CPNP-PC, the pediatric primary care NP board

A newborn has a loud murmur, and echocardiography shows an interrupted aortic arch. On day 3 the infant has a seizure with a serum calcium of 6.2 mg/dL. A cleft palate is also noted. The MOST LIKELY diagnosis is:

1. 22q11.2 deletion
   An interrupted aortic arch (a conotruncal defect), neonatal hypocalcemic seizure from parathyroid hypoplasia, and a cleft palate together point to 22q11.2 deletion syndrome; T-cell function should also be checked because the thymus may be small.
2. 7q11.23 deletion
   The 7q11.23 deletion causes Williams syndrome, which pairs supravalvular aortic stenosis with hypercalcemia, the opposite calcium problem from this infant.
3. Noonan syndrome
   Noonan syndrome typically brings pulmonary valve stenosis or hypertrophic cardiomyopathy with short stature and a webbed neck, not hypocalcemia.
4. CHARGE syndrome
   CHARGE syndrome is recognized by coloboma, choanal atresia, and ear anomalies; heart defects occur, but neonatal hypocalcemia with an interrupted arch is the 22q11.2 pattern.

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A 2-month-old has a single midline sacral dimple 3 mm wide, 1.5 cm above the anus, with a visible base. There is no hair tuft, hemangioma, or skin tag, and the lower-extremity exam is normal. Which is the MOST appropriate plan?

1. no imaging is needed
   A single midline dimple under 5 mm, within 2.5 cm of the anus, with a visible base and no other skin marker is a simple dimple with very low risk of occult dysraphism, so no imaging is required.
2. MRI of the lumbosacral spine
   MRI is the next step after an abnormal ultrasound or with neurologic signs, not for a dimple that meets every simple-dimple criterion.
3. spinal ultrasound
   Spinal ultrasound in the first months is for an atypical dimple (larger, higher, off midline, or with no visible base) or other lumbosacral markers; ordering it here is the common overuse error.
4. referral to pediatric neurosurgery
   Neurosurgery is consulted when imaging shows a tethered cord or lipoma or when there are leg or bladder findings, none of which this infant has.

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A 15-year-old has nodular acne with early scarring despite 3 months of oral doxycycline, topical adapalene, and benzoyl peroxide. A PHQ-A shows mild depressive symptoms without suicidal ideation. Which is the MOST appropriate next step?

1. switch from doxycycline to minocycline
   Moving to another tetracycline treats a failure as if it were intolerance; minocycline adds no efficacy and has more serious adverse effects.
2. defer acne treatment until mood improves
   Holding treatment lets scarring advance, and severe acne itself worsens mood; the depressive symptoms are monitored and treated alongside the acne.
3. 6 more months of oral doxycycline
   Oral antibiotics for acne are limited to roughly 3 to 4 months because of resistance, and prolonging a failed course lets scarring progress.
4. dermatology referral for isotretinoin
   Scarring nodular acne that has failed about 3 months of an oral antibiotic with a retinoid and benzoyl peroxide meets the indication for isotretinoin; mild depressive symptoms call for mood monitoring during iPLEDGE treatment, not for withholding it.

Item 870498 · Flag an error

Parents of a 6-week-old will spend summer evenings outdoors where mosquitoes are common. Which protection is MOST appropriate?

1. 10% DEET lotion on exposed skin
   DEET in a 10% to 30% concentration is acceptable from 2 months of age; applying it at 6 weeks misses that age floor.
2. Oil of lemon eucalyptus spray
   Oil of lemon eucalyptus carries a label restriction against use under 3 years, so it is the wrong choice for an infant.
3. Netting over the stroller or carrier
   Insect repellents are not used before 2 months of age, so a 6-week-old is protected by netting over the stroller or carrier and by covering clothing.
4. Permethrin cream applied to the skin
   Permethrin repels insects when applied to clothing and gear; the skin cream is a scabies treatment, not a mosquito repellent.

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A 6-week-old who is exclusively breastfed cries 3–4 hours most evenings, is gaining weight well, and has a normal examination. In addition to reassurance and soothing techniques, which intervention has the BEST evidence for reducing crying time?

1. Switching to soy-based formula
   Changing a thriving breastfed baby to soy formula gives up breastfeeding for no proven effect on colic.
2. Famotidine for presumed reflux
   Acid suppression does not reduce crying in a well, growing infant without signs of reflux disease and raises the risk of infections.
3. Simethicone drops with feedings
   Simethicone is a popular gas remedy, but trials show it reduces crying no more than placebo.
4. Lactobacillus reuteri drops
   In exclusively breastfed infants with colic, the probiotic L. reuteri DSM 17938 shortened daily crying in randomized trials, so it can be offered alongside reassurance and soothing.

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