Chapter 31: Infectious Diseases

Garzon Maaks: Burns’ Pediatric Primary Care, 7th Edition

MULTIPLE CHOICE

1. When reviewing a white blood cell (WBC) count, the primary care pediatric nurse practitioner
suspects a viral infection when which WBC element is elevated?
a. Bands
b. Leukocytes
c. Lymphocytes
d. Neutrophils
ANS: C
Lymphocytes are usually elevated during viral infections. Bands and neutrophils are generally
elevated with bacterial infections. Leukocytes comprise all WBCs and are usually, although
not always, elevated during bacterial infections.

2. Which lab value is most concerning in an infant with fever and a suspected bacterial
infection?
a. C-reactive protein of 11.5 mg/L
b. Lymphocyte count of 8.7
c. Platelet count of 475
d. White blood cell count of 14
ANS: A
CRP levels are non-specific acute phase indicators of inflammation with low diagnostic value
except in predicting the likelihood of sepsis in infants, especially when the level is greater
than 10 mg/L. Elevated lymphocyte, platelet, or WBC counts help with the differential
diagnosis, but these values are not especially concerning.

3. A 3-year-old child who attends day care has had a fever, nausea, and vomiting several weeks
prior and now has darkened urine and constipation along with hepatomegaly and right upper
quadrant tenderness. What treatment is warranted for this child?
a. HAV vaccine
b. Immunoglobulin G
c. Interferon-alfa
d. Supportive care
ANS: D
The child has symptoms consistent with hepatitis A virus. HAV vaccine and IgG may be given
within 2 weeks of exposure; otherwise supportive care is indicated. Interferon-alfa is used for
hepatitis B virus.

4. A 10-month-old infant who is new to the clinic has chronic hepatitis B infection. What will
the primary care pediatric nurse practitioner do to manage this infant’s disease?
a. Consult a pediatric infectious disease specialist.
b. Prescribe interferon-alfa.
c. Provide supportive care.
d. Consider use of lamivudine.
 ANS: A
A specialist in hepatitis B in children should be consulted for children with chronic hepatitis B
infection because of the risk for developing hepatocellular carcinoma. Interferon-alfa and
lamivudine are not used in infants. Supportive care only is not recommended.

5. A 9-month-old infant has had a fever of 103°F for 2 days and now has a diffuse,
maculopapular rash that blanches on pressure. The infant’s immunizations are up-to-date.
What will the primary care pediatric nurse practitioner do?
a. Administer immunoglobulin G to prevent fulminant illness.
b. Perform serologic testing for human herpes virus -6 and human herpes virus -7.
c. Reassure the parent that this is a mild, self-limiting disease.
d. Recommend avoiding contact with pregnant women.
ANS: C
The infant has symptoms consistent with roseola infantum, which is a benign, self-limiting
disease. It is not necessary to administer IgG or perform serologic testing or to avoid contact
with pregnant women.

6. A child who is immunocompromised has a fever and a rash consisting of macules, papules,
and pustules. What will the primary care pediatric nurse practitioner do?
a. Administer varicella immune globulin (VariZIG).
b. Hospitalize the child for intravenous acyclovir.
c. Order intravenous immunoglobulin as an outpatient.
d. Prescribe oral acyclovir for the duration of the illness.
ANS: B
The description of the rash the immunocompromised child has been exposed to is that of
varicella. Intravenous acyclovir should be given to immunocompromised individuals. Immune
globulin is not effective after the disease has progressed. Oral acyclovir is expensive and not
routinely recommended for most children.

7. The primary care pediatric nurse practitioner is reviewing medical records for a newborn that
is new to the clinic. The toddler’s mother was found to be HIV positive during her pregnancy
with this child and received antiretroviral therapy during pregnancy. The child was born by
cesarean section, begun on anti-retroviral prophylaxis, and did not breastfeed. What is the
correct management for this child?
a. Consult with a pediatric HIV specialist.
b. Discontinue cART after 4 weeks of age.
c. Obtain a CD4+ cell count and HIV RNA levels.
d. Reinforce the need to give cART for life.
ANS: A
PNPs may manage infants exposed in utero to HIV but should do so in consultation with a
pediatric HIV specialist. cART should be given for 6 weeks. Lab work is ordered according to
protocol at the direction of the specialist. Many children who are treated according to the
protocol do not become HIV positive.

8. A preschool-age child is brought to clinic for evaluation of a rash. The primary care pediatric
nurse practitioner notes an intense red eruption on the child’s cheeks and circumoral pallor.
What will the nurse practitioner tell the parents about this rash?
a. This rash may be a prodromal sign of rubella or roseola.
 b. The child will need immunization boosters to prevent serious disease.
c. This is a benign rash with no known serious complications.
d. Expect a lacy, maculopapular rash to develop on the trunk and extremities.
ANS: D
This “slapped cheek” rash is consistent with fifth disease, or erythema infectiosum, and will
be followed by a lacy, maculopapular all-over rash. It is not a prodrome of rubella or roseola,
and immunizations are not indicated. Although it is mostly benign, there can be serious
sequelae, especially for pregnant women.

9. An unimmunized school-age child whose mother is in her first trimester of pregnancy is

diagnosed with rubella after a local outbreak. What will the primary care pediatric nurse
practitioner recommend?
a. Assessment of maternal rubella titers
b. Intravenous immunoglobulin for the child
c. MMR vaccine for the mother and child
d. Possible termination of the pregnancy
ANS: A
Reinfection or revaccination with rubella for pregnant women rarely results in congenital
rubella syndrome, and these are not a reason for pregnancy termination. Maternal rubella
antibody titers should be assessed. MMR vaccine is not given during pregnancy. IVIG is not
indicated; rubella rarely has serious sequelae in children.

10. A child is brought to the clinic with a fever, headache, malaise, and a red, annular macule
surrounded by an area of clearing and a larger, erythematous annular ring. The child
complains of itching at the site. What will the primary care pediatric nurse practitioner do to
determine the diagnosis?
a. Ask about recent tick bites
b. Obtain a skin culture
c. Order blood cultures
d. Perform serologic testing
ANS: A
The presence of an erythema migrans rash with a positive history is diagnostic for Lyme
disease, and no further testing is necessary. Because Borrelia burgdorferi is transmitted to
humans through ticks, asking about recent tick bites is paramount to making this diagnosis.
Skin and blood cultures are not indicated. Serology testing for IgG and IgM antibodies may be
performed if the child is symptomatic without the characteristic EM rash.

11. A child whose family has been camping in a region with endemic Lyme disease suffered
several tick bites. The parents report removing the ticks but are not able to verify the type or
the length of time the ticks were attached. The child is asymptomatic. What is the best course
of action?
a. Administer a prophylactic single dose of doxycycline.
b. Perform serologic testing for IgG or IgM antibodies.
c. Prescribe amoxicillin three times daily for 14 to 21 days.
d. Teach the parents which signs and symptoms to report.
ANS: D
 Prophylaxis should not be given if the type of tick or the timeline for attachment cannot be
verified; however, parents should be encouraged to report signs of Lyme disease if they occur.
Prophylaxis is given if the tick is reliably identified as a nymph or adult Ixodes scapularis
species. Serologic testing may be performed if symptoms occur. Amoxicillin tid for 2 to 3
weeks is indicated for early localized disease.

12. A child with a history of a pustular rash at the site of a cat scratch on one arm now has warm,
tender, swollen axillary lymph nodes on the affected side. The primary care pediatric nurse
practitioner notes induration and erythema of these nodes. What will the nurse practitioner do?
a. Obtain a complete blood count and C-reactive protein.
b. Order an immunofluorescent assay (IFA) for serum antibodies.
c. Perform a needle aspiration of the affected lymph nodes.
d. Prescribe a 5-day course of azithromycin.
ANS: B
IFA shows a good correlation with cat-scratch fever disease and is useful for a more definitive
diagnosis. A complete blood count and C-reactive protein are non-specific indicators of
disease. Needle aspiration is only necessary to determine whether local lymph nodes are
infected. Antibiotics are not given unless nodes are infected.

13. A school-age child has fever of 104°F, sore throat, vomiting and malaise. The primary care
pediatric nurse practitioner observes that the tonsils, oropharynx, and palate are erythematous
and covered with exudate; the tongue is coated and red; and there is a red, sandpaper-like rash
on the child’s neck, trunk, and extremities. A rapid strep test is positive. What will the nurse
practitioner do to manage this child’s illness?
a. Administer intramuscular ceftriaxone.
b. Hospitalize for further diagnostic tests.
c. Prescribe oral amoxicillin.
d. Refer to a pediatric infectious disease specialist.
ANS: C
Scarlatina is caused by erythrogenic toxin from Group A streptococcus. Treatment is the same
as for Group A streptococcus unless complications occur. IM antibiotics are not indicated. The
child does not need hospitalization or referral to a specialist.

14. An adolescent has a TB skin test prior to working as a volunteer in a hospital. The adolescent
is healthy and has not travelled to or from a TB-endemic area or had close contact with
anyone who has TB. The Mantoux skin test shows 10 mm of induration after 48 hours. What
will the primary care pediatric nurse practitioner do?
a. Ask the adolescent about exposure to homeless persons.
b. Order a chest radiograph to rule out active TB.
c. Reassure the adolescent that this is a negative screen.
d. Refer the adolescent to an infectious disease specialist.
ANS: C
In children 4 years and older without risk factors, induration must be at least 15 mm or greater
to be considered to be a positive screen. It is not necessary to question the adolescent about
possible exposures. Chest radiographs are ordered to evaluate for active TB in persons with a
positive screen. Referral to an infectious disease specialist is done if active TB is present.