococcal tonsillopharyngitis (GABHS) in children

Correct answer: N. meningitis prophylaxis for infants and children

Oral rifampin or ciprofloxacin are the antimicrobials of choice for infants and children when treating prophylactically for N. meningitis. In addition to antimicrobial therapy, vaccination is advisable to prevent extended outbreaks if the identified strain is contained in the vaccine.

All of the other infections listed require different antibiotics or are unsafe situations in which to rely solely on rifampin.

100.

The PURPLE acronym helps explain infant patterns in relation to:

  • Crying

  • Feeding

  • Sleeping

  • Growth

Correct answer: Crying

The Period of PURPLE Crying is a resource to assist parents during the developmentally normal fussy period that typically starts at about 2 weeks old, peaks between 3 and 5 weeks old, and may last until 5 months of age. Crying starts and stops for no apparent reason and is unrelated to anything that a parent does. Increased hard-to-soothe crying may not be the result of sickness or discomfort, but rather is a normal early behavioral development and is unrelated to parental skills. 

PURPLE is an acronym that is 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: 

  • P: Peak of crying
  • U: Unexpected
  • R: Resists soothing
  • P: Pain-like face
  • L: Long-lasting
  • E: Evening