Pediatric Assessment: the Pediatric Assessment Triangle, Primary Survey, Weight Estimation, and Family-centered Care Practice Questions

25 multiple-choice questions on Pediatric assessment: the Pediatric Assessment Triangle, primary survey, weight estimation, and family-centered care 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. A 2-year-old sits quietly on her father's lap, tracks you with her eyes, and pushes your hand away. On the PAT, her appearance is:

   1. A. Normal; she is alert and engaged
   2. B. Abnormal, because she is quiet
   3. C. Abnormal, because she resists you
   4. D. Unable to judge without vital signs
   Show answer

   Answer: A. Normal; she is alert and engaged

   Using TICLS, she has good tone, is interactive, tracks with her gaze, and pushes away a stranger, which is normal and reassuring toddler behavior. Being quiet is not abnormal when the child is alert and engaged. Resisting a stranger shows good tone and awareness, not illness. The PAT is a hands-off look that does not require vital signs. (AHA PALS provider manual; Caroline 9th ed.)

2. A 3-year-old in respiratory distress has an SpO2 of 91% on room air. This value is:

   1. A. Normal for a toddler at sea level
   2. B. Low; give oxygen and reassess
   3. C. Acceptable as long as she is crying
   4. D. Too high and a sign of hyperventilation
   Show answer

   Answer: B. Low; give oxygen and reassess

   A healthy child at sea level saturates about 95% or higher on room air, so 91% in a distressed child indicates hypoxemia; give supplemental oxygen and reassess work of breathing and mental status. It is not normal for age. Crying does not make a low saturation acceptable. Hyperventilation cannot raise SpO2 to an abnormal level, and 91% is low, not high. (AHA PALS provider manual.)

3. The Pediatric Assessment Triangle is designed to be completed:

   1. A. After a full set of vital signs is taken
   2. B. After the hands-on head-to-toe exam
   3. C. From across the room in under a minute
   4. D. Once the child is on the monitor
   Show answer

   Answer: C. From across the room in under a minute

   The PAT is a rapid visual and auditory assessment done before touching the child, so it is not distorted by the child becoming upset. Waiting for vital signs or a monitor delays recognition of a sick child, and the head-to-toe exam comes later in the assessment. (AHA PALS provider manual.)

4. Which component of the PAT is the best overall indicator of the adequacy of a child's oxygenation, ventilation, perfusion, and brain function?

   1. A. Work of breathing
   2. B. Circulation to skin
   3. C. Respiratory rate
   4. D. Appearance
   Show answer

   Answer: D. Appearance

   Appearance reflects how well the brain is being oxygenated and perfused, so it is the most important part of the PAT. Work of breathing shows respiratory effort but can look normal in a tiring child heading into failure.

5. A 2-year-old is alert and interactive with normal skin color but has nasal flaring and intercostal retractions. The PAT indicates:

   1. A. Respiratory distress
   2. B. Respiratory failure
   3. C. Compensated shock
   4. D. Cardiopulmonary failure
   Show answer

   Answer: A. Respiratory distress

   An abnormal work of breathing with normal appearance and circulation means respiratory distress. Respiratory failure is suggested when appearance also becomes abnormal, as the child tires or becomes hypoxic.

6. A 10-month-old is limp and responds only to pain, with grunting, retractions, and mottled skin. The PAT indicates:

   1. A. Compensated shock
   2. B. Cardiopulmonary failure
   3. C. Respiratory distress
   4. D. Primary brain dysfunction
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   Answer: B. Cardiopulmonary failure

   All three PAT sides are abnormal, which signals cardiopulmonary failure and the need for immediate ventilation and resuscitation. Compensated shock would show abnormal circulation with a normal appearance and work of breathing.

7. The PAT of a vomiting 3-year-old shows an abnormal appearance and abnormal circulation to the skin. Your next step is to:

   1. A. Take a full SAMPLE history first
   2. B. Wait for a BP before deciding
   3. C. Treat for shock and move quickly
   4. D. Recheck the PAT in 15 minutes
   Show answer

   Answer: C. Treat for shock and move quickly

   Abnormal appearance plus abnormal circulation means the brain is no longer well perfused, which means shock is advanced; go straight to the hands-on primary survey, oxygen, vascular access, fluid boluses and rapid transport. History comes after life threats are treated. Blood pressure falls late in children, so waiting for it delays care. Waiting 15 minutes to reassess lets shock progress. (AHA PALS provider manual.)

8. In the history of a febrile, ill-appearing 18-month-old, which item has special significance?

   1. A. His birth order among siblings
   2. B. His vaccination history
   3. C. His usual bedtime routine
   4. D. His favorite foods
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   Answer: B. His vaccination history

   An unimmunized or underimmunized child is at risk for Hib, pneumococcal disease, measles and pertussis, which changes the likely diagnoses, the precautions you take, and what the hospital will look for. Birth order, bedtime routine and favorite foods do not change emergency care for a febrile, ill child. (Caroline 9th ed.)

9. Which pattern of retractions in a child signals the most severe increase in work of breathing?

   1. A. Mild subcostal pulling
   2. B. Slight intercostal pulling
   3. C. Intercostal during crying
   4. D. Suprasternal retractions
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   Answer: D. Suprasternal retractions

   Retractions above the sternum (suprasternal) and above the clavicles mean the child is using maximal effort, often with upper airway obstruction or severe lower airway disease. Mild subcostal or slight intercostal retractions are seen with milder distress. Intercostal retractions only while crying may reflect crying effort rather than lung disease. (AHA PALS provider manual.)

10. When checking capillary refill in a toddler, the hand or foot should be:

    1. A. Held down below the level of the heart
    2. B. Chilled with a cold pack beforehand
    3. C. Raised slightly above the heart level
    4. D. Squeezed firmly for a full 30 seconds
    Show answer

    Answer: C. Raised slightly above the heart level

    Raise the extremity slightly above heart level, blanch the skin briefly, and time the return of color; this keeps venous pooling from refilling the capillary bed and giving a falsely normal time. Holding it below the heart can make refill look faster than it is. Cold prolongs refill and gives a falsely abnormal result. Long squeezing is unnecessary; a brief blanch is enough. Normal is about 2 seconds or less in a warm environment. (AHA PALS provider manual.)

11. A 2-year-old's skin is mottled over the trunk and extremities in a warm room. This finding most likely indicates:

    1. A. Poor perfusion from shock
    2. B. A normal response to crying
    3. C. A mild fever without illness
    4. D. Local irritation of the skin
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    Answer: A. Poor perfusion from shock

    Mottling in a warm environment reflects intense peripheral vasoconstriction and poor perfusion, so look for other signs of shock. Cold exposure can cause mottling in infants, which is why the setting matters, but crying does not.

12. A tachycardic 3-year-old has a strong femoral pulse but a weak radial pulse. This difference most likely indicates:

    1. A. A normal finding in most healthy toddlers
    2. B. An arterial injury in one arm
    3. C. A hypertensive emergency
    4. D. Peripheral vasoconstriction from shock
    Show answer

    Answer: D. Peripheral vasoconstriction from shock

    A gap between strong central and weak peripheral pulses is an early sign of compensated shock as blood is shunted to the core. It is not a normal toddler finding, and it would not be explained by a single limb injury when both radial pulses are weak.

13. Using the formula 8 + (2 × age in years), the estimated weight of a 6-year-old is:

    1. A. 14 kg
    2. B. 26 kg
    3. C. 20 kg
    4. D. 32 kg
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    Answer: C. 20 kg

    8 + (2 × 6) = 20 kg. Weight estimates guide drug doses and fluid volumes, but a length-based tape is more accurate when available.

14. To use a length-based resuscitation tape correctly, lay the child supine and read the zone at the:

    1. A. Toes, with the red end at the shoulder
    2. B. Heel, with the red end at the head
    3. C. Knee, with the red end at the waist
    4. D. Ankle, with the child standing up
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    Answer: B. Heel, with the red end at the head

    Place the red (head) end at the top of the head, straighten the legs, and read the color zone at the heel. Starting at the shoulder or waist measures the wrong length and gives the wrong zone. The tape is designed for a supine child; reading it at the ankle of a standing child misplaces both ends. (Broselow tape instructions; Caroline 9th ed.)

15. A 12-year-old in cardiac arrest is longer than the end of the length-based tape. Drug doses should be based on:

    1. A. Estimated weight, capped at adult doses
    2. B. The final color zone at the end of the tape
    3. C. A fixed 20-kg pediatric dose
    4. D. Half of the usual adult doses
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    Answer: A. Estimated weight, capped at adult doses

    A child too long for the tape is dosed by estimated weight, without exceeding the adult dose. Using the last color zone would underdose a larger adolescent.

16. A 14-month-old with a temperature of 39.8 °C (103.6 °F) was lethargic, but after acetaminophen her fever has dropped and she is more active. Her improvement after the antipyretic:

    1. A. Proves that the cause is a simple viral illness
    2. B. Means that she no longer needs to be evaluated
    3. C. Shows that the fever itself was the main danger
    4. D. Does not rule out a serious bacterial illness
    Show answer

    Answer: D. Does not rule out a serious bacterial illness

    Fevers from serious bacterial infections and from viral illness both tend to fall with acetaminophen or ibuprofen, so the response to an antipyretic cannot be used to tell them apart. Judge her by her overall appearance, vital signs, and history, and recheck after the fever is down. The fever itself is rarely the danger; the cause is.

17. After forming a general impression with the Pediatric Assessment Triangle, the next step in assessing a child is to:

    1. A. Obtain a full SAMPLE history first
    2. B. Perform the hands-on primary survey
    3. C. Do a detailed head-to-toe exam
    4. D. Measure a full set of vital signs
    Show answer

    Answer: B. Perform the hands-on primary survey

    The PAT tells you how sick the child looks; the hands-on primary survey then finds and treats threats to hemorrhage control, airway, breathing, and circulation. History, vital signs, and the detailed exam come later in the secondary assessment.

18. An infant who opens her eyes only when you flick the soles of her feet is classified on the AVPU scale as:

    1. A. Responsive to verbal
    2. B. Alert
    3. C. Responsive to pain
    4. D. Unresponsive
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    Answer: C. Responsive to pain

    Responding only to a painful stimulus such as flicking the soles is P on the AVPU scale. A verbal response in a preverbal infant means turning to or reacting to the caregiver's voice.

19. The most accurate way to measure the temperature of a 2-month-old with possible fever is a:

    1. A. Rectal thermometer
    2. B. Forehead strip
    3. C. Axillary thermometer
    4. D. Oral thermometer
    Show answer

    Answer: A. Rectal thermometer

    A rectal reading is the most accurate measure in infants, and a rectal temperature of 38.0 C (100.4 F) or higher in a young infant needs urgent evaluation for serious infection. Forehead strips are unreliable. Axillary readings underestimate core temperature and can miss fever. An infant cannot hold an oral thermometer properly. (AAP fever guidance; Caroline 9th ed.)

20. Blood pressure readings are of limited assessment value in children younger than about:

    1. A. 6 months
    2. B. 10 years
    3. C. 14 years
    4. D. 3 years
    Show answer

    Answer: D. 3 years

    Blood pressure is hard to obtain and often unreliable in children under 3, so appearance, heart rate, pulses, and capillary refill guide perfusion assessment. In older children, blood pressure should be measured and compared with age-based norms.

21. An 18-month-old is unexpectedly drowsy while visiting her grandparents. A key history question is:

    1. A. Whether she had her flu shot this year
    2. B. Whether she slept poorly last night
    3. C. What medicines are in the house
    4. D. Whether she has been teething
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    Answer: C. What medicines are in the house

    Unexplained drowsiness in a toddler suggests an ingestion until proven otherwise, and grandparents' homes often hold drugs that are dangerous in small doses, such as sulfonylureas, calcium channel blockers, clonidine and opioids; ask what is in the house, look for containers, and bring them. Poor sleep, teething and flu vaccination do not explain sudden unexpected drowsiness. (Caroline 9th ed.)

22. Parents of a critically ill child ask to stay during the resuscitation. Current family-centered care practice is to:

    1. A. Ask them to wait outside until finished
    2. B. Let them stay with a support person
    3. C. Bring them in once the child improves
    4. D. Allow them in if they stay silent
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    Answer: B. Let them stay with a support person

    Family presence during pediatric resuscitation is supported when a crew member can stay with the family to explain what is happening and it does not interfere with care. Sending them outside removes comfort for the child and support for the family. Waiting until the child improves may mean they are absent if the child dies. Requiring silence is not the standard; a support person helps them cope. (AAP/ACEP patient- and family-centered care statement; Caroline 9th ed.)

23. Calming an anxious parent during the care of a sick toddler is important mainly because:

    1. A. The child's anxiety often mirrors theirs
    2. B. Parents need to sign consent before treatment
    3. C. Calm parents can give the medications
    4. D. It shortens the required scene time
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    Answer: A. The child's anxiety often mirrors theirs

    Young children read the emotions of their caregivers, so a calm parent helps keep the child calm, improves assessment, and lowers oxygen demand. Consent for emergency care is implied when a child is in danger, so calming the parent is not about a signature. Parents do not give the medications. Calming the family is about care, not scene time. (Caroline 9th ed.)

24. When transporting a stable 3-year-old in an ambulance, the child should be secured in:

    1. A. A parent's arms on the bench seat
    2. B. The cot's adult shoulder straps
    3. C. A seat belt in the front cab beside you
    4. D. A size-appropriate child restraint
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    Answer: D. A size-appropriate child restraint

    Children should ride in a properly sized child restraint secured to the cot or a seat. A parent's arms cannot hold a child in a crash. Adult cot straps do not fit a small child and can slide over the neck or abdomen. The front cab is not a patient area and its belt does not fit a toddler. (NHTSA Working Group, Safe Transport of Children in Ground Ambulances, 2012; Caroline 9th ed.)

25. To rate pain in a 4-year-old who can point to pictures, the most appropriate tool is the:

    1. A. 0-to-10 numeric rating scale
    2. B. Visual analog line scale
    3. C. Wong-Baker FACES scale
    4. D. Glasgow Coma Scale
    Show answer

    Answer: C. Wong-Baker FACES scale

    Picture-based faces scales work for children about 3 and older who can point but cannot yet use numbers reliably. Numeric 0-to-10 scales need an understanding of number order, usually from about age 8.