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1. Two weeks after a viral syndrome, a 9-year-old boy presents to your clinic
with a complaint of several days of weakness of his mouth. In addition to the
drooping of the left side of his mouth, you note that he is unable to completely
shut his left eye. His smile is asymmetric, but his examination is otherwise
normal. Which of the following is the most likely diagnosis?

e. Bell palsy

2. An infant can regard his parent's face, follow to the midline, lift his head from
the examining table, smile spontaneously, and respond to a bell. He does not yet
regard his own hand, follow past the midline, nor lift his head to a 45° angle off
the examining table. Which of the following is the most likely age of the infant?

a. 1 month

3. A child is brought to your clinic for a routine examination. She can put on
a T-shirt but requires a bit of help dressing otherwise. She can copy a circle well
but has difficulty in copying a square. Her speech is understandable and she
knows four colors. She balances proudly on each foot for 2 seconds but is
unable to hold the stance for 5 seconds. Which of the following is the most
likely age of this child?

d. 4 years

4. A 4-year-old girl is noticed by her grandmother to have a limp and a somewhat
swollen left knee. The parents report that the patient occasionally complains
of pain in that knee. An ophthalmologic examination reveals findings
as depicted in the photograph. Which of the following conditions is most likely
to be associated with these findings?

a. Juvenile rheumatoid arthritis

5. A previously healthy 4-year-old child pictured below presents to the emergency
room (ER) with a 2-day history of a brightly erythematous rash and
temperature of 40°C (104°F). The exquisitely tender, generalized rash is
worse in the flexural and perioral areas. The child is admitted and over the
next day develops crusting and fissuring around the eyes, mouth, and nose.
The desquamation of skin shown in the photograph occurs with gentle traction.
Which of the following is the most likely diagnosis?

b. Staphylococcal scalded skin syndrome

6. A mother brings to your office an article from the Internet suggesting
that infants in day care have a statistically higher incidence of upper respiratory
infections (p < 0.05) as compared to children not in day care. You explain to
her that this means which of the following?

d. The odds are less than 1 in 20 that the differences in upper respiratory infection
rates observed were only a chance variation.

7. A patient comes to your office for a hospital follow-up. You had sent him
to the hospital 3 weeks earlier for persistent fevers but no other symptoms;
he was diagnosed with endocarditis and is currently being treated appropriately.
Advice to this family should now include which of the following?

c. Provide the child with antibiotic prophylaxis for dental procedures.

8. A mother calls you on the telephone and says that your 4-year-old son
bit the hand of her 2-year-old son 48 hours previously. The area around the
injury has become red, indurated, and swollen, and he has a temperature of
39.4°C (103°F). Which of the following is the most appropriate response?

b. Admit the child to the hospital immediately for surgical debridement and antibiotic

9. The adolescent shown presents with a 14-day history of multiple oval
lesions over her back. The rash began with a single lesion over the lower
abdomen (A); the other lesions developed over the next days (B). These lesions
are slightly pruritic. Which of the following is the most likely diagnosis?

b. Pityriasis rosea

10. A chubby 6-month-old baby boy is brought to the clinic by his father.
His father is concerned that his penis is too small (see photograph). The child
is at the 95% for weight and the 50% for length; he has been developing
normally and has had no medical problems. Which of the following is the
most appropriate first step in management of this child?

b. Evaluation of penile length after retracting the skin and fat lateral to the penile

11. A previously healthy 5-year-old boy has a 1-day history of low-grade
fever, colicky abdominal pain, and a rash. He is well-appearing and alert. His
vital signs, other than a temperature of 38°C (100.5°F) are completely normal.
A diffuse, erythematous, maculopapular, and petechial rash is present on his
buttocks and lower extremities, as shown in the photograph. He has no localized
abdominal tenderness or rebound; bowel sounds are active. Laboratory data
Urinalysis: 30 red blood cells (RBCs) per high-powered field,
2+ protein
Stool: Guaiac positive
Platelet count: 135,000/μL
These findings are most consistent with which of the following?

a. Anaphylactoid purpura

12. A 4-month-old baby boy arrives to the ER cold and stiff. The parents
report that he had been healthy and that they put him to bed as usual for the
night at the regular time. When they next saw him, in the morning, he was
dead. Physical examination is uninformative. A film from a routine skeletal
survey is shown below. Which of the following is the most likely diagnosis?

e. Abuse

13. A 6-year-old boy is often teased at school because he has stooled in his
underwear almost daily for the last 3 months. He was toilet trained at 2 years
of age without difficulty, but over the last 2 years he had developed ongoing
constipation. His family is frustrated because they cannot believe him when
he says "I didn't know I had to go." He is otherwise normal; school is going
well, and his home life is stable. His only finding on examination is significant
for stool in the rectal vault. The plain radiograph of his abdomen is shown.
Initial management of this problem should include which of the following?

d. Clear fecal impaction and short-term stool softener use

14. A 2-year-old child presents to the office with a paternal complaint of
"bowlegs." The girl has always had bowlegs; her previous pediatrician told the
family she would grow out of it. Now, however, it seems to be worsening. Her
weight is greater than 95% for age, and she has significant bowing out of her legs
and internal tibial torsion; otherwise, her examination is normal. A radiograph
of her lower leg is shown. Which of the following is the most likely diagnosis?

e. Blount disease

15. A very concerned mother brings a 2-year-old child to your office
because of two episodes of a brief, shrill cry followed by a prolonged expiration
and apnea. You have been following this child in your practice since
birth and know the child to be a product of a normal pregnancy and delivery,
to be growing and developing normally, and to have no chronic medical
problems. The first episode occurred immediately after the mother refused to
give the child some juice; the child became cyanotic, unconscious, and had
generalized clonic jerks. A few moments later the child awakened and had no
residual effects. The most recent episode (identical in nature) occurred at the
grocery store when the child's father refused to purchase a toy for her. Your
physical examination reveals a delightful child without unexpected physical
examination findings. Which of the following is the most likely diagnosis?

e. Breath-holding spell

16. A 10-year-old child arrives with the complaint of new-onset bed-wetting.
He has had no fever, his urine culture is negative, and he has had no new
stresses in his life. He is well above the 95th percentile for weight as is much
of his family. Which of the following is most helpful in making a diagnosis?

a. Fasting plasma glucose of 135 mg/dL

17. You are called to the ER to see one of your patients. The father of
this 14-year-old mildly retarded child says that he found the child about
20 minutes ago in the neighbor's garden shed with an unknown substance
in his mouth. The child first had a headache, but then became agitated and
confused; while you are talking to the father in the ER the child begins to
have a seizure and dysrhythmia on the cardiac monitor. The blood gas
demonstrates a severe metabolic acidosis. Which of the following agents is
most likely the culprit?

c. Sodium cyanide

18. The mother of a 3-day-old infant brings her child to your office for an
early follow-up visit. The mom notes that the child has been eating well,
has had no temperature instability, and stools and urinates well. She notes
that over the previous 3 days the child has had a progressive "rash" on the
face as pictured here. Which of the following is the most likely diagnosis?

b. Neonatal acne

19. A 2-year-old child (A) presents with a 4-day history of a rash limited
to the feet and ankles. The papular rash is both pruritic and erythematous.
The 3-month-old sibling of this patient (B) has similar lesions also involving
the head and neck. The most appropriate treatment for this condition includes
which of the following?

b. Permethrin

20. An 8-hour-old infant develops increased respiratory distress, hypothermia,
and hypotension. A complete blood count (CBC) demonstrates a white blood
cell (WBC) count of 2500/μL with 80% bands. The chest radiograph is shown
below. Which of the following is the most likely diagnosis?

c. Group B streptococcal pneumonia

21. A 16-year-old arrives to your office soon after beginning basketball season.
He states that he has had progressive pain in his knees. A physical examination
reveals, in addition to tenderness, a swollen and prominent tibial
tubercle. Radiographs of the area are unremarkable. Which of the following
is the most likely diagnosis?

a. Osgood-Schlatter disease

22. You are performing a well-child examination on the 1-year-old child
shown in the picture. For this particular problem, which of the following is
the most appropriate next step in management?

e. Refer immediately to ophthalmology

23. You are seeing a 2-year-old child, brought by his father for a well-child
examination. In providing age-appropriate anticipatory guidance, you should
tell him which of the following?

b. Milk should be switched from whole to skim or low fat.

24. A child can walk well holding on to furniture but is slightly wobbly
when walking alone. She uses a neat pincer grasp to pick up a pellet, and
she can release a cube into a cup after it has been demonstrated to her. She
tries to build a tower of two cubes with variable success. She is most likely
at which of the following age?

e. 1 year

25. You are called by a general practitioner to consult on a patient admitted
to the hospital 4 days ago. The patient is a 7-month-old white boy with
poor weight gain for the past 3 months, who has not gained weight in the
hospital despite seemingly adequate nutrition. You take a detailed diet history
from his foster mother, and the amounts of formula and baby food
intake seem appropriate for age. Physical examination reveals an active,
alert infant with a strong suck reflex who appears wasted. You note generalized
lymphadenopathy with hepatomegaly. In addition, you find a severe
case of oral candidiasis that apparently has been resistant to treatment.
Which of the following is the most appropriate next step in the evaluation
or treatment of this child?

b. Order human immunodeficiency virus (HIV) polymerase chain reaction (PCR).
testing because this is likely the presentation of congenitally acquired HIV.

26. A 5-year-old boy presents with the severe rash shown in the photographs.
The rash is pruritic, and it is especially intense in the flexural
areas. The mother reports that the symptoms began in infancy (when it also
involved the face) and that her 6-month-old child has similar symptoms.
Which of the following is the most appropriate treatment of this condition?

d. Moisturizers and topical steroids

27. A 1-year-old presents for a well-child checkup, but the parents are
concerned about giving the child his immunizations. Which of the following
is a true contraindication to the administration of the fourth DTaP (diphtheria
and tetanus toxoid and acellular pertussis) vaccine?

e. Prolonged seizures 6 days after the last DTaP vaccine

28. A mother arrives to the clinic with her three children (ages 2 months,
18 months, and 36 months). The 18-month-old has an intensely pruritic
scalp, especially in the occipital region, with 0.5-mm lesions noted at the
base of hair shafts, as shown in the picture. Which of the following therapies
should be avoided in this situation?

a. Treatment of all household contacts with 1% lindane (Kwell)

29. A 2-year-old boy has been vomiting intermittently for 3 weeks and has
been irritable, listless, and anorectic. His use of language has regressed to speaking
single words. In your evaluation of this patient, which of the following
is the most reasonable diagnosis to consider?

c. Tuberculous meningitis

30. You find a discrete, whitish polyp that extends through the tympanic
membrane in a child with a history of recurrent otitis media. This most likely
represents which of the following?

a. A cholesteatoma

31. An 8-month-old infant arrives to the emergency department (ED) with
a 2-day history of diarrhea and poor fluid intake. Your quick examination
reveals a lethargic child; his heart rate is 180 beats per minute, his respiratory
rate is 30 breaths per minute, and his blood pressure is low for age. He has
poor skin turgor, 5-second capillary refill, and cool extremities. Which of the
following fluids is most appropriate management for his condition?

c. Normal saline

32. During the examination of a 2-month-old infant, you note that the infant's
umbilical cord is still firmly attached. This finding prompts you to suspect
which of the following?

b. Leukocyte adhesion deficiency

33. You are seeing an established patient, a 4-year-old girl brought in by
her mother for vaginal itching and irritation. She is toilet trained and has not
complained of frequency or urgency, nor has she noted any blood in her urine.
Her mother noted she has been afebrile and has not complained of abdominal
pain. Mom denies the risk of inappropriate contact; the girl also denies anyone
"touching her there." Your physical examination of the perineum is significant
for the lack of foul odor or discharge. You do note some erythema of the
vulvar area but no evidence of trauma. Which of the following is the most
appropriate course of action?

b. Counsel mother to stop giving the girl bubble baths, have the girl wear only cotton
underwear, and improve hygiene.

34. A 20-month-old child is brought to the ED because of fever and irritability
and refusal to move his right lower extremity. Physical examination
reveals a swollen and tender right knee that resists passive motion. Which
of the following is the most likely to yield the diagnosis in this patient?

a. Examination of joint fluid

35. A 14-year-old high school student arrives to your clinic for well-child
care. In reviewing his records you determine that his most recent immunization
for tetanus was at 4 years of age. Which of the following should you

e. Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine adsorbed

36. A 5-year-old boy is brought into the ER immediately after an unfortunate
altercation with a neighbor's immunized Chihuahua that occurred while
the child was attempting to dress the dog as a superhero. The fully immunized
child has a small, irregular, superficial laceration on his right forearm
that has stopped bleeding. His neuromuscular examination is completely
normal, and his perfusion is intact. Management should include which of
the following?

c. Copious irrigation

37. Aunt Mary is helping her family move to a new apartment. During the
confusion, 3-year-old Jimmy is noted to become lethargic. The contents of
Aunt Mary's purse are strewn about on the floor. In the ER, the lethargic
Jimmy is found to have miosis, bradycardia, and hypotension. He develops
apnea, respiratory depression, and has to be intubated. His condition would
most likely benefit from which of the following therapies?

b. Pediatric intensive care unit (PICU) support and trial of naloxone

38. As a city public health officer, you have been charged with the task of
screening high-risk children for lead poisoning. Which of the following is the
best screen for this purpose?

d. Blood lead level

39. A 15-year-old is participating in high school football practice in August
in Texas. He had complained of headache and nausea earlier in practice,
but kept playing after a cup of water. He is now confused and combative.
He is dizzy and sweating profusely. His temperature is 41°C (105.8°F).
Therapy should consist of which of the following?

d. Initiate whole body cold water immersion

40. As part of your anticipatory guidance to new parents of a healthy newborn,
you suggest putting the child in which of the following positions for

a. Supine position

41. A mentally retarded 14-year-old boy has a long face, large ears, micropenis,
and large testes. Chromosome analysis is likely to demonstrate which of the

d. Fragile X syndrome

42. A 5-month-old child with poor growth presents to the ER with generalized
tonic-clonic seizure activity of about 30-minute duration that stops
upon the administration of lorazepam. Which of the following historical bits
of information gathered from the mother is most likely to lead to the correct
diagnosis in this patient?

c. The mother has been diluting the infant's formula to make it last longer

Questions 43 to 48
43. A 1-week-old child's mother complains that the child has a transient
rash that has splotchy areas of erythema with a central clear pustule. Your
microscopic examination of the liquid in the pustule reveals eosinophils.

e. Erythema toxicum

44. An adolescent boy complains of a splotchy red rash on the nape of his
neck, discovered when he had his head shaved for football season. The rash
seems to become more prominent with exercise or emotion. His mother notes
that he has had the rash since infancy, but that it became invisible as hair grew.
He had a similar rash on his eyelids that resolved in the newborn period.

b. Salmon patch

45. A nurse calls you to evaluate an African American newborn whom she
thinks has a bacterial skin infection. The areas in question have many scattered
pustules full of a milky fluid. Upon examining pustules, they easily wipe
away, revealing a small hyperpigmented macule.

d. Pustular melanosis

46. The obstetrical resident on call asks you to evaluate an area of a newborn's
scalp that seems to have no hair and is scaly and yellowish

a. Sebaceous nevus

47. A newborn's mother complains that her infant seems to have very small
white dots all over his nose. The dots do not wipe off with bathing, but they
are also not erythematous

g. Milia

48. A newborn's father complains that his son has dandruff, with many waxy
flakes of skin on the scalp. When he scrapes the lesions, hair often comes
off with the flakes of skin. In addition, the baby has flaking of the eyebrows.

f. Seborrheic dermatitis

Questions 49 to 53
49. A 3-year-old boy awakens every night around 2:00 AM screaming incoherently.
His parents note that he is agitated, seems awake but unresponsive, and
goes back to sleep within a few minutes. He has no memory of the episodes
in the morning

a. Night terrors

50. A 15-month-old toddler continues to wake up crying every night. Her
parents give her a nighttime bottle, rock her, and sing to her to help her go
back to sleep. Her parents are exhausted and ask you if she is having bad

c. Learned behavior

51. Parents hear over their baby monitor that their 5-year-old girl regularly
calls out during the night. When the parents check on her, she is sleeping
comfortably and is in no apparent distress.

e. Somniloquy

52. A 4-year-old boy occasionally wakes in the middle of the night crying.
When his parents check on him, he seems visibly frightened and tells his
parents that Chihuahuas were chasing him.

b. Nightmares

53. A 5-year-old child refuses to sleep in his bed, claiming there are monsters
in his closet and that he has bad dreams. The parents allow him to sleep
with them in their bed to avoid the otherwise inevitable screaming fit. The
parents note that the child sleeps soundly, waking only at sunrise.

c. Learned behavior

Questions 54 to 58
54. A 6-year-old returns from playing all day in the snow with several erythematous,
ulcerative lesions on his fingertips; he complains the lesions are
painful and itchy.

c. Chilblain

55. A teen, just back from a skiing trip, has blistering and peeling of several
areas on her face; she reports the lesions started as firm, cold, white areas that
felt stinging at the time and are now more sensitive than the surrounding skin.

a. Frostnip

56. A 9-year-old girl presents during summer break with an area of erythematous,
firm, and slightly swollen skin at the corner of her mouth and
extending to her cheek. The area is not tender.

d. Cold panniculitis

57. A 14-year-old on a mountain-climbing expedition in December becomes
tired, clumsy, and begins to hallucinate. His heart rate is 45 beats per minute

e. Hypothermia

58. A skier recently rescued from a snowbank following an avalanche (caused
by a barking Chihuahua) complains about his feet. Upon rescue they were
whitish yellow and numb, but now they are blotchy and painful.

b. Frostbite

Questions 59 to 62
59. Megaloblastic anemia, growth failure, paresthesias, sensory defects, developmental
regression, weakness, and fatigue

f. Vitamin B12 deficiency

60. Photophobia, blurred vision, burning and itching of eyes, poor growth,

i. Riboflavin deficiency

61. Irritability, convulsions, hypochromic anemia

g. Vitamin B6 deficiency

62. Megaloblastic anemia, glossitis, pharyngeal ulcers, impaired immunity

a. Folate deficiency

Questions 63 to 66
63. A newborn infant is noted to have microcephaly with sloping forehead,
cutis aplasia on the scalp, microphthalmia, and cleft lip and palate. His echocardiogram
demonstrates a complex heart lesion including atrial septal defect
(ASD), ventricular septal defect (VSD), and dextrocardia.

a. Trisomy 13

64. A 17-year-old boy has an unusual gait, large mouth with tongue protrusion,
hypopigmentation with blond hair and pale blue eyes, and unprovoked
bursts of laughter

c. Angelman syndrome

65. A 6-week-old boy was small for his birth weight and had intrauterine
growth retardation. He is microcephalic, has a rounded face, hypertelorism,
and epicanthal folds. His cry is high-pitched

b. Cri du chat syndrome

66. A 3-day-old infant who was found at birth to have anal atresia also has
vertebral defects, a VSD, tracheoesophageal fistula, absent left kidney, and
shortened arms.


Questions 67 to 70
67. An afebrile, obese 14-year-old boy has developed pain at the right
knee and a limp.

b. Slipped capital femoral epiphysis...

68. A 6-year-old boy has developed a limp and has limited mobility of the
hip, but denies pain and fever.

a. Legg-Calvé-Perthes disease

69. A 2-year-old refuses to walk, has fever, has significant pain with external
rotation of the right leg, and has an elevated WBC count.

d. Septic arthritis of the hip

70. A 3-year-old refuses to walk, is afebrile, had an upper respiratory tract
infection a week ago, has right hip pain with movement, and has a normal
WBC count.

e. Transient synovitis

Questions 71 to 75
71. Over the past several weeks, a 2-year-old girl has exhibited developmental
regression, abnormal sleep patterns, anorexia, irritability, and decreased activity.
These symptoms have progressed to acute encephalopathy with vomiting,
ataxia, and variable consciousness. The family recently moved, and they are
in the process of restoring the interior of their home.

c. Dimercaptosuccinic acid (DMSA, succimer)

72. After a fight with her boyfriend, a 16-year-old girl took "some pills." At
presentation she is alert and complains of emesis, diaphoresis, and malaise.
Her initial liver function tests, obtained about 12-hour postingestion, are
elevated. Repeat levels at 24-hours show markedly elevated aspartate aminotransferase
(AST) and alanine aminotransferase (ALT), along with abnormal
coagulation studies and an elevated bilirubin.

b. N-acetylcysteine (Mucomyst)

73. You are called to the delivery room. A newborn infant seems lethargic
and has poor tone with only marginal respiratory effort, but his heart rate
is above 100 beats per minute. The mother had an uncomplicated pregnancy,
and delivery was uncomplicated and vaginal 10 minutes after spontaneous
rupture of membranes. The mother received only pain medications while
in labor.

d. Naloxone (Narcan)

74. A 4-year-old girl comes into the ER after eating a bottleful of small,
chewable pills she found while at her grandfather's house. She has an increased
respiratory rate, elevated temperature, vomiting, and is disoriented. She is
intermittently complaining that "a bell is ringing" in her ears. She has a metabolic
acidosis on an arterial blood gas.

e. Sodium bicarbonate

75. After helping his father in the yard, a 14-year-old boy complains of weakness
and feels like his muscles are twitching. He begins to drool, and then
collapses in a generalized tonic-clonic seizure. Upon the arrival of EMS, his
heart rate is found to be 40 beats per min and his pupils are pinpoint

a. Atropine and pralidoxime (2-PAM)

Questions 76 to 78
76. A 14-year-old male presents after taking a "happy pill" that his friend
gave him. He is alert and oriented, but complains of a muscle spasm in his
neck, making his head lean on his right shoulder. You also notice he is arching
his back in an unusual manner.

b. Diphenhydramine (Benadryl)

77. A 2-year-old boy found a bottle of his mother's prenatal vitamins and
consumed the majority of them. He now has hematemesis and abdominal
pain. He is febrile, and laboratory tests reveal a leukocytosis and hyperglycemia

a. Deferoxamine mesylate

78. A 17-year-old is brought into the ED by his friends at about 10:00 AM.
They were at a party the night before and drank some "homemade" alcohol.
He is disoriented and confused, and has an anion-gap acidosis. He begins
to have seizures

d. Ethanol

Questions 79 to 83
Excess vitamin intake has been shown to have deleterious effects. Match the
vitamin with the toxic effect. Each lettered option may be used once, more
than once, or not at all..
79. Vitamin A

d. An irritable 8-year-old child with headache, vomiting, alopecia, dry/itchy skin with
desquamation of the palms and soles, hepatosplenomegaly, and swelling of the bones.

80. Nicotinic acid

g. After getting into his mother's bottle of vitamins, a 3-year-old has burning, tingling,
and itching on his arms as well as a reddened face, arms, and chest.

81. Vitamin C

a. A 4-year-old with diarrhea, abdominal pain, and kidney stones which prove to
be caused by calcium oxalate.

82. Vitamin D

e. A 2-year-old presents with nausea, vomiting, poor feeding, abdominal pain, and
constipation. On electrocardiogram (ECG) he has decreased Q-T interval. He has
calcifications in his kidneys noted on a CT scan done for his abdominal pain

83. Pyridoxine

b. A 6-year-old who has developed ataxia and sensory neuropathy.

Questions 84 to 88
84. A 15-year-old with severe acne on an oral preparation of retinoic acid.

c. Bilateral microtia or anotia

85. A woman without prenatal care has a diet low in green vegetables and
enriched grain products.

d. Spina bifida

86. A woman with long-standing hypertension treated with angiotensinconverting
enzyme (ACE) inhibitors

f. Renal dysgenesis

87. A primiparous mother late in her first trimester has a fever and "3-day"

g. Cataracts

88. A 23-year-old pregnant woman with manic-depressive disorder has
had poor prenatal care and was maintained on lithium.

e. Ebstein anomaly

Questions 89 to 92
89. An 18-year-old friend of the family returns from spring break from a
coastal town in Central America. He has an intensely pruritic lesion on his
foot. The lesion is raised, red, serpiginous, and has a few associated bullae.

b. Ivermectin

90. A 2-week-old boy is brought by his mother to the clinic; he has scaly,
yellow patches on his scalp with associated hair loss.

f. Topical steroids or a selenium sulfide-containing product

91. Two days after a backyard party where the children enjoyed limeade and
the adults partook of margaritas, a father brings his 4-year-old child to your
office for a well-child checkup. The child is healthy other than a slight sunburn
and some hyperpigmentation around her face and on her chest. Her father
mentions that he, too, has some splotchy hyperpigmentation on his chest

d. Reassurance only

92. A 4-month-old presents with a dry, scaly rash on his cheeks, arms, and
upper chest. His 10-year-old sister had a similar rash when she was young,
but the rash is now confined to her antecubital and popliteal fossa; her rash
worsens in winter months

a. Mild cleansing cream, topical moisturizers, and topical steroids

Questions 93 to 95
93. A 6-month-old child has a loud systolic murmur at the left lower sternal

d. Ventricular septal defect (VSD)

94. A 14-year-old child has headache, hypertension, edema, and a change
in urine output and color

a. Glomerulonephritis

95. A 3-day-old infant was born to a mother with active systemic lupus
erythematosus (SLE)

c. Vitamin A

Questions 96 to 102
96. Isoniazid therapy in a pregnant teenager

b. Pyridoxine

97. Administration of phenytoin

f. Folate

98. Measles in developing countries

c. Vitamin A

99. Liver disease

a. All fat-soluble vitamins

100. Breast-fed infant in Alaska

d. Vitamin D

101. Sickle-cell disease

f. Folate

102. 1-day-old newborn

e. Vitamin K

Questions 103 to 107
103. A 1-year-old boy has been admitted three times in the past with
abscess formation requiring incision and drainage. He is now admitted for
surgical drainage of a hepatic abscess identified on ultrasound

c. Nitroblue tetrazolium (NBT) test

104. A 5-month-old infant is admitted with severe varicella infection. The
lesions cover the infant's entire body, and the infant is beginning to show
symptoms of respiratory distress. Past medical history is significant for a
history of atopic dermatitis. The family also notes frequent epistaxis; the
last episode required nasal packing in the ED.

f. Platelet count

105. A 3-year-old has had repeated episodes of sinusitis and otitis media.
He was recently admitted for osteomyelitis of his femur with Staphylococcus
aureus. The family notes that while his first 4 or 5 months of life were normal,
he has been persistently ill with multiple infections in the ensuing months.
The mother notes that her brother had similar problems with infections
and died at the age of 3 years from a "lung infection." Physical examination
is significant for the absence of lymph nodes and tonsillar tissue.

b. Serum immunoglobulin levels

106. A general practitioner refers to you for evaluation a 3-year-old boy
with frequent infections. You note the child to have a loud systolic murmur,
posteriorly rotated ears that are small and low-set, down-slanting and widely
spaced eyes, a small jaw, and an upturned nose. At birth the child spent
2 weeks in the nursery for "low calcium" and seizures, and he still receives
calcium supplementation, but the mother does not know why. You would
like to order a rapid diagnostic test for this child.

g. Intradermal skin test using Candida albicans

107. A 2-year-old girl has had two episodes of Neisseria meningitidis septicemia
and is now admitted for Streptococcus pneumoniae septicemia

e. CBC demonstrating Howell-Jolly bodies

108. The term infant pictured below weighs 2200 g (4 lb, 14 oz). He is
found to have a ventricular septal defect on cardiac evaluation. This infant
appears to have features consistent with which of the following?

d. Fetal alcohol syndrome

109. A newborn is noted to be quite jaundiced at 3 days of life. Laboratory
data demonstrate his total bilirubin to be 17.8 mg/dL (direct bilirubin is
0.3 mg/dL). Which of the following factors is associated with an increased
risk of neurologic damage in a jaundiced newborn?

d. Neonatal sepsis

110. A 2-hour-old full-term newborn infant is noted by the nursing staff to
be having episodes of cyanosis and apnea. Per nursery protocol they place an
oxygen saturation monitor on him. When they attempted to feed him, his
oxygen levels drop into the 60s. When he is stimulated and cries, his oxygen
levels increase into the 90s. Which of the following is the most important
next step to quickly establish the diagnosis?

c. Passage of catheter into nose

111. A mother calls you frantic because she has just been diagnosed with
chicken pox. She delivered 7 days ago a term infant that appears to be eating,
stooling, and urinating well. The child has been afebrile and seems to be doing
well. Which of the following is the most appropriate step in management?

e. Advise the mother to continue regular well-baby care for the infant.

112. A mother wishes to breast-feed her newborn infant, but is worried
about medical conditions that would prohibit her from doing so. You counsel
her that of her listed conditions, which of the following is a contraindication
to breast-feeding?

e. HIV infection

113. A mother delivers a neonate with meconium staining and Apgar
scores of 3 at 1 and 5 minutes of life. She had no prenatal care and the delivery
was by emergency cesarean section for what the obstetricians report as
"severe fetal bradycardia." Which of the following sequelae could be expected
to develop in this intubated neonate with respiratory distress?

a. Sustained rise in pulmonary arterial pressure

114. A 2-year-old boy is being followed for congenital cytomegalovirus
(CMV) infection. He is deaf and developmentally delayed. The child's mother
informs you that she has just become pregnant and is concerned that the new
baby will be infected and may develop serious consequences. Which of the
following is true?

a. The mother has antibodies to CMV that are passed to the fetus

115. A full-term infant is born after a normal pregnancy; delivery, however,
is complicated by marginal placental separation. At 12 hours of age, the child,
although appearing to be in good health, passes a bloody meconium stool.
For determining the cause of the bleeding, which of the following diagnostic
procedures should be performed first?

b. An Apt test

116. As you are about to step out of a newly delivered mother's room, she
mentions that she wants to breast-feed her healthy infant, but that her
obstetrician was concerned about one of the medicines she was taking.
Which of the woman's medicines, listed below, is clearly contraindicated in

c. Amphetamines for her attention deficit disorder

117. A recovering premature infant who weighs 950 g (2 lb, 1 oz) is fed
breast milk to provide 120 cal/kg/d. Over the ensuing weeks, the baby is
most apt to develop which of the following?

b. Hypocalcemia

118. A primiparous woman whose blood type is O positive gives birth at
term to an infant who has A-positive blood and a hematocrit of 55%. A total
serum bilirubin level obtained at 36 hours of age is 12 mg/dL. Which of the
following additional laboratory findings would be characteristic of ABO
hemolytic disease in this infant?

b. A positive direct Coombs test

119. The nurse from the level 2 neonatal intensive care nursery calls you to
evaluate a baby. The infant, born at 32 weeks' gestation, is now 1 week old and
had been doing well on increasing nasogastric feedings. This afternoon, however,
the nurse noted that the infant has vomited the last two feedings and
seems less active. Your examination reveals a tense and distended abdomen
with decreased bowel sounds. As you are evaluating the child, he has a grossly
bloody stool. The plain film of his abdomen is shown. The next step in your
management of this infant should include which of the following?

e. Removal of nasogastric tube, placement of a transpyloric tube and, after confirmation
via radiograph of tube positioning, switching feeds from nasogastric to

120. An infant weighing 1400 g (3 lb) is born at 32 weeks' gestation.
Initial evaluation was benign, and the infant was transferred to the level 2
nursery for prematurity. The nurse there calls at 1 hour of life and reports
the infant is tachypneic. Vital signs include a heart rate of 140 beats per
minute, a respiratory rate of 80 breaths per minute, a temperature of 35°C
(95°F), and a peripheral oxygen saturation of 98%. The lungs are clear
with bilateral breath sounds and there is no murmur; the infant is in no distress.
The child's chest radiograph is shown. Which of the following is the
most appropriate next step in evaluating the infant?

d. Place the infant under a warmer.

121. Two new mothers are discussing their infants outside the neonatal intensive
care unit. Both were born at 36 weeks' gestation. One infant weighs 2600 g
(5 lb, 12 oz) while the other infant weighs 1600 g (3 lb, 8 oz). The mother of
the second infant should be told that her child is more likely to have which of
the following conditions?

a. Congenital malformations

122. A 3-day-old infant, born at 32 weeks' gestation and weighing 1700 g
(3 lb, 12 oz), has three episodes of apnea, each lasting 20 to 25 seconds and
occurring after a feeding. During these episodes, the heart rate drops from
140 to 100 beats per minute, and the child remains motionless; between
episodes, however, the child displays normal activity. Blood sugar is 50 mg/dL
and serum calcium is normal. Which of the following is most likely true
regarding the child's apneic periods?

a. They are due to an immature respiratory center

123. You have an 11-day-old term infant in your office for a well-child
visit. The mother notes that she received a letter that day from the state's
Department of Health reporting that her child's newborn screen had come
back abnormal, indicating possible galactosemia. Which of the following is
the most appropriate management at this point?

d. Discontinue breast-feeding and initiate soy formula feedings.

124. The father of a 1-week-old infant comes to the office in a panic. He
has just noticed on his child a right anterior shoulder mass that seems tender.
The father is an osteosarcoma survivor and fears the child has the same
malignancy. In reviewing the baby's discharge papers, you note the child
was a term, appropriate-for-gestational-age vaginal delivery with a birth
weight of 3200 g (7 lb, 1 oz). Apgar scores were 9 at 1 and 5 minutes. Your
examination is significant for a large firm mass on the right clavicle; the rest
of the examination is normal. Management of this problem should include
which of the following?

b. Reassurance and supportive care

125. A 1-day-old infant who was born by a difficult forceps delivery is alert
and active. She does not move her left arm spontaneously or during a Moro
reflex. Rather, she prefers to maintain it internally rotated by her side with
the forearm extended and pronated. The rest of her physical examination is
normal. This clinical scenario most likely indicates which of the following?

c. Left-sided Erb-Duchenne paralysis

126. You are examining a newborn infant in the well-baby nursery. The
infant was the product of a benign pregnancy and vaginal delivery; he
appears to be in no distress. Interestingly, your measurement of frontooccipital
head circumference is about 2 cm larger than the initial measurement
done several hours before. Your examination otherwise is significant
for tachycardia and a "squishy" feel to the entire scalp. You can elicit a fluid
wave over the scalp. Management of this condition should include which
of the following?

a. Transfer to the newborn ICU

127. A 19-year-old primiparous woman develops toxemia in her last trimester
of pregnancy and during the course of her labor is treated with magnesium
sulfate. At 38 weeks' gestation, she delivers a 2100-g (4-lb, 10-oz) infant with
Apgar scores of 1 at 1 minute and 5 at 5 minutes. Laboratory studies at
18 hours of age reveal a hematocrit of 79%, platelet count of 100,000/μL,
glucose 41 mg/dL, magnesium 2.5 mEq/L, and calcium 8.7 mg/dL. Soon
after, the infant has a generalized convulsion. Which of the following is the
most likely cause of the infant's seizure?

a. Polycythemia

128. An infant who appears to be of normal size is noted to be lethargic
and somewhat limp after birth. The mother is 28 years old, and this is her
fourth delivery. The pregnancy was uncomplicated, with normal fetal monitoring
prior to delivery. Labor was rapid, with local anesthesia and intravenous
meperidine (Demerol) administered for maternal pain control. Which
of the following therapeutic maneuvers is likely to improve this infant's
condition most rapidly?

b. Administration of naloxone (Narcan)

129. At 43 weeks' gestation, a long, thin infant is delivered. The infant is
apneic, limp, pale, and covered with "pea soup" amniotic fluid. Which of the
following is the best first step in the resuscitation of this infant at delivery?

a. Intubation and suction of the trachea; provision of oxygen

130. The newborn pictured below was born at home and has puffy, tense eyelids;
red conjunctivae; a copious amount of purulent ocular discharge; and
chemosis 2 days after birth. Which of the following is the most likely diagnosis?

d. Gonococcal ophthalmia

131. After an uneventful labor and delivery, an infant is born at 32 weeks'
gestation weighing 1500 g (3 lb, 5 oz). Respiratory difficulty develops
immediately after birth and increases in intensity thereafter. At 6 hours of
age, the child's respiratory rate is 60 breaths per minute. Examination reveals
grunting, intercostal retraction, nasal flaring, and marked cyanosis in room
air. Auscultation reveals poor air movement. Physiologic abnormalities compatible
with these data include which of the following?

b. Decreased lung compliance, reduced lung volume, right-to-left shunt of blood

132. A term infant is born to a known HIV-positive mother. She has been
taking antiretroviral medications for the weeks prior to the delivery of her
infant. Routine management of the healthy infant should include which of the

c. A course of zidovudine for the infant

133. Initial examination of a full-term infant weighing less than 2500 g (5 lb,
8 oz) shows edema over the dorsum of her hands and feet. Which of the following
findings would support a diagnosis of Turner syndrome?

c. Redundant skin folds at the nape of the neck

134. You have been recently named as the medical director of the normal
newborn nursery in your community hospital and have been asked to
write standardized admission orders for all pediatricians to follow. Which
of the following vaccines will you include on these orders?

b. Hepatitis B vaccine

135. A 1-week-old black infant presents to you for the first time with a
large, fairly well-defined, purple lesion over the buttocks bilaterally, as shown
in the photograph. The lesion is not palpable, and it is not warm nor tender.
The mother denies trauma and reports that the lesion has been present since
birth. This otherwise well-appearing infant is growing and developing normally
and appears normal upon physical examination. Which of the following
is the most appropriate course of action in this infant?

b. Reassurance of the normalcy of the condition

136. A newborn infant develops respiratory distress immediately after
birth. His abdomen is scaphoid. No breath sounds are heard on the left side
of his chest, but they are audible on the right. Immediate intubation is successful
with little or no improvement in clinical status. Emergency chest
x-ray is shown (A) along with an x-ray 2 hours later (B). Which of the following
is the most likely explanation for this infant's condition?

c. Diaphragmatic hernia

137. Shortly after birth, an infant develops abdominal distention and begins
to drool. When she is given her first feeding, it runs out the side of her mouth,
and she coughs and chokes. Physical examination reveals tachypnea, intercostal
retractions, and bilateral pulmonary rales. The esophageal anomaly that
most commonly causes these signs and symptoms is illustrated by which of the
following? (ישנו ציור שאני לא יכולתי להעתיק***)

d. Figure D

138. You are advised by the obstetrician that the mother of a baby she has
delivered is a carrier of hepatitis B surface antigen (HBsAg-positive). Which
of the following is the most appropriate action in managing this infant?

d. Administer hepatitis B immune globulin and hepatitis B vaccine to the infant.

139. You are called to a delivery of a term infant, about to be born via
cesarean section to a mother with multiple medical problems, including a
1-month history of a seizure disorder, for which she takes phenytoin;
rheumatic heart disease, for which she must take penicillin daily for life;
hypertension, for which she takes propranolol; acid reflux, for which she
takes aluminum hydroxide; and a deep venous thrombosis in her left calf
diagnosed 2 days ago, for which she was started on a heparin infusion. The
obstetrician is concerned about the possible effects of the mother's multiple
medications on the newborn infant. Which of the following medications is
most likely to cause harm in this newborn infant at delivery?

a. Propranolol

140. Your older sister, her husband, their 2-day-old infant, and their pet
Chihuahua arrive at your door. The parents of the child are concerned because
the pediatrician noted the child was "yellow" and ordered some studies. They
produce a wad of papers for you to review. Both the mother and baby have
O-positive blood. The baby's direct serum bilirubin is 0.2 mg/dL, with a total
serum bilirubin of 11.8 mg/dL. Urine bilirubin is positive. The infant's white
blood cell count is 13,000/μL with a differential of 50% polymorphonuclear
cells, 45% lymphocytes, and 5% monocytes. The hemoglobin is 17 g/dL, and
the platelet count is 278,000/μL. Reticulocyte count is 1.5%. The peripheral
smear does not show fragments or abnormal cell shapes. Which of the following
is the most likely explanation for this infant's skin color?

b. Physiologic jaundice

141. At the time of delivery, a woman is noted to have a large volume of
amniotic fluid. At 6 hours of age, her baby begins regurgitating small
amounts of mucus and bile-stained fluid. Physical examination of the infant
is normal, and an abdominal x-ray is obtained (see below). Which of the
following is the most likely diagnosis of this infant's disorder?

d. Duodenal atresia

142. The mother and father of a newborn come in for the 2-week
checkup. The mother complains of "colic" and asks if she can switch to
goat's milk instead of breast milk. Which of the following should be your
main concern about using goat's milk instead of breast milk or cow's milk?

b. It has insufficient folate.

143. You see the newborn baby shown below for the first time in the nursery.
You consult plastic and reconstructive surgeon as well as the hospital's
speech therapist. Understandably, the parents have many questions. Which of
the following statements is appropriate anticipatory guidance for this family?

d. Recurrent otitis media and hearing loss are likely complications.

144. The mother of a 2-week-old infant reports that since birth, her infant
sleeps most of the day; she has to awaken her every 4 hours to feed, and she
will take only an ounce of formula at a time. She also is concerned that the
infant has persistently hard, pellet-like stools. On your examination you
find an infant with normal weight and length, but with an enlarged head.
The heart rate is 75 beats per minute and the temperature is 35°C (95°F).
The child is still jaundiced. You note large anterior and posterior fontanelles,
a distended abdomen, and an umbilical hernia. This clinical presentation is
likely a result of which of the following?

a. Congenital hypothyroidism

145. A routine prenatal ultrasound reveals a male fetus with meningomyelocele.
The 24-year-old primigravid mother is told the infant will require surgery
shortly after birth. You counsel her about the etiology of this defect and the risk
of further pregnancies being similarly affected, and state which of the following?

d. Supplementation of maternal diet with folate leads to a decrease in incidence of
this condition.

146. A term, 4200-g (9-lb, 4-oz) female infant is delivered via cesarean
section because of cephalopelvic disproportion. The amniotic fluid was
clear, and the infant cried almost immediately after birth. Within the first
15 minutes of life, however, the infant's respiratory rate increased to 80 breaths
per minute, and she began to have intermittent grunting respirations. The
infant was transferred to the level 2 nursery and was noted to have an oxygen
saturation of 94%. The chest radiograph is shown. Which of the following is
the most likely diagnosis?

e. Transient tachypnea of the newborn

147. The infant in the following picture presents with hepatosplenomegaly,
anemia, persistent rhinitis, and a maculopapular rash. Which of the following
is the most likely diagnosis for this child?

d. Congenital syphilis

148. A well-appearing, 3200-g (7-lb, 1-oz) black infant is noted to have fifth
finger (postaxial) polydactyly. The extra digit has no skeletal duplications and
is attached to the rest of the hand by a threadlike soft tissue pedicle (see
photograph). Appropriate treatment for this condition includes which of the

b. Excision of extra digit

149. An infant born at 35 weeks' gestation to a mother with no prenatal care
is noted to be jittery and irritable, and is having difficulty feeding. You note
coarse tremors on examination. The nurses report a high-pitched cry and note
several episodes of diarrhea and emesis. You suspect which of the following?

c. Heroin withdrawal syndrome

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