Pediatric Examination and Board Review (211 page)

(B) obtain a CBC

(C) A and B

(D) administer IM antibiotics

(E) none of the above

5.
If a mother has a positive cervical culture for gonococcus (
N gonorrhoeae
) and was not treated before delivery, what would you do?

(A) culture the baby’s conjunctivae and wait for the results

(B) obtain a blood culture

(C) observe for illness before intervening

(D) give IM ceftriaxone 50 mg/kg, one time

(E) B and D

6.
If a mother has untreated
Chlamydia
at the time of delivery, what would you do?

(A) give a double dose of erythromycin ophthalmic ointment

(B) do a nasopharyngeal culture and wait for results

(C) start oral erythromycin

(D) monitor for signs and symptoms of infection

(E) A and B

7.
At the end of the first day of life, you see that no urine output has been recorded by the nurse for an otherwise well newborn with a normal examination. Your best course of action should be

(A) catheterize the bladder

(B) give 4 ounces of glucose water

(C) order a renal ultrasound

(D) do nothing but continue to observe

(E) give a 20 mL/kg bolus of IV fluids

8.
An 18-hour-old breastfeeding newborn spits yellow material after a feed. You should

(A) order an upper GI series

(B) observe

(C) order a lower GI series

(D) order a flat plate of the abdomen

(E) hold all feeds

9.
A 40-hour old formula-fed newborn has had no stools recorded in the nurses’ notes. The best course of action includes

(A) asking the mother if the baby has passed any stools

(B) ordering a glycerin suppository

(C) performing a rectal examination

(D) B and C

(E) ordering a suction rectal biopsy

10.
The mother of a 10-hour-old newborn wants the formula changed to soy because the baby has vomited the regular formula after taking 40 mL. The best course of action includes

(A) agreeing that the baby cannot tolerate the cow’s milk based formula

(B) taking a family history for lactose intolerance

(C) suggesting that the baby may have been overfed

(D) suggesting that a more elemental formula be used

(E) suggesting that a nurse perform the next feed for observational purposes

11.
The parents of a breast-fed baby girl tell you on day 2 that the baby is voiding blood. The best course of action includes

(A) order prothrombin time (PT) and partial thromboplastin time (PTT) determinations immediately

(B) explain to the parents that this is vaginal withdrawal bleeding and is normal

(C) order a renal ultrasound to look for renal vein thrombosis or tumor

(D) consult hematology/oncology

(E) consult urology

12.
The mother of a full-term 12-hour-old breast-fed baby is worried that the baby is sleepy and has had only one successful feeding. There is no history of diabetes in the mother. The mother’s rectovaginal culture obtained at 36 weeks’ gestation grew no GBS, and there was neither prolonged rupture of membranes before delivery nor signs of chorioamnionitis at time of delivery. The next best step you should do is

(A) order a glucose screen

(B) order the nurse to feed formula

(C) ask the mother to put the baby skin to skin with her

(D) order a glucose water feeding

(E) turn the heat up in the mother’s room

13.
On the admission for physical examination in the nursery, you note a grade 2/6 ejection systolic murmur at the upper left sternal border of an otherwise healthy newborn. The best course of action includes

(A) tell the parents that the baby might have congenital heart disease

(B) request a cardiac consult

(C) observe

(D) transfer to the NICU

(E) obtain a blood gas

14.
On physical examination at 50 hours, you find a grade 3/6 systolic murmur at the lower left sternal border. The best course of action includes

(A) discharge the baby with instructions to follow up with a pediatrician in 48 hours

(B) tell the parents the baby might have congenital heart disease

(C) request a cardiac consult

(D) order an ECG and measure the oxygen saturation

(E) C and D

15.
At the time of discharge of a 2-day-old term baby, you tell the parents to

(A) make an appointment with their pediatrician for a 2-week visit

(B) see how things go and call the pediatrician as needed

(C) book a pediatric visit before leaving the hospital for 1-2 days after discharge

(D) book a pediatric visit before leaving the hospital for 3-4 days after discharge

(E) A and B

ANSWERS

1.
(E)
In most hospitals, IM vitamin K and prophylaxis for conjunctivitis are administered in the birth room. Vitamin K is not absorbed after oral administration. The hepatitis B vaccine series is ideally initiated at birth but seldom in the delivery room.

2.
(E)
A term AGA baby is not at high risk for hypoglycemia. Babies at risk for hypoglycemia include those who are SGA, LGA, infants of diabetic moms, and premature babies. A routine hematocrit is not needed. The hematocrit should be done if the baby looks pale or ruddy.

3.
(D)
Because the baby was born at term and there are no other risk factors such as prolonged rupture of membranes more than 18 hours, maternal fever, history of a sibling with early-onset GBS disease, or urine culture positive for GBS during this pregnancy, no further workup or treatment is indicated.

4.
(E)
The baby is of term gestation; there are no other risk factors except mother’s colonization, and she has received adequate intrapartum antibiotic treatment.

5.
(E)
One dose of IM ceftriaxone should be given to babies born to mothers with untreated gonococcal infection. A conjunctival and blood culture should be done before treatment.

6.
(D)
Until recently, the AAP recommended that babies born to mothers with untreated
Chlamydia
infection should be treated with erythromycin for 14 days. Because the efficacy of prophylactic treatment is not known and there are reports linking erythromycin use in neonates to hypertrophic pyloric stenosis, the AAP now recommends that only infected infants should be treated. So nothing should be done at birth.

7.
(D)
If the baby has been feeding well, looks well, appears to be well hydrated, and the examination is normal, chances are that the baby had passed urine but it was not recorded.

8.
(B)
A small amount of spitting is common and most likely normal. The color of the vomitus is important. If there is any history of the baby vomiting bile or blood, further investigation should be done. In this patient who is being breast-fed, the yellow spitup is more than likely breast milk itself if the abdominal examination is normal. So no workup is indicated at this time.

9.
(A)
Most newborn babies (98%) pass meconium in the first 24 hours of life. Delayed meconium passage beyond 48 hours in an otherwise healthy full-term infant suggests Hirschsprung disease. Begin the evaluation by asking the mother to confirm the history.

10.
(C)
Generally a 10-hour-old baby will take anywhere from 15 to 30 mL per feeding.

11.
(B)
Pseudomenses or withdrawal bleeding can occur in normal newborn baby girls in the first few days of life.

12.
(C)
Because there is no history of diabetes in the mother and the neonate is full term, problems with hypoglycemia are less likely. Administration of glucose water is no longer an accepted practice and does nothing to help encourage breastfeeding in the neonate. Formula usually is not offered to healthy breastfeeding neonates and may actually interfere with successful breastfeeding in neonates. Turning up the heat in the room does not help arouse the neonate and may actually make the neonate sleepier.

13.
(C)
A grade II/VI murmur on the first day of life is most likely secondary to transition from in utero to extrauterine life and is a result of a PDA, or, alternatively, a sign of tricuspid regurgitation. An ECG, a chest radiograph, and an echocardiogram would be useful first steps.

14.
(C)
A murmur grade III/VI or louder on day 3 needs to be evaluated by a cardiologist. A chest x-ray, EKG, and echocardiogram will likely be necessary.

15.
(C)
The AAP recommends that babies discharged early be seen by a physician within 2 days of going home to assess bilirubin problems or feeding issues.

S
UGGESTED
R
EADING

Martin R, Fanaroff AA, Walsh M.
Fanaroff and Martin’s
Neonatal-Perinatal Medicine Diseases of the Fetus and Infant.
8th ed. Chicago, IL: Elsevier Mosby; 2006.

Puig G, Sguassero Y. Early skin-to-skin contact for mothers and their healthy newborn infants: RHL commentary (last revised November 9, 2007). The WHO Reproductive Health Library. Geneva, Switzerland: World Health Organization.