Facts read from pncb.org and 1 more · last checked Nov 7, 2026
Area III is what happens once the diagnosis is made: the drug and the dose for this child, the office procedure, the referral or report, and the follow-up that tells you the plan worked.
Practice questions
60 questions written to the CPNP-PC outline; each choice is explained once you pick.
Counseling: the condition, the medicine, its side effects and when to come back.
Prescribing: prescription, over-the-counter and complementary therapies, shared decisions.
Procedures and emergencies: the ten named office procedures and the first response to a life-threatening event.
Referral and reporting: specialists, community resources, child protective services.
Coordination: children with special health care needs and the move to adult care.
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16 management questions
0 / 16 answered16 questions
Tap an option: why each one is right or wrong appears under it.
Management · 30%
A 10-year-old has had periumbilical pain several times a week for 6 months, with normal growth, no alarm features, and normal CBC, CRP, celiac serology, and urinalysis. The child has missed 15 days of class. Which is the MOST appropriate management?
Staying home rewards the pain with avoidance and deepens disability; normal routines are part of recovery.
Acid suppression does not help functional periumbilical pain without dyspeptic features and adds infection and fracture risks.
Endoscopy has a very low yield without alarm signs and reinforces the idea that something is being missed.
With no alarm features and normal screening labs, this is functional abdominal pain; validating the pain, explaining gut-brain sensitivity, and keeping the child in school are the core of treatment.
A 5-year-old has newly diagnosed epilepsy with occasional generalized seizures. Which safety advice is MOST appropriate?
Most sports and play are encouraged with sensible precautions; blanket restriction harms fitness and social life without real benefit.
Baths carry a higher drowning risk than showers, because a seizure in standing water can be fatal within minutes.
Drowning is the biggest injury risk for children with epilepsy, so swimming happens only under constant, close adult supervision, and showers replace baths as the child bathes alone.
A seizure-free period does not remove the risk, so even a well-controlled child does not swim alone.
An 11-year-old has migraine without aura about twice a month. Ibuprofen at onset relieves most attacks, but some persist and cause missed school. Which is the MOST appropriate addition?
Daily prevention is for frequent (roughly 4 or more a month) or disabling migraine; two attacks a month are managed with better acute treatment.
Butalbital products cause medication-overuse headache and dependence and have no place in pediatric migraine.
When an NSAID at onset does not stop every attack, a triptan is the next acute step, and rizatriptan is FDA-approved for ages 6 to 17.
Codeine is contraindicated under 12 years because of unpredictable conversion to morphine, and opioids worsen migraine outcomes.
A 6-year-old has 2 days of red eye with thick yellow discharge and lashes matted shut in the morning. Vision is normal, there is no photophobia, and the ears are normal. Which treatment is MOST appropriate?
Oral therapy is for conjunctivitis-otitis syndrome, where amoxicillin-clavulanate covers nontypeable Haemophilus; the ears here are normal.
Ketotifen is an antihistamine for itchy, watery allergic conjunctivitis, not purulent infection.
Thick purulent discharge with lashes matted shut, normal vision, and normal ears suggests bacterial conjunctivitis, treated with a topical broad-spectrum antibiotic.
Steroid-containing eye drops can worsen infection, including unrecognized herpes, and are not started in primary care.
A 2-month-old with Down syndrome had a normal newborn thyroid screen. According to AAP health supervision guidance, when should thyroid function be tested next?
Five-year intervals miss disease during the years when thyroid function changes most often.
Hypothyroidism is subtle and its signs overlap with features of Down syndrome, so symptom-driven testing finds it late.
Children with Down syndrome have a high risk of acquired hypothyroidism, so AAP health supervision guidance calls for TSH at birth, 6 months, 12 months, and then every year.
Skipping the 6-month check and testing every 2 years leaves long gaps in which hypothyroidism can develop unnoticed.
Parents of a 4-year-old report that 1–2 hours after falling asleep the child sits up screaming, appears terrified, does not respond to them, and has no memory of it in the morning. Which advice is MOST appropriate?
Waking during a sleep terror prolongs confusion and agitation; comforting after waking suits nightmares, which come later in the night and are remembered.
Melatonin helps sleep onset, not partial arousals, and is not needed for typical sleep terrors.
A sleep study is for atypical, frequent, or stereotyped events that suggest seizures or for signs of sleep apnea, not for classic sleep terrors.
Screaming episodes 1 to 2 hours after sleep onset with unresponsiveness and no memory are sleep terrors from deep non-REM sleep; parents keep the child safe, avoid sleep deprivation, and let the episode pass.
A 2-year-old has had 2 febrile seizures; the second lasted 12 minutes. Development is normal, and the family lives 40 minutes from an emergency department. Which is MOST appropriate?
There is no evidence that a daily antiseizure drug improves outcomes after febrile seizures, so daily levetiracetam only adds adverse effects.
Daily prophylaxis is not recommended for febrile seizures, but a child who has had a prolonged seizure and lives far from care can be sent home with a rescue benzodiazepine for a seizure lasting over 5 minutes.
Antipyretics make a feverish child comfortable but do not prevent febrile seizures.
Phenobarbital lowers recurrence somewhat, but its behavioral and cognitive effects outweigh the benefit for a benign condition.
A 6-year-old with functional constipation and soiling was disimpacted and has passed soft stools every day on maintenance therapy for 2 weeks. The parents want to stop. Which is MOST appropriate?
Stimulant laxatives are rescue or add-on agents, not a replacement for the maintenance regimen.
Three weeks in total is still far short of the time the rectum needs, so withholding returns.
Stopping as soon as stools soften is the most common reason functional constipation relapses.
Maintenance laxative therapy runs for at least 2 months, with at least a month symptom-free before a slow taper, because the stretched rectum needs time to recover.
A 13-year-old meets Rome IV criteria for irritable bowel syndrome with constipation and has no alarm features. Dietary changes have not improved stool frequency. Which medication is MOST appropriate to start?
Antispasmodics relieve cramping for some patients but slow the bowel, the opposite of what IBS-C needs.
When diet changes fail in constipation-predominant IBS, an osmotic laxative such as polyethylene glycol is the first medication used in children.
Low-dose amitriptyline can help pain in some children, but its anticholinergic effect worsens constipation.
Loperamide slows transit and is used for diarrhea-predominant IBS; it would worsen constipation.
A 9-month-old has hemoglobin of 9.2 g/dL with microcytosis. The infant has been drinking whole cow's milk since 6 months of age. Which is MOST appropriate?
Dietary iron cannot replace stores once the infant is anemic, and the cow's milk that caused the deficit continues.
Goat's milk is also low in iron and folate and is not appropriate before 12 months.
Iron treats the deficit, but continuing cow's milk keeps the blood loss and poor absorption going.
Whole cow's milk before 12 months causes iron deficiency through low iron, poor absorption, and occult gut bleeding, so it is replaced with breast milk or iron-fortified formula while oral iron treats the anemia.
A 14-year-old with BMI 42 kg/m² (class 3 obesity), prediabetes, and obstructive sleep apnea has continued to gain weight despite 12 months of intensive health behavior and lifestyle treatment. Which is the MOST appropriate next step?
An adolescent 13 or older with class 3 obesity and comorbidities who has not responded to intensive lifestyle treatment meets the AAP 2023 criteria for referral to a metabolic and bariatric surgery program.
There is no requirement to wait for adulthood; comorbidities progress while waiting.
Repeating a year of a failed approach is the watchful waiting the guideline rejects.
Metformin may help glycemia but produces little weight loss and is not a stand-alone treatment for class 3 obesity.
An 18-month-old with gastroenteritis and mild-to-moderate dehydration vomits after each large drink of oral rehydration solution. Which is the MOST appropriate next step?
In mild to moderate dehydration with vomiting, one dose of ondansetron cuts vomiting and IV use, and ORS given in small sips every minute or two is better tolerated than large drinks.
Promethazine carries a boxed warning against use under 2 years because of fatal respiratory depression.
Juice and sports drinks have too much sugar and too little sodium for rehydration and can worsen diarrhea.
IV fluids are for severe dehydration or failure of oral rehydration after an antiemetic and small sips have been tried.
A 13-year-old develops sudden leg weakness and cannot walk after a family conflict. Hoover sign is positive, reflexes are normal, and neurology confirms a functional gait disorder. Which management is MOST appropriate?
Functional symptoms are not feigned; calling them voluntary is inaccurate and damages trust.
Rest and wheelchair use reinforce the abnormal movement pattern and deepen disability.
Repeating tests after a positive diagnosis signals doubt and undermines engagement in treatment.
A functional gait disorder is real and involuntary; care starts with a clear explanation of the positive signs, followed by rehabilitation-based physiotherapy and CBT.
A 16-year-old has had irregular menses since menarche at 12, hirsutism, and elevated free testosterone; BMI is 31. Pregnancy test, TSH, and prolactin are normal. Along with lifestyle changes, which medication is MOST appropriate?
For an adolescent with PCOS, irregular menses, and hyperandrogenism, a combined oral contraceptive is first-line with lifestyle change: it regulates bleeding, protects the endometrium, and lowers free androgens by suppressing ovarian output and raising SHBG.
Clomiphene induces ovulation for someone trying to conceive; it does not treat irregular menses or hirsutism in a teen.
Spironolactone is an antiandrogen added for persistent hirsutism; used alone it does not regulate cycles and is teratogenic without reliable contraception.
A progestin minipill protects the endometrium but does not lower androgens, so it leaves the hirsutism untreated.
A 12-year-old has a fishhook embedded in the pad of the index finger; the barb can be felt just beneath the skin. After a digital block, which removal technique is MOST appropriate?
A retained fragment invites infection and continued pain.
With the barb palpable just under the skin, the advance-and-cut technique pushes the point out, cuts off the barb, and backs the hook out without tearing tissue.
Retrograde pulling works only for barbless or very superficial hooks; with a barb it tears tissue.
Referral is for hooks near joints, tendons, nerves, or the eye; a fingertip pad hook is managed in the office.
A running total sits here; it fills in after your last pick.
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Prescribing traps specific to children
Per dose or per day. Pediatric doses are often written in mg/kg/day split into doses; reading that as mg/kg/dose multiplies the total. Weight-based doses also stop at the adult maximum.
Codeine and tramadol. The FDA contraindicated both for children under 12 in 2017, and for pain after tonsillectomy or adenoidectomy under 18.
Aspirin in a viral illness. It is avoided in children and teens because of Reye syndrome; specific indications such as Kawasaki disease are managed by specialists.
Doxycycline as forbidden under 8. Under current AAP Red Book guidance, short courses can be used at any age; the tooth-staining concern applies to older tetracyclines.
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Suspected abuse and the duty to report
Every state makes NPs mandated reporters. The threshold is reasonable suspicion, not proof: a pattern of injuries that does not fit the history or the child's development is enough to report. The report goes to child protective services or the police as state law sets out; telling a supervisor does not replace it. Child maltreatment is a clinical category of its own in the PNCB outline (p. 4).
Which procedures does PNCB expect a primary care PNP to know?
Ten are named, from cerumen removal and fluoride varnish to nursemaid's elbow reduction and wart removal. The full list is on the study guide.
Does Area III include gastrointestinal disease?
Yes. Gastroenterology, fifth of the 21 categories, runs through all four areas; until it has its own page, its items sit in the area pages and the 60-question set.