A 3-year-old with suspected abuse is stable; you note patterned bruising and tenderness without obvious deformity. What is the most appropriate next step in the management of this patient?
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USMLE Step 2 Quiz
Practice Pediatric Emergencies And Acute Care in USMLE Step 2 with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.
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A 3-year-old with suspected abuse is stable; you note patterned bruising and tenderness without obvious deformity. What is the most appropriate next step in the management of this patient?
This quiz focuses on Pediatric Emergencies And Acute Care, giving you a quick way to practice the rules, question types, and explanations that matter most for USMLE Step 2.
Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.
A 3-year-old with suspected abuse is stable; you note patterned bruising and tenderness without obvious deformity. What is the most appropriate next step in the management of this patient?
Explanation: This question tests the ability to manage pediatric emergencies and acute care situations, focusing on rapid identification and intervention. Pediatric emergencies require prompt recognition of symptoms and immediate management to stabilize the patient while minimizing harm. In this scenario, the child presents with suspected abuse, stable condition, patterned bruising, and tenderness without obvious deformity, indicating a need for skeletal survey and evaluation. Choice A is correct because it aligns with guidelines for managing suspected child abuse, ensuring timely and effective care. Choice B is incorrect as it suggests avoiding imaging to limit radiation and sending home with instructions, which could worsen the child's condition or delay necessary treatment. To prepare for similar questions, students should familiarize themselves with pediatric emergency protocols, ensure understanding of age-specific presentations, and practice applying clinical guidelines in time-sensitive scenarios. Watch for: recognizing subtle signs of distress, avoiding assumptions based on adult protocols.
A 10-year-old girl fell off a bicycle; she is pale, anxious, HR 150, BP 78/42, cool extremities, capillary refill 5 seconds. What is the most appropriate initial management for this child's condition?
Explanation: This question tests the ability to manage pediatric emergencies and acute care situations, focusing on rapid identification and intervention. Pediatric emergencies require prompt recognition of symptoms and immediate management to stabilize the patient while minimizing harm. In this scenario, the child presents with pallor, anxiety, HR 150, BP 78/42, cool extremities, and capillary refill 5 seconds after falling off a bicycle, indicating a need for fluid resuscitation. Choice A is correct because it aligns with guidelines for managing hypovolemic shock, ensuring timely and effective care. Choice E is incorrect as it suggests administering furosemide to prevent fluid overload, which could worsen the child's condition or delay necessary treatment. To prepare for similar questions, students should familiarize themselves with pediatric emergency protocols, ensure understanding of age-specific presentations, and practice applying clinical guidelines in time-sensitive scenarios. Watch for: recognizing subtle signs of distress, avoiding assumptions based on adult protocols.
A 15-year-old with type 1 diabetes is confused and vomiting; glucose 520 mg/dL, pH 7.12, K 5.6. What is the most appropriate initial management for this child's condition?
Explanation: This question tests the ability to manage pediatric emergencies and acute care situations, focusing on rapid identification and intervention. Pediatric emergencies require prompt recognition of symptoms and immediate management to stabilize the patient while minimizing harm. In this scenario, the child presents with confusion, vomiting, glucose 520 mg/dL, pH 7.12, and K 5.6 in type 1 diabetes, indicating a need for fluid resuscitation followed by insulin. Choice A is correct because it aligns with guidelines for managing diabetic ketoacidosis, ensuring timely and effective care. Choice C is incorrect as it suggests starting insulin bolus without IV fluids to reduce glucose quickly, which could worsen the child's condition or delay necessary treatment. To prepare for similar questions, students should familiarize themselves with pediatric emergency protocols, ensure understanding of age-specific presentations, and practice applying clinical guidelines in time-sensitive scenarios. Watch for: recognizing subtle signs of distress, avoiding assumptions based on adult protocols.
A 2-year-old girl has bruises in different stages on trunk and ears; caregiver history changes; child is quiet but stable. What is the most appropriate next step in the management of this patient?
Explanation: This question tests the ability to manage pediatric emergencies and acute care situations, focusing on rapid identification and intervention. Pediatric emergencies require prompt recognition of symptoms and immediate management to stabilize the patient while minimizing harm. In this scenario, the child presents with bruises in different stages on trunk and ears, changing caregiver history, and is quiet but stable, indicating a need for abuse reporting. Choice A is correct because it aligns with guidelines for managing suspected child abuse, ensuring timely and effective care. Choice B is incorrect as it suggests discharging with routine follow-up since vitals are normal, which could worsen the child's condition or delay necessary treatment. To prepare for similar questions, students should familiarize themselves with pediatric emergency protocols, ensure understanding of age-specific presentations, and practice applying clinical guidelines in time-sensitive scenarios. Watch for: recognizing subtle signs of distress, avoiding assumptions based on adult protocols.
A 6-year-old has fever, headache, confusion, and petechiae; vitals show HR 150, BP 88/46, SpO2 95%. What is the most appropriate initial management for this child's condition?
Explanation: This question tests the ability to manage pediatric emergencies and acute care situations, focusing on rapid identification and intervention. Pediatric emergencies require prompt recognition of symptoms and immediate management to stabilize the patient while minimizing harm. In this scenario, the child presents with fever, headache, confusion, petechiae, HR 150, BP 88/46, and SpO₂ 95%, indicating a need for empiric antibiotics. Choice A is correct because it aligns with guidelines for managing suspected meningococcemia, ensuring timely and effective care. Choice B is incorrect as it suggests performing lumbar puncture before giving any antibiotics, which could worsen the child's condition or delay necessary treatment. To prepare for similar questions, students should familiarize themselves with pediatric emergency protocols, ensure understanding of age-specific presentations, and practice applying clinical guidelines in time-sensitive scenarios. Watch for: recognizing subtle signs of distress, avoiding assumptions based on adult protocols.
A 2-year-old girl is suddenly lethargic and confused; fingerstick glucose is 38 mg/dL, no seizure activity. What is the most appropriate initial management for this child's condition?
Explanation: This question tests the ability to manage pediatric emergencies and acute care situations, focusing on rapid identification and intervention. Pediatric emergencies require prompt recognition of symptoms and immediate management to stabilize the patient while minimizing harm. In this scenario, the child presents with sudden lethargy and confusion with fingerstick glucose 38 mg/dL and no seizure activity, indicating a need for glucose correction. Choice A is correct because it aligns with guidelines for managing hypoglycemia, ensuring timely and effective care. Choice B is incorrect as it suggests ordering head CT before treating to exclude intracranial pathology, which could worsen the child's condition or delay necessary treatment. To prepare for similar questions, students should familiarize themselves with pediatric emergency protocols, ensure understanding of age-specific presentations, and practice applying clinical guidelines in time-sensitive scenarios. Watch for: recognizing subtle signs of distress, avoiding assumptions based on adult protocols.
A 12-year-old with suspected hemorrhagic shock is receiving resuscitation; bedside FAST is positive for free fluid. What is the most appropriate next step in the management of this patient?
Explanation: This question tests the ability to manage pediatric emergencies and acute care situations, focusing on rapid identification and intervention. Pediatric emergencies require prompt recognition of symptoms and immediate management to stabilize the patient while minimizing harm. In this scenario, the child presents with suspected hemorrhagic shock and positive bedside FAST for free fluid during resuscitation, indicating a need for surgical consultation. Choice A is correct because it aligns with guidelines for managing abdominal trauma with instability, ensuring timely and effective care. Choice B is incorrect as it suggests discontinuing resuscitation and prioritizing CT with IV contrast, which could worsen the child's condition or delay necessary treatment. To prepare for similar questions, students should familiarize themselves with pediatric emergency protocols, ensure understanding of age-specific presentations, and practice applying clinical guidelines in time-sensitive scenarios. Watch for: recognizing subtle signs of distress, avoiding assumptions based on adult protocols.
A 6-week-old infant is brought to the emergency department for irritability, poor feeding, and a fever of 39.0°C (102.2°F). On examination, the infant is lethargic, has a high-pitched cry, and the anterior fontanelle is noted to be full and tense. Vital signs are stable after a fluid bolus, and IV access is established.
After blood cultures are drawn, what is the most critical next step in management?
Explanation: This infant presents with signs and symptoms highly concerning for bacterial meningitis (fever, lethargy, bulging fontanelle). In infants with suspected meningitis, prompt administration of empiric antibiotics is critical to prevent morbidity and mortality. While a lumbar puncture (LP) is essential for diagnosis, antibiotic administration should not be delayed if the LP cannot be performed immediately. The principle 'time is brain' applies, and the benefits of early antibiotic therapy far outweigh the minimal impact on the diagnostic yield of the cerebrospinal fluid if there is a short delay. A head CT is generally not required before an LP in an infant unless there are focal neurologic deficits or signs of herniation.
A 4-month-old infant presents with vomiting and increased irritability over the past 12 hours. The caregiver reports the infant fell from a couch two days ago but seemed fine afterward. Today, the infant had a brief generalized seizure. On examination, the infant is lethargic, has a heart rate of 80/min, and a bulging anterior fontanelle. There are no external signs of trauma.
Which of the following is the most appropriate initial imaging study to evaluate for an intracranial injury?
Explanation: In an infant presenting with altered mental status, seizures, and signs of increased intracranial pressure (bulging fontanelle, bradycardia - Cushing's triad component), an emergent evaluation for intracranial pathology is required. A non-contrast head CT scan is the imaging modality of choice in the acute setting because it is fast, widely available, and highly sensitive for detecting acute hemorrhage (subdural, epidural, subarachnoid, or intraparenchymal), which is a major concern in this case, especially given the history of a fall. While head ultrasound can be used, it is less sensitive for peripheral bleeds. MRI provides greater detail but is time-consuming and often requires sedation, making it less suitable for an unstable patient. Skull films are useful for fractures but do not visualize the brain parenchyma or bleeding.
A 4-year-old unvaccinated girl is brought to the emergency department with a 6-hour history of high fever, sore throat, and difficulty swallowing. She is sitting upright, leaning forward on her hands, and drooling. Her voice is muffled. Her temperature is 40.0°C (104°F), heart rate is 140/min, and respiratory rate is 34/min. She appears anxious and is in moderate respiratory distress.
What is the most appropriate immediate next step in management?
Explanation: This patient's presentation with high fever, drooling, dysphagia, and the characteristic 'tripod' posture is highly suggestive of epiglottitis, a life-threatening emergency. The primary concern is acute airway obstruction. Therefore, the most critical immediate step is to secure the airway in a controlled environment, typically an operating room with an anesthesiologist and otolaryngologist present. Any attempt to visualize the pharynx (e.g., with a tongue depressor) or cause distress (e.g., by taking the child for an X-ray) can precipitate laryngospasm and complete airway obstruction. While antibiotics and steroids are part of the treatment, they are administered only after the airway is secured.
A 6-month-old infant is brought to the clinic in November with a 3-day history of rhinorrhea, cough, and fussiness. Today, the mother notes he is breathing fast and not feeding well. On examination, the infant has a respiratory rate of 65/min with subcostal retractions and diffuse expiratory wheezes. His oxygen saturation is 91% on room air.
Which of the following interventions is most likely to improve this infant's clinical condition?
Explanation: This infant has bronchiolitis, a viral lower respiratory tract infection (most commonly caused by RSV) characterized by inflammation and obstruction of the small airways. The clinical presentation of tachypnea, wheezing, and retractions in a child under two years old is classic. The mainstay of management is supportive care, which includes ensuring adequate hydration, nasal suctioning to clear secretions, and supplemental oxygen for hypoxemia (typically defined as SpO2 <90-92%). Routine use of bronchodilators (albuterol), corticosteroids, and chest physiotherapy has not been shown to be effective and is not recommended.
An 18-month-old boy is brought to the emergency department after a sudden episode of choking, coughing, and gasping while playing and eating nuts. The episode resolved, but his mother notes he has had a persistent cough. On examination, he is in no acute distress. Auscultation of the chest reveals decreased air entry on the right side and a focal expiratory wheeze.
What is the most appropriate next step in the management of this child?
Explanation: The history of a choking episode followed by respiratory symptoms, along with the physical finding of unilateral wheezing, is highly suspicious for foreign body aspiration. Even if a chest X-ray is normal or shows non-specific findings like air trapping, the clinical suspicion warrants further investigation. Rigid bronchoscopy is the gold standard for both diagnosis and removal of an airway foreign body. Flexible bronchoscopy is primarily diagnostic. Abdominal thrusts are only for a patient with an active, complete airway obstruction. While X-rays can be suggestive, a negative X-ray does not rule out aspiration, and bronchoscopy is still indicated based on the history and physical exam.
A 3-year-old girl is brought to the emergency department with a 2-day history of fever and malaise. She is now lethargic and difficult to arouse. Her temperature is 40.0°C (104°F), heart rate is 165/min, blood pressure is 65/40 mm Hg, and respiratory rate is 40/min. Her extremities are cool with a capillary refill time of 5 seconds. After receiving two 20 mL/kg boluses of normal saline, her blood pressure remains 68/42 mm Hg and her mental status has not improved.
Which of the following is the most appropriate next therapeutic step?
Explanation: This patient is in fluid-refractory septic shock, also known as 'cold shock' due to her cool extremities and poor perfusion. After adequate fluid resuscitation (typically 40-60 mL/kg), persistent hypotension necessitates the initiation of vasoactive agents. In pediatric cold shock, epinephrine is often the first-line vasopressor because it provides both inotropic support (improves contractility) and vasoconstriction (increases systemic vascular resistance). Norepinephrine is typically preferred for 'warm shock'. While hydrocortisone may be considered for catecholamine-resistant shock, a vasopressor is the immediate next step. Blood transfusion is only indicated for hemorrhage or severe anemia.
A 16-year-old male is brought to the trauma bay after a high-speed motor vehicle collision. He is intubated in the field for respiratory distress. Upon arrival, his blood pressure is 80/50 mm Hg and heart rate is 140/min. On physical examination, there are no breath sounds over the left hemithorax, his trachea is deviated to the right, and his neck veins are distended.
What is the most appropriate immediate action?
Explanation: This patient has clinical signs of a tension pneumothorax, which is causing obstructive shock. The classic triad is hypotension, jugular venous distension, and absent breath sounds on the affected side. Tracheal deviation is a late and ominous sign. This is a clinical diagnosis that requires immediate intervention without waiting for radiographic confirmation, as delay can be fatal. The immediate life-saving procedure is needle decompression (thoracostomy) in the second intercostal space at the midclavicular line. This converts the tension pneumothorax to a simple pneumothorax, relieving the pressure on the mediastinal structures and improving venous return. A chest tube is then placed as a definitive treatment, but needle decompression is the faster, emergent step.
A 6-year-old girl with a known diagnosis of epilepsy is brought to the emergency department. Her mother reports she has been having a generalized tonic-clonic seizure for the past 10 minutes without returning to consciousness. Paramedics have established an IV line and are administering oxygen.
What is the most appropriate initial medication to administer to terminate the seizure?
Explanation: This patient is in status epilepticus, defined as a single seizure lasting longer than 5 minutes or multiple seizures without a return to baseline. The first-line treatment for status epilepticus is a benzodiazepine due to its rapid onset of action. Intravenous (IV) lorazepam is the preferred agent in a patient with established IV access. If IV access is not available, intramuscular midazolam or rectal diazepam can be used. Second-line agents, such as fosphenytoin, levetiracetam, or valproic acid, are administered if the seizure persists after adequate doses of benzodiazepines.
A 5-month-old infant is brought to the pediatrician for evaluation of leg swelling and fussiness. The parents state the infant rolled off the bed yesterday, a height of about 2 feet. The infant is not yet crawling. On examination, there is swelling and tenderness over the right thigh. An X-ray reveals a spiral fracture of the mid-shaft of the femur.
In addition to consulting orthopedics for fracture management, what is the most appropriate next step?
Explanation: A spiral femur fracture in a non-ambulatory infant is highly suspicious for non-accidental trauma. The mechanism described (rolling off a bed) is inconsistent with the force required to cause this type of fracture. Physicians have a legal and ethical obligation to report suspected child abuse. The standard of care in this situation is to admit the child to the hospital, obtain a full skeletal survey to look for other occult fractures of different ages, perform a funduscopic exam and head imaging, and make a report to Child Protective Services (CPS). Reassurance is inappropriate, and discharge would place the child at risk.
During a routine well-child visit for a 3-year-old boy, the physician notes several well-demarcated, loop-shaped bruises on the child's lower back and buttocks. When asked, the mother states the child is very clumsy and 'bruises like a peach.' The child is quiet and avoids eye contact with the physician.
What is the physician's most appropriate and legally mandated action?
Explanation: Patterned bruises, such as the loop-shaped marks described (suggestive of being struck with a cord or belt), are pathognomonic for physical abuse. The location of the bruises (back and buttocks) is also not typical for accidental injuries in a toddler. While a bleeding disorder is a consideration for extensive bruising, patterned injuries strongly point to an external object as the cause. All physicians in the United States are mandated reporters of suspected child abuse and neglect. The physician's primary responsibility is to ensure the child's safety, which requires making a report to Child Protective Services or the equivalent state agency for further investigation.
An unresponsive 15-year-old is brought to the emergency department by friends. They state he was found unconscious at a party. Vital signs are: heart rate 55/min, blood pressure 90/60 mm Hg, respiratory rate 6/min, and oxygen saturation 85% on room air. Physical examination reveals constricted, pinpoint pupils. Needle tracks are noted on his arms.
Administration of which of the following is most likely to rapidly reverse this patient's condition?
Explanation: This patient's clinical presentation, consisting of the classic triad of central nervous system depression (unresponsive), respiratory depression (RR 6/min), and pupillary constriction (miosis), is pathognomonic for opioid toxicity. Naloxone is a competitive opioid antagonist that can rapidly reverse the effects of opioids. Flumazenil is a benzodiazepine antagonist. Sodium bicarbonate is used for tricyclic antidepressant overdose. N-acetylcysteine is the antidote for acetaminophen toxicity. Given the clinical picture, naloxone is the indicated emergent treatment.
A 2-year-old boy is brought to the emergency department by his parents in the evening with a 1-day history of a harsh, barking cough and noisy breathing. His symptoms are worse at night. He has a low-grade fever of 38.1°C (100.6°F). On examination, he is alert and has coarse, inspiratory stridor at rest. His respiratory rate is 32/min, and oxygen saturation is 96% on room air. Lung auscultation is clear bilaterally.
Which of the following is the most appropriate initial pharmacologic treatment for this child?
Explanation: This patient presents with classic signs and symptoms of moderate croup (laryngotracheitis), characterized by a barking cough and inspiratory stridor at rest. The mainstay of treatment for all forms of croup, including mild to severe, is a single dose of corticosteroids, such as dexamethasone. Corticosteroids reduce airway inflammation and edema, improving symptoms. Nebulized racemic epinephrine is reserved for patients with more severe croup who have significant respiratory distress or impending respiratory failure, as it provides rapid but temporary vasoconstriction of the upper airway mucosa. Albuterol is used for bronchospasm, which is not a feature of croup. Antibiotics like ceftriaxone are not indicated as croup is typically caused by a virus (parainfluenza virus).
A 9-month-old infant is brought to the emergency department with a 3-day history of profuse watery diarrhea and vomiting. The mother reports decreased urine output for 12 hours. On examination, the infant is lethargic, with a sunken anterior fontanelle and dry mucous membranes. Vital signs are: heart rate 180/min, blood pressure 70/45 mm Hg, respiratory rate 50/min, and temperature 37.0°C (98.6°F). Capillary refill is 4 seconds.
What is the most appropriate initial step in management?
Explanation: This infant is in compensated hypovolemic shock secondary to gastroenteritis, as evidenced by tachycardia, delayed capillary refill, and lethargy, despite a blood pressure that is low-normal for age. The cornerstone of initial management is rapid volume expansion to restore intravascular volume and improve perfusion. The standard approach is to administer a 20 mL/kg bolus of an isotonic crystalloid, such as 0.9% saline or Lactated Ringer's solution, over 5-20 minutes. Maintenance fluids containing dextrose are inappropriate for initial resuscitation. Vasopressors are considered only if the patient remains hypotensive despite adequate fluid resuscitation. Diagnostic workup like stool cultures is secondary to immediate stabilization.