Pediatrics 6 - Questions v1

Exam Section : Item 1 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Pediatrics Self-Assessment 4 hr 57 min 37 sec
1. A 20-year-old woman, gravida 1, para 0, at 36 weeks' gestation delivers a stillborn infant. She had no prenatal care, and
the prenatal course was complicated by maternal cocaine and alcohol use. She also was seen in the emergency
department at 20 weeks' gestation after being assaulted by her boyfriend. Examination at the time showed scalp and
forearm lacerations and bruising of the abdomen and face. She took phenytoin during the pregnancy for a seizure
disorder; she had no seizures during the pregnancy. An autopsy of the fetus shows multiple fractures of thin ribs and
multiple fractures of the rather broad and ribbon-shaped tubular bones. Examination of the fetus shows blue sclerae,
soft calvaria, a small chest, and bent short extremities. Which of the following is the most likely underlying cause of this
condition?
0 A) Abnormality in type I collagen

0 B) Alcohol-induced fetal abnormalities
0 C) Intrauterine trauma resulting from abuse to the mother
0 D) Placental insufficiency from cocaine use
0 E) Teratogenicity of phenytoin
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2. A previously healthy 1-year-old boy is brought to the physician because of a 2-month history of increasing weakness
and difficulty feeding . He is alert. Examination shows tongue fasciculations and profound hypotonia. Deep tendon
reflexes are absent. Which of the following is the most likely diagnosis?
0 A) Botulism
0 B) Guillain-Barre syndrome
0 C) Myasthenia gravis
0 D) Progressive infantile spinal muscular atrophy
0 E) Transverse myelitis
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3. An asymptomatic 10-year-old boy is brought to the physician for a well-child examination. He has no history of serious
illness and takes no medications. His parents both have essential hypertension and hyperlipidemia. He has an active
lifestyle and plays several sports. He consumes a wide variety of foods, including meat, fruit, and vegetables, and
drinks two to three glasses each of whole milk and fruit juice daily. He is currently at the 75th percentile for height and
above the 97th percentile for weight and BMI. Vital signs are within normal limits. The remainder of the examination
shows no abnormalities. Which of the following is the most likely cause of this patient's current weight?
0 A) Excessive intake of carbohydrates
0 B) Excessive intake of fat
0 C) Excessive intake of total calories
0 D) Inadequate intake of fruits and vegetables
0 E) Inadequate physical activity
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4. A 10-month-old girl is brought to the physician because of a 5-day history of a rash over the cheeks and diaper area
that she constantly rubs. Her mother says that for the past 24 hours, she has been unwilling to stand . She is afebrile
and otherwise healthy. Her mother and 6-year-old brother have asthma. Examination shows erythematous lichenified
papules and plaques, and excoriations on the diaper area. She has red lichenified plaques on the cheek and chin.
Which of the following is the most likely diagnosis?
0 A) Atopic dermatitis
0 B) Candidiasis
0 C) Food allergy
0 D) Tinea corporis
0 E) Toxic epidermal necrolysis
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5. An otherwise healthy 6-year-old boy is brought to the physician because of the growth of pubic hair over the past 2
years. He is 157 cm (5 ft 2 in) tall and weighs 50 kg (110 lb). He appears muscular. Pubic hair development is Tanner
stage 5. Examination shows a mature penis. Testicular volume is normal for age. Which of the following is the most
likely site of excessive hormonal production?
0 A) Adrenal cortex
0 B) Hypothalamus
0 C) Liver
0 D) Pituitary gland
0 E) Testes
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6. A 3-week-old boy is brought to the physician 4 hours after the onset of vomiting watery, green material. His mother says
that he has been drawing up his legs as if in pain while vomiting. He appears uncomfortable. He is afebrile. The
abdomen is tender but not distended. An abdominal x-ray shows dilated loops of small bowel and air-fluid levels. Which
of the following is the most likely diagnosis?
0 A) Appendicitis Q F) Hepatitis
0 B) Congenital megacolon (Hirschsprung disease) Q G) lntussusception
0 C) Duodenal atresia 0 H) Pancreatitis
0 D) Foreign body ingestion 0 I) Pyloric stenosis
0 E) Gastroesophageal reflux disease 0 J) Volvulus
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7. A previously healthy 6-month-old boy is admitted to the hospital because of a 1-day history of fever, lethargy, and
vomiting. His temperature is 39°C (102.2°F), pulse is 160/min, and respirations are 34/min. Examination shows nuchal
rigidity and a bulging anterior fontanel. The remainder of the examination shows no abnormalities. Laboratory studies
show:
Hemoglobin 12.2 g/dL
Leukocyte count 17,300/mm 3
Platelet count 262,000/mm 3
Serum
Na+ 121 mEq/L
K+ 4.2 mEq/L
cI - 105 mEq/L
Hco3- 16 mEq/L
Glucose 150 mg/dL
Which of the following is the most likely explanation for this patient's serum sodium concentration?
0 A) Excessive intake of free water
0 B) Factitious hyponatremia due to hyperglycemia
0 C) Increased loss of chloride in the kidneys
0 D) Increased secretion of ADH (vasopressin)
0 E) Insufficient intake of sodium chloride
0 F) lntravascular volume depletion
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8. A 2-month-old boy is brought to the physician for a well-child examination. Pregnancy was uncomplicated. He was born
at term following forceps delivery for fetal heart rate decelerations. Apgar scores were 4 and 8 at 1 and 5 minutes,
respectively. He is at the 50th percentile for length and 75th percentile for weight. He keeps his head turned to the right
and cries when it is moved toward the left. Examination shows flattening of the right posterior part of the skull. A 1.5-cm
mass is palpated in the left side of the neck. Which of the following is the most likely cause of these findings?
0 A) Cervical spine hemivertebrae

0 B) Craniosynostosis
0 C) Hypoxic-ischemic encephalopathy
0 D) Left clavicle fracture
0 E) Prenatal stroke
Q F) Right clavicle fracture
Q G) Sternomastoid injury
Q H) Syringobulbia
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9. A previously healthy 7-year-old girl is admitted to the hospital because of an 11-day history of fever, fatigue, and
progressive nonproductive cough. During the past 2 weeks, she has had a decreased appetite, resulting in a
1.4-kg (3-lb) weight loss. The family lives on a farm in Missouri, and the patient often plays in an abandoned chicken
coop. Her direct contact to animals is limited to a pet dog and turtle. She has not travelled outside of the state during
the past 9 months and has never been out of the USA. She appears alert. She is at the 50th percentile for height and
weight. Her temperature is 37°C (98.6°F), pulse is 110/min, respirations are 34/min, and blood pressure is
96/57 mm Hg. Mild wheezes are heard bilaterally. The remainder of the examination shows no abnormalities.
Laboratory studies show:
Leukocyte count 11 ,300/mm J
Segmented neutrophils 48%
Bands 2%
Lymphocytes 46%
Monocytes 4%
Platelet count 210,000/mm J
An x-ray and CT scan of the chest are shown. A blood culture obtained 4 days ago shows no growth. A PPD skin test
performed 3 days ago shows no induration; a mumps control skin test shows 8 mm of induration. A biopsy specimen of
a mediastinal lymph node shows necrotizing granulomas. Which of the following is the most likely diagnosis?
Q A) Acute lymphocytic leukemia

Q B) Acute myelocytic leukemia
Q C) Chlamydia trachomatis infection
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9. A previously healthy 7-year-old girl is admitted to the hospital because of an 11-day history of fever, fatigue , and
progressive nonproductive cough. During the past 2 weeks, she has had a decreased appetite, resulting in a
1.4-kg (3-lb) weight loss. The family lives on a farm in Missouri, and the patient often plays in an abandoned chicken
coop. Her direct contact to animals is limited to a pet dog and turtle. She has not travelled outside of the state during
the past 9 months and has never been out of the USA. She appears alert. She is at the 50th percentile for height and
weight. Her temperature is 37°C (98.6°F), pulse is 110/min, respirations are 34/min, and blood pressure is
96/57 mm Hg. Mild wheezes are heard bilaterally. The remainder of the examination shows no abnormalities.
Leukocyte count 11 ,300/mm 3
Bands 2%
Lymphocytes 46%
Monocytes 4%
An x-ray and CT scan of the chest are shown. A blood culture obtained 4 days ago shows no growth. A PPD skin test
performed 3 days ago shows no induration; a mumps control skin test shows 8 mm of induration. A biopsy specimen of
a mediastinal lymph node shows necrotizing granulomas. Which of the following is the most likely diagnosis?
0 A) Acute lymphocytic leukemia
0 B) Acute myelocytic leukemia
0 C) Chlamydia trachomatis infection
0 D) Histoplasmosis
0 E) a fever
Q F) Salmonella enteritidis infection
Q G) Tuberculosis
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Exam Section: Item 10 of 50 National Board of Medical Examiners Time Remaining:
10. A 25-year-old woman, gravida 2, para 1, at 20 weeks' gestation comes to the physician for a routine prenatal visit. She
feels well, and her pregnancy has been uncomplicated. Examination shows a uterus consistent in size with a 20-week
gestation. She reports that her first child had bloody diarrhea as an infant when he was fed cow milk-based formula .
The diarrhea resolved when the formula was changed to a hypoallergenic type. She states that she avoids dairy
products because they upset her stomach. She asks how she can prevent food allergies in her next child. Which of the
following is the most appropriate recommendation?
Q A) Delay the introduction of solid food until the age of 9 months

Q B) Do not feed the infant eggs or peanut-based products until the age of 9 months
Q C) Exclusively breast-feed for at least 6 months
Q D) Use a hypoallergenic formula for at least 6 months
Q E) Use a lactose-free formula exclusively for at least 9 months
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11 . A 2-month-old boy is brought to the physician because of a 2-week history of sweating and fatigue during feedings. His
mother has also noticed that he seems to breathe fast and has a pounding heart rate at rest. He was born at term
following an uncomplicated pregnancy and delivery. He is at the 50th percentile for length and 5th percentile for
weight. His temperature is 37°C (98.6°F), pulse is 145/min, respirations are 70/min, and blood pressure is 92/40 mm
Hg. Examination shows prominence of the left precordium and a palpable parasternal lift. A blowing holosystolic
murmur is heard best over the lower left sternal border. A chest x-ray shows cardiomegaly and increased pulmonary
vascular markings. Which of the following is the most likely explanation for this patient's symptoms?
0 A) Anomalous pulmonary blood return

0 B) Increased peripheral vascular resistance
0 C) Increased systemic vascular resistance
0 D) Intermittent supraventricular tachycardia
0 E) Left-to-right shunt
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12. A 15-year-old girl is brought to the physician because of a 3-day history of severe pain and swelling in her right
sternoclavicular joint. Ten days ago, the patient had a sore throat. She has no history of serious illness and takes no
medications. Her temperature is 40°C (104 °F). Examination shows erythema, swelling, and tenderness of the right
sternoclavicular joint. Aspiration of the affected joint yields thick, yellow, purulent fluid. A Gram stain of the fluid shows
numerous segmented neutrophils and numerous gram-negative diplococci. Which of the following is the most
appropriate next step in diagnosis?
0 A) Culture of the aspirate fluid
0 B) Chest x-ray
0 C) Echocardiography
0 D) CT scan of the left sternoclavicular joint
0 E) Indium-labeled leukocyte scan
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13. A 5000-g (11-lb 1-oz) male infant is born at term to a 35-year-old woman following an uncomplicated pregnancy and
delivery. Initial examination shows that he is large for gestational age and has macroglossia, visceromegaly, and an
omphalocele. This infant most likely has which of the following associated conditions?
0 A) Congenital heart disease
0 B) Hypoglycemia
0 C) lmperforate anus
0 D) Polycythemia
0 E) Renal tubular acidosis
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■ Mark Pediatrics Self-Assessment 4 hr 56 min O sec
14. A 9-year-old girl is brought to the physician because of headache and dizziness for the past week. She has a history of
recurrent urinary tract infections. At the age of 2 years, she received the diagnosis of vesicoureteral reflux and was
treated with prophylactic amoxicillin until the age of 6 years. She has been admitted to the hospital twice for treatment
of pyelonephritis. Development is appropriate for age, and her immunizations are up-to-date. Her height and weight
are below the 5th percentile. Her temperature is 37.2°C (99°F), pulse is 80/min, respirations are 16/min, and blood
pressure is 160/100 mm Hg in all four extremities. Funduscopic examination shows narrowing of the retinal arteries.
Cardiopulmonary examination shows no abnormalities. Which of the following is the most appropriate next step in
diagnosis?
Q A) Follow-up blood pressure measurement in 1 week

Q B) Blood culture
Q C) Measurement of serum urea nitrogen and creatinine concentrations
Q D) Thyroid function tests
Q E) CT scan of the head
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15. An 8-year-old boy is brought to the physician because of a 4-day history of pallor. He has not had cough, rash,
abdominal pain, vomiting, or diarrhea. He is alert but pale. His temperature is 37°C (98.6°F), pulse is 150/min,
respirations are 36/min, and blood pressure is 90/72 mm Hg. Examination shows no abnormalities. The stool is
maroon, and test for occult blood is positive. His hemoglobin concentration is 8 g/dl. Which of the following is the most
appropriate next step in diagnosis?
0 A) X-ray of the abdomen

0 B) Upper gastrointestinal series
0 C) HIDAscan
0 D) Meckel scan
0 E) Anoscopy
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16. A 7-year-old boy is brought to the emergency department 30 minutes after the onset of confusion, decreased
awareness, headache, weakness, and dyspnea. When his mother returned home from work, she found him sitting in
front of the television with the space heater on and an open package of cookies and glass of milk nearby. The most
appropriate treatment is administration of which of the following?
0 A) Acetylcysteine
0 B) Amyl nitrite
0 C) Atropine
0 D) Deferoxamine
0 E) Dimercaprol (BAL)
Q F) Methylene blue
Q G) Naloxone
0 H) Oxygen
0 I) Vitamin K
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17. A previously healthy 16-year-old girl is brought to the physician because of a 4-month history of progressive fatigue
and nervousness, intermittent blurred vision, and declining school performance. She has had a 3-kg (6.6-lb) weight
loss during this period despite an increased appetite. Her sister has hypothyroidism treated with levothyroxine. The
patient's temperature is 37.5°C (99.5°F), pulse is 120/min, respirations are 18/min, and blood pressure is
110/80 mm Hg. Examination shows warm flushed skin and fine soft hair. There is mild exophthalmos and lid lag.
Funduscopic examination and visual fields show no abnormalities. Examination of the neck shows an enlarged thyroid
gland with a bruit. There is a fine tremor when her upper extremities are outstretched. Which of the following is the
most likely cause of this patient's findings?
Q A) Levothyroxine overdose
Q B) Lymphocytic infiltration of the thyroid gland
Q C) Malignant infiltration of the thyroid gland
Q D) Thyroid-stimulating hormone (TSH)-producing pituitary tumor
Q E) TSH receptor autoantibodies
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18. A 2807-g (6-lb 3-oz) newborn has a strong cry immediately after delivery. She was born at term following an
uncomplicated pregnancy and a spontaneous vaginal delivery complicated by a few decelerations. The newborn was
suctioned at the perineum and placed on the warmer/resuscitation table. After 10 seconds of warming, the newborn's
pulse is greater than 100/min, and respirations are 20/min. Examination shows peripheral cyanosis and minimal
movement of the upper and lower extremities. Which of the following is the most appropriate next step in
management?
0 A) Tactile stimulation and oxygen therapy
0 B) Naloxone therapy
0 C) Subcutaneous epinephrine therapy
0 D) Positive-pressure ventilation via face mask
0 E) Immediate intubation
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19. A 2-week-old female newborn is brought to the physician because of bruising on her arms and legs for 2 days. She
was born at term following an uncomplicated pregnancy. The delivery was precipitous, but the newborn fed well soon
after birth. Examination shows petechiae over the face and trunk, scattered ecchymoses over the extremities, and an
erythematous, fleshy irregular mass on the thigh. A bruit is heard over the hepatic area. Laboratory studies show a
hemoglobin concentration of 13 g/dl, leukocyte count of 5000/mm 3, and platelet count of 15,000/mm 3. Which of the
following is the most likely underlying cause of these findings?
0 A) Cutaneous lymphoma
0 B) Cystic hygroma
0 C) Hemangioma
0 D) Juvenile xanthogranuloma
0 E) Lymphangioma
Q F) Mastocytoma
Q G) Neurofibroma
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20. A previously healthy 6-year-old boy is brought to the physician because of progressive
hair loss over the past 4 weeks. Examination shows a swollen and purulent area on the
scalp. A photograph is shown. The remainder of the examination shows no
abnormalities. Which of the following is the most appropriate next step in management?
0 A) Topical corticosteroid therapy

0 B) Oral antibacterial therapy
0 C) Oral antifungal therapy
0 D) Surgical excision
0 E) No intervention necessary
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21 . A 3-year-old boy is brought to the emergency department because of a 1-day history of increasingly severe abdominal
pain. His parents say that he injured his stomach when he ran into the corner of a table 4 days ago. He cried
immediately after the injury but then seemed to feel better. His temperature is 37°C (98.6°F). Abdominal examination
shows a 2 x 2-cm mass at the midline. Serum studies show increased amylase and lipase activities. Which of the
following is the most appropriate next step in diagnosis?
0 A) X-ray of the abdomen

0 B) Barium enema
0 C) Barium swallow
0 D) CT scan of the abdomen
0 E) Endoscopy
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22. A full-term 24-hour-old newborn has respiratory distress and seizures. Apgar scores were 8 and 9 at 1 and 5 minutes,
respectively. An x-ray of the chest shows diffuse hazy infiltrates bilaterally. Leukocyte count is
12,500/mm 3 (65% segmented neutrophils and 10% bands). Examination of cerebrospinal fluid shows
4 leukocytes/mm 3 (90% lymphocytes), a glucose concentration of 75 mg/dL, and a protein concentration of 25 mg/dL.
0 A) Group B streptococcal sepsis

0 B) Meconium aspiration
0 C) Pneumococcal meningitis
0 D) Pneumocystis jiroveci (formerly P. carinii) pneumonia
0 E) Respiratory syncytial virus pneumonia
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23. An 18-month-old boy has had cough, coryza, vomiting, and diarrhea for 5 days and pallor and lethargy for 1 day. His
mother states that his urine output has decreased, and the urine is now dark red. He responds poorly to stimuli. He
has a grade 3/6 systolic murmur with a gallop and diffuse abdominal tenderness. Laboratory studies show:
Hematocrit 24%
Serum
Na + 138 mEq/L
cI - 118 mEq/L
K+ 6.5 mEq/L
HC0 3- 15 mEq/L
Creatinine 2.6 mg/dL
Urea nitrogen 60 mg/dL
Q A) Goodpasture syndrome
Q B) Hemolytic uremic syndrome
Q C) Henoch-Schonlein nephritis
Q D) Postinfectious glomerulonephritis
Q E) Systemic vasculitis
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24. A 5-year-old boy is brought to the physician for a

well-child examination. He is active and has been
healthy except for an episode of otitis media 3 weeks
ago treated with amoxicillin. His parents emigrated
from Vietnam. His diet consists mainly of fruits and
vegetables; he occasionally eats fish and chicken but
no red meat. Examination shows no abnormalities.
Hemoglobin 10 g/dL
Mean corpuscular volume 64 µm 3
Leukocyte count 6100/mm J
Red cell distribution width 10% (N=13%- 15%)
A blood smear is shown. Which of the following is the

most likely explanation for this patient's anemia?
0 A) Antibiotic-induced autoimmune hemolysis

0 B) Iron deficiency
0 C) Thalassemia minor
0 D) Transient postinfectious bone marrow

suppression
0 E) Vitamin B 12 (cobalamin) deficiency
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25. A 17-year-old girl comes to the physician for a routine health maintenance examination prior to beginning college. She
has had intermittent urinary frequency over the past 6 months without urgency or pain with urination. She feels
otherwise well and has no history of serious illness. Menarche was at the age of 14 years. Menses occur every
3 to 4 months and last 3 to 8 days. Her last menstrual period was 3 weeks ago. She is not sexually active. She is
165 cm (5 ft 5 in) tall and weighs 80 kg (177 lb); BMI is 30 kg/m 2. Vital signs are within normal limits. Examination
shows a mild increase in hair growth over the upper lip and upper extremities. There are hyperpigmented , velvety,
hyperkeratotic plaques on the neck, axillae, and groin. The remainder of the examination shows no abnormalities.
Urinalysis shows no abnormalities. Which of the following is the most likely diagnosis?
0 A) Cushing syndrome
0 B) Hypothyroidism
0 C) Ovarian neoplasm
0 D) Type 2 diabetes mellitus
0 E) Urinary tract infection
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26. A ?-month-old girl is brought to the physician because of a 3-day history of fever and cough. She was born at term
following an uncomplicated delivery. She was treated for acute otitis media at 5 months of age. She takes no
medications. Immunizations are up-to-date. She appears ill. She is at the 50th percentile for length and 25th percentile
for weight. Her temperature is 38.5°C (101.3°F), pulse is 140/min, respirations are 80/min, and blood pressure is
90/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 80%. Several 0.5- to 1.5-cm, mobile lymph
nodes are palpated in the anterior cervical chain, axillae, and groin. Examination shows white plaques on the buccal
mucosa. Diffuse crackles are heard bilaterally. The spleen tip is palpated 2 cm below the left costal margin. Laboratory
studies show:
Leukocyte count 10,500/mmJ
Lymphocytes 30%
Monocytes 4%
Bronchoalveolar lavage shows Pneumocystis jiroveci (formerly P carinii). Which of the following is the most likely
diagnosis?
0 A) Chediak-Higashi syndrome
0 B) Chronic granulomatous disease
0 C) Complement deficiency
0 D) HIV infection
0 E) Hyperimmunoglobulinemia E syndrome
Q F) Severe combined immunodeficiency (SCID)
Q G) Thymic-parathyroid dysplasia (DiGeorge syndrome)
Q H) Wiskott-Aldrich syndrome
0 I) X-linked agammaglobulinemia
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27. A previously healthy 16-year-old girl is brought to the physician by her parents 1 day after she fainted during soccer
practice. Her teammates said that she fell to the ground while running and appeared to be unconscious for
approximately 15 seconds; no abnormal movements were noted. There is no prior history of syncope, palpitations, or
murmurs. Her parents are concerned because a maternal cousin died suddenly at the age of 22 years of an unknown
cause. The patient is alert and oriented. Her vital signs are within normal limits. Examination shows no abnormalities.
Which of the following is the most appropriate next step?
0 A) Reassurance
0 B) Chest x-ray
0 C) ECG
0 D) EEG
0 E) Admission to the hospital for observation
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28. A previously healthy 16-year-old girl is brought to the emergency department by friends after they found her
unresponsive at a party. There is no history of trauma. Her temperature is 37°C (98.6°F), pulse is 80/min, respirations
are 6/min, and blood pressure is 95/55 mm Hg. Physical examination shows constricted pupils. The abdomen is
slightly distended , and bowel sounds are decreased. Neurologic examination shows a diminished gag reflex and
generalized hypertonia. The most appropriate next step in management is administration of which of the following?
0 A) Activated charcoal
0 B) 5% Glucose
0 C) Methadone
0 D) Naloxone
0 E) 0.9% Saline
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29. A previously healthy 14-year-old girl is brought to the physician because of a 6-week history of right knee pain. She
plays volleyball for her school, and the pain is worse after jumping or running . There is no history of trauma. She
appears well. Examination shows a tender right knee; there is crepitance with flexion . Which of the following is the
most likely diagnosis?
0 A) Conversion disorder
0 B) Dermatomyositis
0 C) Growing pains
0 D) Juvenile rheumatoid arthritis
0 E) Legg-Calve-Perthes disease
Q F) Neuroblastoma with bone marrow metastases
Q G) Patellofemoral instability
0 H) Septic arthritis
0 I) Transient synovitis
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30. A 1-day-old, 1400-g (3-lb 2-oz) newborn has tachypnea, expiratory grunting, flaring of the alae nasi, and peripheral
edema. He is cyanotic while breathing room air. Laboratory studies show:
Serum
Na+ 138 mEq/L
cI - 100 mEq/L
K+ 4.2 mEq/L
HC0 3- 14 mEq/L
Urea nitrogen 12 mg/dL
Urine
pH 6.2
Protein 1+
RBC 0- 1/hpf
WBC 0-1/hpf
Arterial blood gas analysis on room air shows:

7.17
50 mm Hg
40 mm Hg
Which of the following is the most likely acid-base disorder?
0 A) Lactic acidosis with respiratory compensation
0 B) Pure metabolic acidosis
0 C) Respiratory acidosis and metabolic compensation
0 D) Respiratory acidosis complicated by renal failure
0 E) Respiratory and metabolic acidosis
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31 . A 17-year-old girl comes to the physician because of a 2-day history of pain in the right lower quadrant of her
abdomen. She has had no loss of appetite. She was able to attend school today. Her last menstrual period was
24 days ago. She is not sexually active. Her temperature is 36.5°C (97.?°F), pulse is 88/min, respirations are 16/min,
and blood pressure is 110/70 mm Hg. Abdominal examination shows no rebound tenderness. Pelvic examination is
difficult to perform because of discomfort but shows a tender right adnexa. A pregnancy test is negative.
Ultrasonography shows a 3.5-cm right ovarian cyst that appears to be filled with fluid. Which of the following is the
most appropriate next step in management?
0 A) Observation
0 B) Intravenous antibiotic therapy
0 C) Diagnostic laparoscopy
0 D) Ovarian biopsy
0 E) Appendectomy
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32. A 2-year-old girl is brought to the emergency department 30 minutes after a syncopal episode. At the time of the
episode, she turned blue around the mouth while having a temper tantrum; she then fell down and became
unresponsive. Her extremities became rigid and shook and then became limp. After a few seconds, she resumed
normal activity. She currently is alert, active, and well hydrated. Her temperature is 37.1 °C (98.8°F), pulse is 110/min,
respirations are 22/min, and blood pressure is 94/52 mm Hg. The lungs are clear to auscultation. A grade 1/6, systolic
ejection murmur is heard at the lower left sternal border with no gallops or rubs. The cranial nerves are intact. Muscle
tone is normal, and deep tendon reflexes are 2+ bilaterally. Which of the following is the most likely cause of this
patient's syncopal episode?
0 A) Atonic seizure
0 B) Breath holding
0 C) Hypochondriasis
0 D) Low cardiac output
0 E) Complex partial seizure
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33. A 6-year-old boy is brought to the emergency department 1O minutes after a firecracker accident; he has pain and
tearing of the right eye. The right eye appears normal. Both pupils are equally round and accommodate to light. His
visual acuity is 20/20. Ocular movements are full. Which of the following is the most likely cause of the eye pain?
0 A) Increased intraocular pressure
0 B) Inflammation of periorbital tissues
0 C) Loss of corneal epithelium
0 D) Obstruction of the lacrimal duct
0 E) Retinal detachment
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34. A previously healthy 1-month-old girl is brought to the emergency department because of a 3-day history of cough and
difficulty breast-feeding. Her mother is concerned because the patient's face turns red when she coughs. She was
born at term following an uncomplicated pregnancy, labor, and delivery. She is otherwise healthy. Her mother has had
a similar cough for 3 weeks. The patient appears thin. Her temperature is 37.8°C (100°F), pulse is 110/min, and
respirations are 45/min. Examination shows moist mucous membranes and clear rhinorrhea. During the examination,
she has a long series of single coughs ending with a loud , high-pitched inhalation. Which of the following is the most
likely diagnosis?
0 A) Acute bronchiolitis
0 B) Chlamydia! pneumonia
0 C) Foreign body aspiration
0 D) Pertussis
0 E) Viral laryngotracheobronchitis
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35. A 12-year-old girl is brought to the physician for a well-child examination . She has no history of serious illness.
Immunizations are up-to-date. Menarche has not occurred. She is not sexually active. Her mother asks if her daughter
should receive the human papillomavirus (HPV) vaccine. She is reluctant to give permission to administer the vaccine
if her daughter is not at risk for infection. The patient and her mother should be advised that which of the following is
the most appropriate timing for the patient to receive the HPV vaccine?
0 A) Within the next year

0 B) Within 1 year after menarche
0 C) Immediately after she becomes sexually active
0 D) At the time of her first Pap smear
0 E) The vaccine is not indicated if she and her future sexual partners use condoms
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36. A 10-year-old boy with sickle cell disease is brought to the physician because of a 2-day history of increasing fatigue
and shortness of breath. He has had a persistent upper respiratory tract infection for 5 days that has been
unresponsive to over-the-counter medications. His temperature is 39.5°C (103.1°F), pulse is 120/min, respirations are
28/min, and blood pressure is 80/55 mm Hg. Examination shows pale conjunctivae and dry mucous membranes.
Cardiac examination shows an active precordium; a grade 3/6, systolic ejection murmur is heard along the left sternal
border. His hematocrit is 16%. Which of the following is most likely to be increased in this patient?
0 A) Cardiac output
0 B) Central venous pressure
0 C) Peripheral tissue oxygenation
0 D) Pulmonary vascular resistance
0 E) Systemic afterload
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37. A previously healthy 8-year-old girl is brought to the emergency department because of fever, rash, and lethargy for
4 hours. She has had one previous episode of similar symptoms. Her brother died of fulminant meningococcemia
4 years ago. Her temperature is 38.6°C (101.5°F), pulse is 128/min, respirations are 32/min, and blood pressure is
95/42 mm Hg. There are scattered purpuric lesions over the trunk and extremities. Her capillary refill time is
4 seconds. Which of the following is the most likely cause?
0 A) AIDS
0 B) Child abuse
0 C) Complement system immunodeficiency
0 D) Congenital humoral system immunodeficiency
0 E) Frequent exposure to multiple pathogens
0 F) Vitamin A deficiency
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38. A 4-month-old female infant is brought to the physician by her mother for a routine examination. The patient was born
at 27 weeks' gestation to a 26-year-old multiparous woman after premature rupture of the membranes and premature
labor. The patient's birth weight was 1200 g (2 lb 10 oz), and she spent the first 3 months of her life in the hospital.
During hospitalization, she was treated for sepsis and respiratory distress syndrome that required intubation ,
mechanical ventilation, and umbilical artery catheterization. She is currently receiving oxygen and diuretic therapy at
home. She is at the 5th percentile for length and weight. Her temperature is 37.2°C (99°F), pulse is 104/min,
respirations are 32/min, and blood pressure is 78/45 mm Hg. Breath sounds are decreased bilaterally, and wheezing is
heard occasionally. Cardiac examination shows a pronounced S 2 and a precordial heave. Abdominal examination
shows hepatomegaly. An ECG shows right axis deviation and right ventricular hypertrophy. Which of the following is
the most likely cause of these cardiac findings?
0 A) Cardiomyopathy
0 B) lntracardiac left-to-right shunting
0 C) Peripheral pulmonary stenosis
0 D) Pulmonary hypertension
0 E) Pulmonary outlet obstruction
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39. A previously healthy 16-year-old girl comes to the physician because of heavy vaginal bleeding for 5 weeks. Menarche
was at the age of 12 years. Menses occur at irregular 30- to 45-day intervals. Examination shows no abnormalities
except for blood at the cervical os. On day 21 of her menstrual cycle, her serum progesterone concentration is
0.5 ng/ml (follicular N<3; luteal N>3-5). Which of the following is the most likely underlying cause of these findings?
0 A) Anovulation
0 B) Gonadal dysgenesis 45,X (Turner syndrome)
0 C) Pituitary tumor
0 D) Sexual abuse
0 E) van Willebrand disease
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40. A 9-year-old boy with chronic renal failure is brought to the physician for a follow-up examination 2 days after he began
enalapril therapy for hypertension . He feels well. His temperature is 37°C (98.6°F), pulse is 92/min, respirations are
18/min, and blood pressure is 130/70 mm Hg. Cardiac examination shows a normal S 1 and S 2. No murmurs are heard.
There is no peripheral edema. Serum studies show:
Before Treatment After Treatment
Na+ (mEq/L) 141 136
K+ (mEq/L) 4 .5 5.4
Cl - (mEq/L) 102 100
HC0 3- (mEq/L) 18 17
Urea nitrogen (mg/dl) 55 57
Creatinine (mg/dl) 3.1 3.1
Which of the following is the most likely cause of this patient's hyperkalemia?
0 A) Acute progression of chronic renal failure
0 B) Decreased glomerular perfusion
0 C) Metabolic acidosis
0 D) Primary adrenal insufficiency
0 E) Suppression of aldosterone
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41 . A female newborn has mild cyanosis and a cardiac murmur 4 hours after an uncomplicated vaginal delivery. Heart
sounds are heard best on the right. A chest x-ray shows dextrocardia with no evidence of pulmonary disease.
Echocardiography shows a complex congenital heart defect with a regurgitant atrioventricular valve. Abdominal
ultrasonography shows no evidence of a spleen. A blood smear shows Howell-Jolly bodies. This newborn is at
greatest risk for which of the following?
0 A) Anemia
0 B) Bleeding disorder
0 C) Cerebral infarction
0 D) Sepsis
0 E) Thrombocytosis
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42. Four days after admission to the hospital for evaluation of a high-grade fever, a 12-year-old girl has decreased urine
output. Her urine output has been 2 ml/h during the past 12 hours. She has a 4-week history of temperatures to
40.6°C (105°F), facial rash, and diffuse joint pain. On admission, a diagnosis of hypertensive encephalopathy was
made, and antihypertensive therapy was begun. Her current temperature is 39.8°C (103.6°F), pulse is 110/min,
respirations are 45/min, and blood pressure is 168/98 mm Hg. The remainder of the examination shows no
abnormalities. Laboratory studies show:
Serum
Na+ 129 mEq/L
K+ 9 mEq/L
Urea nitrogen 130 mg/dl
Creatinine 10.2 mg/dl
Urine
RBC >100/hpf
RBC casts occasional
An ECG is shown . Which of the following is the most appropriate next step in management?
-
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Pediatrics Self-Assessment 4 hr 53 min 4 sec
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42. Four days after admission to the hospital for evaluation of a high-grade fever, a 12-year-old girl has decreased urine
output. Her urine output has been 2 mL/h during the past 12 hours. She has a 4-week history of temperatures to
40.6°C (105°F), facial rash, and diffuse joint pain. On admission, a diagnosis of hypertensive encephalopathy was
made, and antihypertensive therapy was begun. Her current temperature is 39.8°C (103.6°F), pulse is 110/min,
respirations are 45/min, and blood pressure is 168/98 mm Hg. The remainder of the examination shows no
Serum
Na+ 129 mEq/L
K+ 9 mEq/L
Urea nitrogen 130 mg/dl
Creatinine 10.2 mg/dl
Urine
RBC >100/hpf
RBC casts occasional
An ECG is shown. Which of the following is the most appropriate next step in management?
0 A) Bolus of methylprednisolone
0 B) Intravenous administration of calcium chloride
0 C) Intravenous administration of 0.9% sodium chloride
0 D) Plasmapheresis
0 E) Hemodialysis
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43. A 15-year-old girl is brought to the emergency department 2 hours after she attempted suicide by taking an overdose
of aspirin. On arrival, she appears slightly agitated. Her temperature is 38°C (100.4 °F), pulse is 112/min, respirations
are 34/min, and blood pressure is 118/72 mm Hg. Examination shows "sigh-like" respirations and diffuse mild
abdominal tenderness. This patient is most likely to have which of the following sets of electrolyte findings?
Na+ K+ Cl- HC0 3-

(mEq/L) (mEq/L) (mEq/L) (mEq/L)
0 A) 129 5.3 104 21
0 B) 136 5.4 112 13
0 C) 141 4 .2 102 8
0 D) 148 4.1 98 28
0 E) 154 4.6 102 34
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44. A previously healthy 10-year-old boy is brought to the emergency department 1 hour after falling against the crossbar
of his bicycle in a straddle position. He has not voided since that time. He appears to be in severe pain. His
temperature is 37°C (98.6°F), pulse is 120/min, respirations are 25/min, and blood pressure is 105/75 mm Hg.
Examination shows a large perinea! hematoma and blood at the urethral meatus. No other abnormalities are noted.
X-ray of the pelvis shows no abnormalities. Which of the following is the most appropriate next step in management?
0 A) Renal ultrasonography
0 B) Retrograde urethrography
0 C) CT scan of the abdomen
0 D) Intravenous pyelography
0 E) Insertion of a urinary catheter
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45. A 7-year-old Hispanic girl with a 1-year history of acute lymphocytic leukemia is brought to the physician for a routine
examination 6 weeks after starting treatment with two new chemotherapeutic medications. She has had decreased
appetite, nausea, and increasing hair loss since starting treatment. She was in remission until 2 months ago. The
child's parents state that there is an herbal remedy in Mexico that is believed to be a cure for their daughter's condition
with few side effects. They ask for the physician's help in obtaining the herbal remedy so they can discontinue their
daughter's current medications. Which of the following is the most appropriate response to the parents' request?
Q A) Advise them to continue her medications while investigating the information further
Q B) Contact child protective services
Q C) Dismiss the idea because it is unproven
Q D) Offer to add the herbal remedy to the patient's current regimen
Q E) Offer to transfer the daughter to a hospital in Mexico
Q F) Psychiatric assessment of parents
Q G) Recommend they find another physician if alternative medications are used
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46. A 6-year-old girl with nephrotic syndrome is brought to the physician because of a 2-day history of fever, abdominal
swelling, and loose stools. Her temperature is 39.4°C (103°F). Abdominal examination shows distention, diffuse
tenderness, and generalized rebound tenderness in all quadrants. Which of the following is the most likely diagnosis?
0 A) Celiac disease
0 B) Congenital megacolon (Hirschsprung disease)
0 C) Inflammatory bowel disease
0 D) Intussusception
0 E) Necrotizing enterocolitis
0 F) Spontaneous bacterial peritonitis
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47. A 2-week-old girl is brought for her first well-child examination. Newborn screening showed an increased
thyroid-stimulating hormone (TSH) concentration. Her mother takes propylthiouracil for hyperthyroidism. The patient is
active and eating well. Examination shows no abnormalities. Which of the following is the most appropriate
management of this patient?
0 A) Reassurance and follow-up examination in 1 month
0 B) Measurement of serum growth hormone concentration
0 C) Measurement of serum thyroid-binding globulin concentration
0 D) Measurement of serum thyroxine (T 4) and TSH concentrations
0 E) Thyroid scan
0 F) Levothyroxine therapy
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48. A female newborn is found to have mild cyanosis periorally and of the hands and feet 4 hours after birth. She was born
at 37 weeks' gestation following an uncomplicated pregnancy and spontaneous vaginal delivery. Apgar scores were
9 and 9 at 1 and 5 minutes, respectively. She weighs 3600 g (7 lb 15 oz). Her temperature is 37°C (98.6°F), pulse is
160/min, respirations are 60/min, and blood pressure is 90/40 mm Hg. The remainder of the examination shows no
Hemoglobin 15 g/dL
Hematocrit 45%
Leukocyte count 15,000/mm3
Platelet count 290,000/mm3
0 A) Acrocyanosis
0 B) Addison disease
0 C) Methemoglobinemia
0 D) Sickle cell disease
0 E) Tetralogy of Fallot
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49. A 9-year-old boy is admitted to the hospital for treatment of status asthmaticus. He is intubated and mechanically
ventilated . His temperature is 37°C (98.6°F), pulse is 145/min, respirations are 40/min, and blood pressure is 90/60
mm Hg. Examination shows decreased breath sounds over the right upper lobe. A chest x-ray shows the tip of the
endotracheal tube in the right main stem bronchus and haziness in the right upper lobe. Which of the following is the
most likely explanation for the x-ray findings?
0 A) Air trapping
0 B) Alveolar collapse
0 C) Bronchial dilation
0 D) Interstitial edema
0 E) Pleural effusion
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50. A 3-year-old girl is brought to the physician by her mother, who is concerned that her daughter might have been
abused . The mother states that her daughter has been touching her genital area since she began attending day care
6 weeks ago. The mother says, "I've heard about bad things happening to kids in day care." The patient is a picky
eater and is occasionally defiant. She has had intermittent nighttime awakening. She interacts well with other children
but sometimes does not want to share her toys. She separates from her mother after initial hesitation when dropped
off at the preschool. Her teacher reports no behavior problems. Today, the patient appears mildly anxious. Physical
examination shows no abnormalities. Which of the following is the most appropriate next step?
Q A) Reassure the mother that this is normal behavior

Q B) Interview the patient for suspected sexual abuse
Q C) Recommend parent management training
Q D) Recommend individual psychotherapy
Q E) Schedule an appointment with child protective services
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Pediatrics 6 - Questions v1

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Pediatrics 6 - Questions v1

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Exam Section : Item 1 of 50 National Board of Medical Examiners Time Remaining:

■ Mark Pediatrics Self-Assessment 4 hr 57 min 37 sec

0 A) Abnormality in type I collagen

0 C) Intrauterine trauma resulting from abuse to the mother

0 D) Placental insufficiency from cocaine use

0 D) Progressive infantile spinal muscular atrophy

0 A) Excessive intake of carbohydrates

0 B) Excessive intake of fat

0 C) Excessive intake of total calories

0 D) Inadequate intake of fruits and vegetables

0 E) Inadequate physical activity

0 E) Toxic epidermal necrolysis

0 B) Congenital megacolon (Hirschsprung disease) Q G) lntussusception

0 C) Duodenal atresia 0 H) Pancreatitis

0 D) Foreign body ingestion 0 I) Pyloric stenosis

0 E) Gastroesophageal reflux disease 0 J) Volvulus

0 A) Excessive intake of free water

0 B) Factitious hyponatremia due to hyperglycemia

0 C) Increased loss of chloride in the kidneys

0 D) Increased secretion of ADH (vasopressin)

0 E) Insufficient intake of sodium chloride

0 F) lntravascular volume depletion

0 A) Cervical spine hemivertebrae

0 D) Left clavicle fracture

Q A) Acute lymphocytic leukemia

0 A) Acute lymphocytic leukemia

0 B) Acute myelocytic leukemia

0 C) Chlamydia trachomatis infection

Q A) Delay the introduction of solid food until the age of 9 months

0 A) Anomalous pulmonary blood return

0 C) Increased systemic vascular resistance

0 D) Intermittent supraventricular tachycardia

0 A) Culture of the aspirate fluid

0 D) CT scan of the left sternoclavicular joint

0 E) Indium-labeled leukocyte scan

0 A) Congenital heart disease

0 E) Renal tubular acidosis

Q A) Follow-up blood pressure measurement in 1 week

0 A) X-ray of the abdomen

0 A) Tactile stimulation and oxygen therapy

0 C) Subcutaneous epinephrine therapy

0 D) Positive-pressure ventilation via face mask

0 A) Topical corticosteroid therapy

0 C) Oral antifungal therapy

0 A) X-ray of the abdomen

0 D) CT scan of the abdomen

0 A) Group B streptococcal sepsis

0 D) Pneumocystis jiroveci (formerly P. carinii) pneumonia

0 E) Respiratory syncytial virus pneumonia

Which of the following is the most likely diagnosis?

24. A 5-year-old boy is brought to the physician for a

A blood smear is shown. Which of the following is the

0 A) Antibiotic-induced autoimmune hemolysis

0 D) Transient postinfectious bone marrow

0 D) Type 2 diabetes mellitus

0 E) Urinary tract infection

0 B) Chronic granulomatous disease

0 E) Admission to the hospital for observation

0 D) Juvenile rheumatoid arthritis

Arterial blood gas analysis on room air shows:

Which of the following is the most likely acid-base disorder?

0 A) Lactic acidosis with respiratory compensation

0 B) Pure metabolic acidosis

0 C) Respiratory acidosis and metabolic compensation