Child Abuse and Neglect, SUID and SIDS, BRUE, and the Death of a Child Practice Questions

25 multiple-choice questions on Child abuse and neglect, SUID and SIDS, BRUE, and the death of a child for paramedic and EMT students, from Chapter 44 (Pediatric Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. The most common form of child maltreatment reported in the United States is:

   1. A. Physical abuse
   2. B. Neglect
   3. C. Sexual abuse
   4. D. Emotional abuse
   Show answer

   Answer: B. Neglect

   Neglect, the failure to provide food, shelter, supervision, medical care, or safety, accounts for most substantiated maltreatment cases. Physical abuse is more visible but less common.

2. Under the TEN-4-FACESp bruising rule, bruising on which areas in a child 4 years or younger should raise concern for abuse?

   1. A. Shins, knees, and forehead
   2. B. Elbows, palms, and chin
   3. C. Torso, ears, and neck
   4. D. Forearms, hands, and knees
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   Answer: C. Torso, ears, and neck

   TEN stands for torso, ears, and neck, areas rarely bruised by accident; FACESp adds the frenulum, angle of the jaw, cheeks, eyelids, subconjunctivae, and patterned bruises. Shins, knees, and forehead are typical sites of accidental bruising in active toddlers.

3. A 3-month-old has a small bruise on his cheek. His parents say it happened when he rolled off the bed. This is concerning mainly because:

   1. A. Cheek bruises are common in infants
   2. B. Any bruise is suspicious at this age
   3. C. Rolling begins by 1 month of age
   4. D. Bruises at this age are birth-related
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   Answer: B. Any bruise is suspicious at this age

   Under the TEN-4 rule, any bruise in an infant younger than 4 months is a red flag because infants who do not yet cruise rarely bruise; most do not roll until about 4 to 6 months. The history is also developmentally unlikely.

4. Which household factor most increases a young child's risk of fatal maltreatment?

   1. A. An unrelated adult living in the home
   2. B. Both biological parents living at home
   3. C. Grandparents living nearby
   4. D. An older sibling at home
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   Answer: A. An unrelated adult living in the home

   In a large population study, children living with an unrelated adult were about eight times more likely to die of maltreatment than children living with two biological parents. Two biological parents had the lowest risk. Nearby grandparents and older siblings are not risk factors and often provide support. (Stiffman et al., Pediatrics 2002.)

5. A tired parent says her 6-week-old cries for hours and she feels she might lose control. The best advice is to:

   1. A. Rock her hard until she stops
   2. B. Give her a little cough syrup
   3. C. Put cereal in her bottle tonight
   4. D. Put her down safely, step away
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   Answer: D. Put her down safely, step away

   The Period of PURPLE Crying program teaches that crying peaks around 6 to 8 weeks and that an overwhelmed caregiver should place the baby on her back in a safe crib, walk away to calm down, and call for help; never shake a baby. Hard rocking can injure the brain. Cough and cold medicines are dangerous in infants. Cereal in a bottle is a choking risk and does not stop crying. (National Center on Shaken Baby Syndrome; Barr et al., Pediatrics 2009.)

6. A 3-year-old has a triangular burn on his back with sharp edges in the shape of a clothes iron. This pattern most suggests:

   1. A. A splash from a hot drink
   2. B. An intentional contact burn
   3. C. A scald from bathwater
   4. D. A spreading bacterial skin infection
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   Answer: B. An intentional contact burn

   A burn with crisp edges matching the outline of a hot object, such as an iron, curling iron or lighter, on a protected area like the back is typical of an inflicted contact burn; document and report. Splash burns have irregular edges and drip marks. Bathwater scalds follow the waterline. An infection does not take the shape of an object. (Christian, AAP 2015.)

7. A 5-year-old has several U-shaped bruises on the backs of his thighs. These are most consistent with:

   1. A. Being hit with a looped cord
   2. B. Normal play on a playground
   3. C. A bleeding disorder
   4. D. Contact dermatitis from clothes
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   Answer: A. Being hit with a looped cord

   Loop-shaped or U-shaped bruises are patterned injuries made by a folded cord, belt or wire and are a red flag for physical abuse. Playground falls injure bony leading edges such as shins, knees and forehead. A bleeding disorder causes bruises without a pattern. Contact dermatitis is an itchy rash, not a bruise. (Christian, AAP 2015.)

8. Which history finding is most suggestive of child abuse?

   1. A. A prompt call for help after the injury
   2. B. A consistent story from each caregiver
   3. C. A mechanism inconsistent with development
   4. D. Injuries over bony prominences such as shins
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   Answer: C. A mechanism inconsistent with development

   A mechanism the child is developmentally incapable of, such as an infant who cannot crawl climbing out of a crib, is a red flag. Injuries over bony prominences like the knees and forehead are typical of accidents.

9. A 6-year-old has streaky brown-red marks on her hands and forearms a day after squeezing limes outdoors on a sunny day. These marks most likely represent:

   1. A. Inflicted slap bruises
   2. B. Cigarette burns
   3. C. Immersion burns
   4. D. Phytophotodermatitis
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   Answer: D. Phytophotodermatitis

   Lime and other citrus juices react with sunlight to cause phytophotodermatitis, streaky or drip-shaped red to brown marks that can be mistaken for bruises or burns; the history and pattern explain it. Slap bruises show finger outlines. Cigarette burns are round, uniform craters. Immersion burns have sharp waterlines. (Christian, AAP 2015, abuse mimics.)

10. A 4-year-old has a minor forearm bruise, you suspect abuse, and the parent refuses transport. You should:

    1. A. Accept the refusal and leave
    2. B. Take the child without telling the parent
    3. C. Call police and medical control
    4. D. Confront the parent about the abuse
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    Answer: C. Call police and medical control

    When abuse is suspected and a caregiver refuses care, law enforcement can take the child into protective custody, and medical control can guide you; document carefully and report as required. Leaving the child fails your duty to protect and report. Removing a child without authority can create legal and safety problems. Confronting the parent can escalate danger. (Caroline 9th ed.)

11. When documenting bruises on a child you suspect is being abused, you should:

    1. A. Describe size, color, and location
    2. B. Estimate their age from the color
    3. C. Record the largest bruise and skip others
    4. D. Wait for the hospital to describe them
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    Answer: A. Describe size, color, and location

    Describe each bruise objectively by size, shape, color and location, and quote the caregiver's explanation, because the scene picture you record is valuable evidence. Bruise color does not reliably show its age, so avoid dating bruises. Every bruise matters, not just the largest. The hospital did not see the scene or the early findings. (Maguire et al., Arch Dis Child 2005; Christian, AAP 2015.)

12. The father of an injured toddler becomes hostile when you ask how the injury happened. You should:

    1. A. Confront him about the inconsistencies in his story
    2. B. Stay calm and focus on transporting the child
    3. C. Leave the child at home with the father
    4. D. Question the child about the abuse
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    Answer: B. Stay calm and focus on transporting the child

    Avoid accusations, which can escalate danger and lead to refusal of transport; your priority is to get the child to safety and report your concerns. Request law enforcement if the scene becomes unsafe.

13. A 10-year-old with type 1 diabetes has had five DKA episodes this year because his insulin is repeatedly not given at home despite teaching. This pattern is best described as:

    1. A. Insulin resistance
    2. B. Factitious disorder
    3. C. Type 2 diabetes
    4. D. Medical neglect
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    Answer: D. Medical neglect

    Repeated failure of caregivers to provide necessary treatment that causes harm, after they have been taught, is medical neglect and must be reported. Insulin resistance is not the problem when insulin is not being given. Factitious disorder involves fabricating or inducing illness, not omitting care. Type 2 diabetes does not explain repeated DKA from missed insulin. (Caroline 9th ed.)

14. When caring for a child who may have been sexually abused, you should:

    1. A. Avoid detailed questioning about the event
    2. B. Examine the genitalia in detail at the scene
    3. C. Have the child bathe before transport
    4. D. Ask the child to identify the abuser
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    Answer: A. Avoid detailed questioning about the event

    Detailed questioning should be left to trained forensic interviewers to avoid further trauma and contaminating the investigation; treat injuries and preserve evidence. Bathing destroys evidence.

15. Sudden unexpected infant death (SUID) includes SIDS, deaths of unknown cause, and:

    1. A. Deaths from known heart defects
    2. B. Deaths in children over 2 years
    3. C. Deaths during planned surgery
    4. D. Accidental suffocation in bed
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    Answer: D. Accidental suffocation in bed

    SUID is the umbrella term for sudden, unexpected deaths of infants under 1 year, made up of SIDS, unknown causes, and accidental suffocation and strangulation in bed. Expected deaths from known heart disease are not SUID. Children over 2 are beyond the infant age range. Deaths during planned surgery are not sudden unexpected infant deaths. (CDC SUID and SIDS.)

16. Under the 2022 AAP safe sleep recommendations, offering a pacifier at nap and bedtime:

    1. A. Raises the risk of choking at night
    2. B. Should wait until after age 1
    3. C. Is linked to a lower SIDS risk
    4. D. Is linked to a higher SIDS risk
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    Answer: C. Is linked to a lower SIDS risk

    The AAP recommends offering a pacifier at nap and bedtime because its use is associated with a lower risk of SIDS; for breastfed infants, start once breastfeeding is well established, and do not hang it on a cord. It does not raise choking risk. Waiting until age 1 misses the peak SIDS period. It lowers, not raises, the risk. (Moon et al., Pediatrics 2022.)

17. Under the 2022 AAP guidance, an infant should sleep:

    1. A. In the parents' bed, between the two parents
    2. B. In the parents' room, on a separate surface
    3. C. On a sofa with a parent for warmth
    4. D. In a separate room from 1 week of age
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    Answer: B. In the parents' room, on a separate surface

    The AAP recommends room-sharing without bed-sharing, with the infant on a separate, firm, flat surface in the parents' room, ideally for at least the first 6 months. Bed-sharing raises the risk of sleep-related death. Sleeping with an adult on a sofa or armchair carries the highest risk. A separate room loses the protective effect of room-sharing. (Moon et al., Pediatrics 2022.)

18. At an infant death scene where resuscitation is not started because of obvious signs of death, it is most important to document:

    1. A. The parents' guess about the cause
    2. B. The infant's birth weight
    3. C. The infant's vaccination dates
    4. D. How and where the infant was found
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    Answer: D. How and where the infant was found

    Investigators rely on EMS for the infant's position, the sleep surface, bedding and objects nearby, who else was in the bed, and the room temperature, so record these carefully and disturb the scene as little as possible. The parents' theory of the cause and the infant's birth weight may be noted, but neither replaces an exact description of the sleep position and surroundings. Vaccination dates are obtained later and do not cause SIDS. (CDC SUIDI reporting form.)

19. When evaluating an infant who has died of SIDS, dependent lividity may be mistaken for:

    1. A. Petechiae from sepsis
    2. B. A diaper rash
    3. C. Bruising from abuse
    4. D. A birthmark
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    Answer: C. Bruising from abuse

    Blood pooling in dependent areas after death can resemble bruising and lead to false accusations; note its location relative to how the infant was found. Document findings objectively without drawing conclusions.

20. The 4-year-old sibling of an infant who just died keeps asking when the baby is coming back. Preschool children often:

    1. A. Understand death as adults do
    2. B. Think death can be reversed
    3. C. Show no reaction to a death
    4. D. Accept the death after one talk
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    Answer: B. Think death can be reversed

    Children about 3 to 5 years old often see death as temporary or reversible, so they need simple, honest words such as 'died' and repeated explanations; most understand that death is permanent by about 5 to 7 years. They do not yet understand death as adults do, and a single conversation is rarely enough. They react, often through behavior changes or regression. (AAP, Supporting the Grieving Child and Family, 2016.)

21. Under the AAP criteria, which feature makes a BRUE in an infant higher risk?

    1. A. Age younger than 60 days
    2. B. An event of 20 seconds
    3. C. Full-term birth at 39 weeks
    4. D. A first-ever episode
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    Answer: A. Age younger than 60 days

    The AAP defines a lower-risk BRUE as an infant older than 60 days, born at 32 weeks or later (corrected age at least 45 weeks), with a first event lasting under 1 minute and no CPR by a trained provider; age under 60 days makes the event higher risk. An event of 20 seconds, term birth, and a first episode are all lower-risk features. (Tieder et al., Pediatrics 2016.)

22. Which finding at a home most suggests supervisory neglect of young children?

    1. A. Toddlers home with a 16-year-old
    2. B. Toddlers home with no adult
    3. C. A parent working from home
    4. D. A parent asleep while toddlers nap
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    Answer: B. Toddlers home with no adult

    Neglect, the most common form of maltreatment, includes failure to supervise; toddlers left with no adult are at high risk of drowning, falls, burns and poisoning, and this must be reported. A responsible 16-year-old sitter, a parent who sleeps while the children nap, and a parent working from home each mean that someone is present and able to respond. (Caroline 9th ed.)

23. Parents of an infant who died suddenly ask why police are coming. You should explain that:

    1. A. It means abuse has already been confirmed
    2. B. It is required because CPR was not done
    3. C. It is routine after any sudden death
    4. D. It is needed to move the body
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    Answer: C. It is routine after any sudden death

    State law requires a medical examiner or coroner and law enforcement investigation of every sudden, unexpected infant or child death, so explaining that it is routine helps parents feel less accused. It does not mean abuse has been found, and the investigation happens whether or not resuscitation was attempted. The medical examiner, not the police, directs moving the body. (CDC SUIDI; Caroline 9th ed.)

24. When telling parents that their child has died, you should:

    1. A. Use the words dead or died
    2. B. Use phrases like passed on
    3. C. Wait for the police to tell them
    4. D. Say the child is just sleeping
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    Answer: A. Use the words dead or died

    Clear words such as dead or died prevent misunderstanding and false hope. Euphemisms such as passed on leave room for doubt. The news should come from the caregivers present, not be put off until police arrive. Saying the child is sleeping confuses families and can frighten siblings about going to sleep. (AAP, Supporting the Grieving Child and Family, 2016; Caroline 9th ed.)

25. After a difficult pediatric death, the crew should:

    1. A. Avoid discussing the call with one another
    2. B. Return to service without a review
    3. C. Accept personal blame for the outcome
    4. D. Use peer support or debriefing resources
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    Answer: D. Use peer support or debriefing resources

    Pediatric deaths are among the most stressful calls, and peer support or other mental health resources help providers cope. Suppressing the experience and avoiding discussion increase the risk of lasting stress reactions. Skipping review loses the chance to process the call. Taking personal blame for an unpreventable death harms the provider. (Caroline 9th ed.)