Special Populations: Pregnancy, Children, Older Adults, and Pelvic Fractures Practice Questions

25 multiple-choice questions on Special populations: pregnancy, children, older adults, and pelvic fractures for paramedic and EMT students, from Chapter 37 (Abdominal and Genitourinary Trauma). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. Until about 12 weeks of gestation, the uterus is well protected from blunt trauma because it:

   1. A. Lies within the bony pelvis
   2. B. Is shielded by the lower ribs
   3. C. Floats freely in amniotic fluid
   4. D. Sits behind both of the kidneys
   Show answer

   Answer: A. Lies within the bony pelvis

   In the first trimester the uterus remains inside the pelvis, so direct injury requires a pelvic fracture or penetrating wound. By 20 weeks it reaches the umbilicus and becomes exposed to abdominal blows.

2. In a woman at 20 weeks of gestation, the top of the uterus (fundus) is usually at the level of the:

   1. A. Xiphoid process
   2. B. Pubic symphysis
   3. C. Umbilicus
   4. D. Left costal margin
   Show answer

   Answer: C. Umbilicus

   The fundus reaches the umbilicus at about 20 weeks and nears the costal margin by 36 weeks. A fundus at the umbilicus indicates a potentially viable fetus later in pregnancy, which matters for destination.

3. A 28-year-old woman at 30 weeks of gestation was in a crash. She has abdominal pain, dark vaginal bleeding, and a firm, tender uterus. You should suspect:

   1. A. Placenta previa
   2. B. Normal labor
   3. C. A urinary infection
   4. D. Placental abruption
   Show answer

   Answer: D. Placental abruption

   Abruption is separation of the placenta from the uterine wall, causing pain, a rigid tender uterus, and dark bleeding that may be concealed. Placenta previa typically causes painless bright red bleeding.

4. After abdominal trauma in late pregnancy, fetal parts that are easily felt through the abdominal wall suggest:

   1. A. Normal fetal position
   2. B. Uterine rupture
   3. C. Placenta previa
   4. D. Early labor
   Show answer

   Answer: B. Uterine rupture

   Uterine rupture lets the fetus move into the peritoneal cavity, so fetal parts are palpable just under the skin, and the mother may be in profound shock. It is rare but carries very high fetal mortality.

5. Which finding in a pregnant trauma patient may be the earliest sign of maternal blood loss?

   1. A. Fetal distress or bradycardia
   2. B. Falling maternal blood pressure
   3. C. Maternal skin flushing and warmth
   4. D. Swelling of both ankles and feet
   Show answer

   Answer: A. Fetal distress or bradycardia

   The body shunts blood away from the uterus to protect the mother, so fetal distress can appear before maternal vital signs change. Maternal hypotension is a late finding in pregnancy because of her larger blood volume.

6. The normal fetal heart rate range is about:

   1. A. 60 to 100 beats/min
   2. B. 80 to 120 beats/min
   3. C. 180 to 220 beats/min
   4. D. 110 to 160 beats/min
   Show answer

   Answer: D. 110 to 160 beats/min

   A fetal heart rate between 110 and 160 beats/min is normal, and bradycardia below 110 suggests fetal hypoxia, often from maternal shock or abruption. A rate of 60 to 100 is the normal adult range.

7. A pregnant woman should be taught to wear a lap belt:

   1. A. High, across the top of the belly
   2. B. Low, across the hips below the belly
   3. C. Directly over the center of the belly
   4. D. Without wearing the shoulder strap
   Show answer

   Answer: B. Low, across the hips below the belly

   A lap belt worn low across the pelvis transfers force to bone, while a belt over the uterus can cause abruption or rupture. The shoulder belt should be worn too, crossing between the breasts.

8. Peritoneal signs in late pregnancy may be less obvious after trauma because:

   1. A. Pregnancy hormones block abdominal pain
   2. B. The uterus absorbs the spilled blood
   3. C. A stretched abdominal wall masks them
   4. D. Pregnant women feel no visceral pain
   Show answer

   Answer: C. A stretched abdominal wall masks them

   The stretched abdominal wall and displaced organs make guarding and rigidity harder to elicit, so injury may be masked. Pregnant women still feel abdominal pain, and its absence does not exclude injury.

9. A 34-year-old woman at 34 weeks of gestation is stable after a minor crash and has no complaints. The best course of action is to:

   1. A. Transport for fetal monitoring
   2. B. Release her if she feels fine
   3. C. Have her see her doctor next week
   4. D. Check fetal movement and release
   Show answer

   Answer: A. Transport for fetal monitoring

   Even minor trauma can cause placental abruption that shows only on hours of fetal monitoring, so pregnant patients past 20 weeks should be evaluated in hospital. Absence of maternal symptoms does not rule out fetal compromise.

10. A woman at 36 weeks of gestation with a gunshot wound to the abdomen is in cardiac arrest despite CPR. The intervention that may benefit both mother and fetus, done at the hospital, is:

    1. A. A rapid saline bolus through a leg vein
    2. B. A perimortem cesarean (hysterotomy)
    3. C. Turning her fully prone during CPR
    4. D. Stopping compressions to check the fetus
    Show answer

    Answer: B. A perimortem cesarean (hysterotomy)

    In cardiac arrest with the uterus at or above the umbilicus (about 20 weeks or later), the AHA recommends perimortem (resuscitative) cesarean delivery if there is no return of circulation, ideally with delivery within about 5 minutes of arrest. Emptying the uterus relieves aortocaval compression, improves maternal resuscitation, and gives a 36-week fetus a chance. The paramedic's role is high-quality CPR with continuous manual left uterine displacement, early notification so the team is ready, and rapid transport. Fluid through a leg vein must pass the compressed (and here possibly injured) inferior vena cava; access above the diaphragm is preferred. Prone CPR is not used and makes uterine displacement and airway care impossible. Stopping compressions to check the fetus cuts perfusion to both mother and fetus.

11. Rh immune globulin may be given in the hospital after trauma in pregnancy because:

    1. A. Fetal blood can enter an Rh-negative mother
    2. B. It stops ongoing bleeding from the placental bed
    3. C. It speeds healing of a ruptured uterus
    4. D. It raises the mother's blood pressure
    Show answer

    Answer: A. Fetal blood can enter an Rh-negative mother

    Even minor trauma can mix fetal and maternal blood, and an Rh-negative mother may make antibodies that harm this or a later fetus. Rh immune globulin prevents this sensitization; it does not treat bleeding.

12. Children are more prone to abdominal organ injury than adults partly because they have:

    1. A. Thicker abdominal wall muscle
    2. B. A stiffer, more protective rib cage
    3. C. Larger organs and less muscle and fat
    4. D. Smaller livers in relation to body size
    Show answer

    Answer: C. Larger organs and less muscle and fat

    A child's liver and spleen are proportionally larger and less covered by the flexible ribs, and the thin abdominal wall offers little cushioning. A flexible rib cage transmits force to organs without breaking.

13. A 7-year-old fell from a tree onto his abdomen. He has a pulse of 140/min and his BP is 98/60 mmHg. You should recognize that:

    1. A. His vitals are normal for his age
    2. B. Low BP would appear early in a child
    3. C. His fast pulse reflects his fear
    4. D. He may be in compensated shock
    Show answer

    Answer: D. He may be in compensated shock

    Children maintain blood pressure until they lose a large share of their volume, so tachycardia is the key early sign and hypotension is a late, ominous one. Attributing tachycardia to fear risks missing hemorrhage.

14. An 8-year-old in a lap belt only was in a frontal crash. He has an abdominal belt bruise and back pain. The pattern you should suspect is:

    1. A. A pneumothorax with a fractured clavicle
    2. B. Bowel injury and lumbar spine fracture
    3. C. Bilateral femur and wrist fractures
    4. D. Head injury with facial fractures
    Show answer

    Answer: B. Bowel injury and lumbar spine fracture

    A lap belt that rides up on a child's soft abdomen causes the seat belt syndrome of bowel and mesenteric injury with a lumbar flexion-distraction fracture. Booster seats position the belt over the pelvis to prevent this.

15. A 2-year-old is lethargic and vomiting, with a tense, distended abdomen and a pulse of 170/min. The caregiver says he rolled off a couch yesterday. You see bruises of different colors on his abdomen and back. You should be most concerned about:

    1. A. Abuse with an abdominal organ injury
    2. B. Gastroenteritis with simple dehydration
    3. C. Minor bruising from the fall off the couch
    4. D. Expected pain from a short fall
    Show answer

    Answer: A. Abuse with an abdominal organ injury

    Abdominal trauma is a leading cause of death from child physical abuse. A history that does not explain the findings, a delay in seeking care, bruises of different ages on the abdomen and back, and a distended abdomen with tachycardia and lethargy point to inflicted injury such as a liver, duodenal, or pancreatic injury with bleeding or peritonitis. Treat for shock, transport to a pediatric trauma center, document your findings objectively, and report as a mandated reporter without confronting the caregiver. Gastroenteritis does not explain the bruising or a tense abdomen. A roll off a couch is a short fall that rarely causes serious abdominal injury, so neither minor bruising nor expected pain from the fall explains shock and distension. (AAP: Christian CW, Pediatrics 2015;135:e1337; Caroline 9th ed.)

16. Gastric distension in an injured child is a concern mainly because it can:

    1. A. Mimic a full bladder on exam
    2. B. Raise blood pressure dangerously
    3. C. Impair breathing and cause vomiting
    4. D. Cause a fracture of the lower rib cage
    Show answer

    Answer: C. Impair breathing and cause vomiting

    Children swallow air when crying and during bag-mask ventilation, and a distended stomach pushes up on the diaphragm and raises the risk of vomiting and aspiration. It also makes the abdominal exam harder.

17. An 80-year-old fell from standing and has mild left upper quadrant pain. She takes apixaban. Your greatest concern is:

    1. A. An occult hip fracture from the fall
    2. B. A UTI as the cause of the fall
    3. C. Rib pain limiting her breathing
    4. D. Ongoing bleeding from a minor injury
    Show answer

    Answer: D. Ongoing bleeding from a minor injury

    Anticoagulants turn minor organ injuries into potentially fatal bleeds, and older adults often have blunted signs of shock. Even a ground-level fall with abdominal pain warrants trauma evaluation. A hip fracture, rib pain, or an infection behind the fall all deserve attention, but none is as immediately dangerous as unchecked bleeding in an anticoagulated patient with left upper quadrant pain.

18. Older adults with abdominal injury may show less tenderness and guarding than younger patients because of:

    1. A. Reduced pain response and lax muscles
    2. B. A slower onset of internal bleeding with age
    3. C. Lower rates of solid organ injury
    4. D. Stronger reflex guarding with age
    Show answer

    Answer: A. Reduced pain response and lax muscles

    Aging blunts pain perception, and weaker abdominal muscles guard less, so serious injury may produce subtle findings. Bleeding does not start more slowly, organ injury is not less common, and guarding weakens rather than strengthens with age. A high index of suspicion based on mechanism is essential.

19. In a 75-year-old with chronic hypertension, a BP of 110/70 mmHg after abdominal trauma should be viewed as:

    1. A. Normal and reassuring
    2. B. A sign of overhydration
    3. C. Evidence of no significant bleeding
    4. D. Possible relative hypotension
    Show answer

    Answer: D. Possible relative hypotension

    If the patient's usual systolic is 160 to 180, a reading of 110 may represent significant blood loss. Comparing to the baseline is more useful than an absolute number.

20. The pelvic fracture pattern associated with the most blood loss is the:

    1. A. Isolated fracture of one pubic ramus
    2. B. Avulsion of the anterior iliac spine
    3. C. Open-book (anteroposterior) fracture
    4. D. Isolated fracture of the coccyx tip
    Show answer

    Answer: C. Open-book (anteroposterior) fracture

    An anteroposterior compression injury opens the pelvic ring, enlarges its volume, and tears the posterior venous plexus, allowing massive bleeding. Isolated ramus or coccyx fractures are stable and bleed little.

21. A pelvic binder reduces bleeding mainly by:

    1. A. Compressing the femoral arteries at the groin
    2. B. Reducing pelvic volume and stabilizing bone
    3. C. Pushing blood from the legs to the heart
    4. D. Sealing the bladder against urine leaks
    Show answer

    Answer: B. Reducing pelvic volume and stabilizing bone

    Closing the pelvic ring reduces the space for blood to accumulate and limits bone movement so clots can form. It is not a tourniquet on the femoral arteries.

22. If no commercial pelvic binder is available for a hypotensive patient with a suspected unstable pelvis, you can:

    1. A. Wrap a sheet snugly around the iliac crests
    2. B. Apply an elastic bandage around the waist
    3. C. Place a pillow beneath the lower back
    4. D. Wrap and tie a sheet around the trochanters
    Show answer

    Answer: D. Wrap and tie a sheet around the trochanters

    A folded sheet wrapped around the greater trochanters and tightened with a knot or clamps works as an improvised binder. Placing it too high, over the iliac crests or the waist, can widen the fracture and does not close the pelvic ring, and an elastic wrap stretches rather than holding firm. A pillow under the back does not reduce pelvic volume.

23. A 26-year-old at 28 weeks of gestation was in a crash. She is pale with a pulse of 128/min and a BP of 90/60 mmHg. The best way to improve the fetus's chance of survival is to:

    1. A. Check fetal heart tones before moving her
    2. B. Withhold oxygen to protect the fetus
    3. C. Treat the mother's shock and transport
    4. D. Keep her supine and flat on the board
    Show answer

    Answer: C. Treat the mother's shock and transport

    The fetus survives only if the mother is resuscitated. In shock the mother's body shunts blood away from the uterus, so fetal hypoxia begins before her vital signs fall far. Treat her shock with oxygen, IV access and fluid or blood per protocol, manual left uterine displacement, and rapid transport to a trauma center with obstetric capability. Stopping to check fetal heart tones delays care and does not change field treatment. Oxygen helps the fetus; withholding it worsens fetal hypoxia, and ATLS advises keeping maternal saturation high (above 95%). Lying supine lets the uterus compress the vena cava and can drop her pressure further. (ATLS 10th ed., Trauma in Pregnancy; PHTLS 10th ed.)

24. An 84-year-old woman with osteoporosis fell from standing and has groin pain and cannot bear weight. Compared with a younger adult, she:

    1. A. Can fracture the pelvis with minor force
    2. B. Needs high energy to break the pelvis
    3. C. Rarely bleeds from a pelvic fracture
    4. D. Should walk to test hip stability
    Show answer

    Answer: A. Can fracture the pelvis with minor force

    Osteoporotic bone can break with a ground-level fall, and older adults on anticoagulants can bleed significantly from even a stable pelvic fracture. Asking her to bear weight could displace the fracture.

25. After a minor crash, a woman at 31 weeks feels well but reports cramping that now comes every 5 minutes. The best interpretation is that:

    1. A. Cramping is from the seat belt bruise
    2. B. Contractions may signal an abruption
    3. C. These are Braxton Hicks contractions
    4. D. She can be released with no transport
    Show answer

    Answer: B. Contractions may signal an abruption

    Regular uterine contractions after trauma can be the first sign of placental abruption or preterm labor, even when the mother looks well. She needs transport for several hours of fetal and uterine monitoring. Regular contractions every 5 minutes should not be put down to Braxton Hicks contractions or a belt bruise, and dismissing them risks missing fetal compromise.