PALS Certification Exam — Questions and Answers

Question 1: When titrating dopamine for a child in cold septic shock, which dose range provides predominantly beta-1 inotropic effects?

1–3 mcg/kg/min (dopaminergic)
20–25 mcg/kg/min (vasopressin-like)
5–10 mcg/kg/min (beta-1 predominant) (Correct answer)
15–20 mcg/kg/min (alpha predominant)

Correct answer: 5–10 mcg/kg/min (beta-1 predominant)

At 5–10 mcg/kg/min, dopamine primarily stimulates beta-1 receptors, increasing heart rate and contractility.

Question 2: Which of the following does not usually result in a youngster experiencing a sudden cardiac arrest?

Hypertrophic cardiomyopathy
Myocarditis
Long QT syndrome
Drug intoxication (Correct answer)

Correct answer: Drug intoxication

While drug intoxication can cause various cardiac issues, it is not considered one of the usual primary causes of sudden cardiac arrest in youngsters compared to underlying structural or electrical heart conditions. Myocarditis, hypertrophic cardiomyopathy, and long QT syndrome are well-established, common causes of sudden cardiac death in otherwise healthy-appearing children and adolescents.

Question 3: A 5-year-old child is semiconscious with an intact gag reflex requiring airway support. Which airway adjunct is most appropriate?

Oropharyngeal airway (OPA)
Cuffed endotracheal tube
Nasopharyngeal airway (NPA) (Correct answer)
Laryngeal mask airway (LMA)

Correct answer: Nasopharyngeal airway (NPA)

The nasopharyngeal airway is better tolerated in patients with an intact gag reflex because it does not stimulate the posterior pharynx as readily as an OPA.

Question 4: During a code, a 7-year-old is bradycardic and unresponsive despite two doses of atropine and one dose of epinephrine. The team starts CPR. What compression-to-ventilation ratio is correct for a 2-rescuer pediatric CPR scenario (intubated)?

5:1
Continuous compressions at 100–120/min with asynchronous ventilations at 1 breath every 2–3 seconds (Correct answer)
30:2
15:2

Correct answer: Continuous compressions at 100–120/min with asynchronous ventilations at 1 breath every 2–3 seconds

Once an advanced airway is in place for a child, CPR delivers continuous compressions at 100–120/min with asynchronous breaths at 1 per 2–3 seconds.

Question 5: A 3-year-old presents with sudden onset stridor, drooling, and refusal to lie down. Which condition is most likely?

Croup (laryngotracheobronchitis)
Epiglottitis (Correct answer)
Bronchiolitis
Foreign body aspiration

Correct answer: Epiglottitis

Epiglottitis classically presents with the 'tripod position,' drooling, high fever, and toxic appearance — lying down worsens airway obstruction.

Question 6: During the secondary assessment of a pediatric patient, SAMPLE history is obtained. What does the 'A' in SAMPLE stand for?

Activity level
Allergies (Correct answer)
Airway history
Age and weight

Correct answer: Allergies

A in SAMPLE stands for Allergies, including drug, food, and environmental allergies that may affect treatment choices.

Question 7: Which of the following is considered the MOST common cause of bradycardia in infants and children?

Congenital heart block
Hypoxia (Correct answer)
Hypothermia
Drug overdose

Correct answer: Hypoxia

Unlike in adults, bradycardia in the pediatric population is most often a secondary event caused by hypoxia from respiratory failure or shock. This is why the initial steps of the PALS Bradycardia Algorithm always focus on establishing a patent airway, ensuring adequate oxygenation, and assisting ventilation.

Question 8: What is the goal SpO2 before performing rapid sequence intubation (RSI) in a pediatric patient if clinical conditions permit?

SpO2 greater than 85%
SpO2 greater than 90%
SpO2 greater than 99% (Correct answer)
SpO2 greater than 95%

Correct answer: SpO2 greater than 99%

The goal of pre-oxygenation before RSI is SpO2 greater than 99% to maximize the safe apnea time available during the intubation procedure.

Question 9: Which of the following is the most reliable indicator of correct ETT placement after intubation?

Continuous waveform capnography (Correct answer)
Mist in the ETT
Visible chest rise with ventilation
Symmetric breath sounds on auscultation

Correct answer: Continuous waveform capnography

Continuous waveform capnography (ETCO2) is the gold standard for confirming and continuously monitoring ETT placement in a perfusing patient.

Question 10: Which oxygen delivery device provides the highest concentration of supplemental oxygen to a spontaneously breathing child in respiratory distress?

Partial rebreather mask at 6 L/min
Non-rebreather mask at 10–15 L/min (Correct answer)
Simple face mask at 8 L/min
Nasal cannula at 4 L/min

Correct answer: Non-rebreather mask at 10–15 L/min

A non-rebreather mask with flow rates of 10–15 L/min can deliver oxygen concentrations up to 90–95% by preventing exhaled gas from diluting the oxygen supply.

Question 11: A post-arrest child on TTM develops shivering. Why is shivering problematic in this setting?

It indicates return of neurological function and should be encouraged
It only increases discomfort but has no physiological effect
It causes bradycardia requiring atropine
It raises core temperature and counteracts cooling (Correct answer)

Correct answer: It raises core temperature and counteracts cooling

Shivering generates heat, which raises core temperature and undermines the cooling goals of TTM.

Question 12: During pediatric resuscitation, which finding on capnography suggests ROSC (return of spontaneous circulation) has occurred?

Sudden drop in ETCO₂ below 10 mmHg
Gradual rise in ETCO₂ over several minutes
Flat ETCO₂ waveform throughout
Sudden increase in ETCO₂ to 35–45 mmHg (Correct answer)

Correct answer: Sudden increase in ETCO₂ to 35–45 mmHg

A sudden abrupt increase in ETCO₂ to normal values (35–45 mmHg) during CPR is a reliable indicator of ROSC.

Question 13: Which of the following is considered a late and ominous sign of shock in a pediatric patient?

Tachycardia
Delayed capillary refill
Hypotension (Correct answer)
Cool extremities

Correct answer: Hypotension

In pediatric shock, compensatory mechanisms like tachycardia and peripheral vasoconstriction (leading to cool extremities and delayed capillary refill) work to maintain blood pressure. Hypotension is a late sign, indicating that these compensatory mechanisms are failing and the child is in decompensated shock, which can quickly lead to cardiopulmonary arrest.

Question 14: A 4-year-old is in respiratory failure from severe pneumonia. Tidal volume during bag-mask ventilation should be targeted at which amount?

10–12 mL/kg
5–8 mL/kg (Correct answer)
3–4 mL/kg
15 mL/kg

Correct answer: 5–8 mL/kg

PALS recommends tidal volumes of 5–8 mL/kg for pediatric bag-mask ventilation to provide adequate ventilation while avoiding barotrauma.

Question 15: A 6-year-old with symptomatic bradycardia does not respond to oxygenation and ventilation. What is the first medication given?

Amiodarone
Lidocaine
Adenosine
Atropine (Correct answer)

Correct answer: Atropine

Atropine 0.02 mg/kg IV/IO is the first-line drug for symptomatic bradycardia after oxygenation/ventilation fails.

Question 16: A child arrests due to suspected tension pneumothorax (T cause). What is the immediate intervention?

IV epinephrine
Needle thoracostomy (Correct answer)
Defibrillation
Pericardiocentesis

Correct answer: Needle thoracostomy

Needle thoracostomy (decompression) at the 2nd intercostal space mid-clavicular line relieves tension pneumothorax.

Question 17: During a resuscitation, the team identifies the pediatric patient's bradycardia is caused by increased vagal tone from suctioning. Which drug is most appropriate?

Epinephrine
Atropine (Correct answer)
Amiodarone
Lidocaine

Correct answer: Atropine

Atropine is the drug of choice for vagally mediated bradycardia because it blocks parasympathetic (vagal) tone.

Question 18: Which intraosseous (IO) site is generally preferred for rapid vascular access in a child in cardiac arrest?

Distal femur
Proximal tibia (Correct answer)
Iliac crest
Calcaneus

Correct answer: Proximal tibia

The proximal tibia is the preferred IO site in children due to ease of access and large marrow cavity.

Question 19: A nurse asks why the defibrillator must be in 'synchronized' mode before cardioverting SVT. What is the correct explanation?

To deliver more energy than standard defibrillation
To avoid delivering a shock during the vulnerable T-wave period (Correct answer)
To reduce the energy requirement by 50%
To allow multiple shocks in rapid succession

Correct answer: To avoid delivering a shock during the vulnerable T-wave period

Synchronized cardioversion delivers the shock on the R wave to avoid the vulnerable T-wave repolarization period, which could trigger ventricular fibrillation.

Question 20: When assessing the 'Appearance' component of the PAT in an infant, which finding is most consistent with abnormal tone?

Limp body with no movement (Correct answer)
Crying vigorously
Normal startle response
Flexed extremities at rest

Correct answer: Limp body with no movement

A limp, hypotonic infant indicates abnormal tone and is a significant PAT appearance abnormality suggesting serious illness.

Question 21: During pediatric cardiac arrest resuscitation, which action should be taken IMMEDIATELY after defibrillation?

Administer epinephrine before resuming CPR
Increase oxygen flow and wait 30 seconds before resuming CPR
Check rhythm and pulse immediately after the shock
Resume CPR for 2 minutes before checking rhythm again (Correct answer)

Correct answer: Resume CPR for 2 minutes before checking rhythm again

CPR should resume immediately after defibrillation without delaying for a pulse or rhythm check; 2 minutes of CPR follow each shock.

Question 22: A lone rescuer finds a 7-year-old unresponsive with no breathing. The rescuer has a phone. What is the correct sequence?

Start CPR for 5 cycles → call 911 → continue CPR
Start CPR → call 911 after 2 minutes
Call 911 first → then start CPR
Call 911 on speakerphone simultaneously while beginning CPR (Correct answer)

Correct answer: Call 911 on speakerphone simultaneously while beginning CPR

A lone rescuer should activate EMS on speakerphone while simultaneously beginning CPR to minimize delay in both actions.

Question 23: During two-rescuer infant CPR, the two thumb-encircling technique is preferred because it:

Reduces the risk of rib fractures compared to the two-finger method
Generates higher systolic blood pressure and coronary perfusion pressure (Correct answer)
Is easier to perform for untrained bystanders
Allows faster compression rates than any other technique

Correct answer: Generates higher systolic blood pressure and coronary perfusion pressure

The two thumb-encircling technique generates higher coronary perfusion pressure and systolic blood pressure, improving outcomes.

Question 24: A 4-year-old has a heart rate of 68 bpm with poor perfusion. After ensuring airway and oxygenation, what is the next intervention if the child remains symptomatic?

Give epinephrine 0.01 mg/kg IV/IO (Correct answer)
Begin CPR immediately
Perform synchronized cardioversion
Administer adenosine 0.1 mg/kg IV

Correct answer: Give epinephrine 0.01 mg/kg IV/IO

If bradycardia with poor perfusion persists despite adequate oxygenation, epinephrine is the drug of choice in PALS.

Question 25: Which of the following best describes 'post-cardiac arrest syndrome'?

Only neurological dysfunction following ROSC
Systemic ischemia-reperfusion response affecting brain, heart, and other organs (Correct answer)
Pulmonary edema caused exclusively by fluid overload
Cardiac arrhythmia occurring within 1 hour of ROSC

Correct answer: Systemic ischemia-reperfusion response affecting brain, heart, and other organs

Post-cardiac arrest syndrome is a global ischemia-reperfusion injury affecting the brain, myocardium, and systemic vasculature after ROSC.

Question 26: Which of the following arrhythmias would be indicated by typical sawtooth P-wave activity on the ECG monitor, using the ILCOR PALS Provider Manual?

Supraventricular tachycardia
Atrial flutter (Correct answer)
Atrial fibrillation
Sinus tachycardia

Correct answer: Atrial flutter

The characteristic 'sawtooth' pattern of P-waves on an ECG, particularly in leads II, III, and aVF, is a hallmark finding of atrial flutter. This pattern represents rapid and regular atrial depolarization, typically at a rate of 250-350 bpm. This distinct ECG finding helps differentiate atrial flutter from other arrhythmias like atrial fibrillation or sinus tachycardia.

Question 27: An 8-year-old child is intubated and mechanically ventilated after achieving Return of Spontaneous Circulation (ROSC). The initial SpO2 reading is 100% while receiving 100% FiO2. What is the most appropriate next step regarding oxygen therapy?

Immediately perform an arterial blood gas (ABG) before making any changes.
Maintain FiO2 at 100% for 24 hours to ensure maximal oxygen delivery.
Titrate FiO2 downwards to achieve a target SpO2 between 94% and 99%. (Correct answer)
Begin to wean from the ventilator, as 100% saturation indicates stability.

Correct answer: Titrate FiO2 downwards to achieve a target SpO2 between 94% and 99%.

After ROSC, both hypoxia and hyperoxia can be harmful, with hyperoxia potentially causing reperfusion injury from oxygen-free radicals. [1, 4] The PALS guidelines recommend titrating the fraction of inspired oxygen (FiO2) to the lowest level required to maintain an oxygen saturation (SpO2) between 94% and 99%. [1, 2, 4, 5] While an ABG is useful, the immediate action is to reduce the FiO2 to avoid the harmful effects of 100% oxygen.

Question 28: Which of the following is a sign of 'compensated' respiratory distress rather than 'decompensated' respiratory failure?

Altered mental status and cyanosis
Absent respiratory effort
Tachycardia with maintained SpO2 ≥94% (Correct answer)
Bradycardia and hypotension

Correct answer: Tachycardia with maintained SpO2 ≥94%

In compensated respiratory distress the child works harder to breathe but maintains oxygenation; decompensation occurs when compensatory mechanisms fail.

Question 29: A 2-year-old is brought in with vomiting and diarrhea for 3 days. HR is 175, CRT is 5 sec, skin turgor is poor, and mucous membranes are dry. What is the primary shock type?

Obstructive shock
Hypovolemic shock (Correct answer)
Distributive shock
Cardiogenic shock

Correct answer: Hypovolemic shock

Prolonged vomiting and diarrhea cause volume depletion leading to hypovolemic shock, the most common type of shock in children.

Question 30: In pediatric assessment, which capillary refill time is considered abnormal?

Greater than 2 seconds (Correct answer)
Greater than 5 seconds
Less than 1 second
1 to 2 seconds

Correct answer: Greater than 2 seconds

Capillary refill greater than 2 seconds is abnormal and suggests reduced perfusion to the extremities.

Question 31: A child presents with a heart rate of 280 bpm, narrow QRS, and no discernible P waves. Which arrhythmia is most likely?

Ventricular tachycardia
Sinus tachycardia
Third-degree heart block
Supraventricular tachycardia (SVT) (Correct answer)

Correct answer: Supraventricular tachycardia (SVT)

SVT typically presents with rates >220 bpm in infants or >180 bpm in children, narrow QRS complexes, and absent or retrograde P waves.

Question 32: An 8-month-old infant is found apneic with a brachial pulse of 45/min and signs of poor perfusion. Despite effective bag-mask ventilation with 100% oxygen, the heart rate remains 45/min and perfusion is poor. What is the most appropriate immediate action?

Attach an AED and wait for rhythm analysis.
Provide rescue breaths only and recheck the pulse in 2 minutes.
Administer IV epinephrine 0.01 mg/kg.
Begin high-quality chest compressions and continue assisted ventilations. (Correct answer)

Correct answer: Begin high-quality chest compressions and continue assisted ventilations.

The PALS algorithm states that if a child has a heart rate less than 60/min with signs of poor perfusion despite adequate oxygenation and ventilation, CPR should be initiated. This infant's heart rate is 45/min with poor perfusion, meeting the criteria to start chest compressions along with ventilations.

Question 33: What is the target mean arterial pressure (MAP) goal when managing pediatric septic shock?

Age-appropriate normal MAP (Correct answer)
MAP > 80 mmHg to ensure perfusion
Greater than 45 mmHg for all ages
MAP > 65 mmHg regardless of age

Correct answer: Age-appropriate normal MAP

MAP goals in pediatric septic shock should be age-appropriate, as normal MAP varies significantly from infants to adolescents.

Question 34: Which hemodynamic pattern is characteristic of hypovolemic shock?

Low CO, low SVR
High CO, high SVR
High CO, low SVR
Low CO, high SVR (Correct answer)

Correct answer: Low CO, high SVR

Hypovolemic shock causes reduced preload, leading to low cardiac output and compensatory increased systemic vascular resistance.

Question 35: A 4-year-old with a history of fever and vomiting presents with a heart rate of 170/min. The ECG shows a narrow QRS complex and visible P waves before each QRS. The heart rate decreases when the child's fever is treated. Which of the following is the most likely rhythm?

Ventricular Tachycardia
Supraventricular Tachycardia (SVT)
Atrial Flutter
Sinus Tachycardia (Correct answer)

Correct answer: Sinus Tachycardia

Sinus tachycardia is a physiologic response to stressors like fever or dehydration. Key features include a heart rate typically less than 180 bpm in a child, the presence of normal P waves, and rate variability that responds to treatment of the underlying cause. SVT typically has a rate over 180 bpm in children and absent or abnormal P waves.

Question 36: Which of the following conditions is a reversible cause of bradycardia that should be specifically addressed in pediatric patients?

Hypernatremia
Hypertension
Hyperthyroidism
Hypothermia (Correct answer)

Correct answer: Hypothermia

Hypothermia is a reversible H cause of bradycardia; rewarming the patient can restore normal heart rate.

Question 37: Which medication is used to treat supraventricular tachycardia in a hemodynamically stable child when adenosine fails?

Verapamil (only in children > 1 year) (Correct answer)
Vasopressin
Atropine
Epinephrine

Correct answer: Verapamil (only in children > 1 year)

Verapamil may be considered for SVT in children older than 1 year if adenosine fails, but is contraindicated in infants due to risk of cardiovascular collapse.

Question 38: A 1-year-old with a history of prematurity presents with wheeze and respiratory distress. The parents report this is the first episode. What additional history finding would support reactive airway disease over bronchiolitis?

Family history of atopy and asthma (Correct answer)
Exposure to a sibling with RSV
URI prodrome over the past 3 days
Fever of 38.5°C

Correct answer: Family history of atopy and asthma

A strong family history of atopy or asthma in a first-episode wheeze shifts the diagnosis toward reactive airway disease, although this age group often has overlapping presentations.

Question 39: A child in cardiac arrest has a rhythm showing organized electrical activity on the monitor but no pulse. What rhythm is this?

Asystole
Sinus bradycardia
Pulseless electrical activity (PEA) (Correct answer)
Ventricular fibrillation

Correct answer: Pulseless electrical activity (PEA)

PEA is defined as organized electrical activity on the cardiac monitor without a detectable pulse.

Question 40: The principle of "knowing one's limitations" is crucial for a high-performance resuscitation team. Which of the following actions is the best example of this principle?

A team member who is struggling to obtain IV access asks another provider to try. (Correct answer)
The team leader insists on performing all complex procedures personally.
A junior team member remains silent even when they suspect an incorrect drug is being prepared.
A provider attempts an unfamiliar procedure without asking for guidance.

Correct answer: A team member who is struggling to obtain IV access asks another provider to try.

Knowing one's limitations means recognizing when a task is difficult or beyond one's ability and seeking help early. This prioritizes the patient's well-being over personal pride and is a sign of a mature and effective team member.

Question 41: In a pediatric patient with distributive shock from anaphylaxis, what is the FIRST drug to administer?

IV ranitidine
IV methylprednisolone
IM epinephrine 0.01 mg/kg (max 0.5 mg) (Correct answer)
IV diphenhydramine

Correct answer: IM epinephrine 0.01 mg/kg (max 0.5 mg)

IM epinephrine is the first-line treatment for anaphylaxis, reversing bronchospasm and vasodilation before antihistamines or steroids.

Question 42: A 3-year-old with a history of congenital heart disease develops a wide-complex tachycardia at 190 bpm with signs of shock. What is the first action?

Prepare for synchronized cardioversion (Correct answer)
Administer adenosine 0.1 mg/kg IV
Start amiodarone infusion
Obtain 12-lead ECG

Correct answer: Prepare for synchronized cardioversion

Unstable wide-complex tachycardia with shock requires immediate synchronized cardioversion regardless of rhythm identification.

Question 43: A 4-year-old presents with a heart rate of 200 bpm, narrow QRS complexes, and no P waves visible. The child is alert and playing. What is the most likely rhythm?

Atrial flutter
Ventricular tachycardia
Supraventricular tachycardia (SVT) (Correct answer)
Sinus tachycardia

Correct answer: Supraventricular tachycardia (SVT)

SVT typically presents with abrupt-onset rates >180-220 bpm, narrow QRS, absent or retrograde P waves, and the child may still be alert if compensated.

Question 44: Which ECG feature best distinguishes sinus tachycardia from SVT in a pediatric patient?

Narrow QRS complex
Regular rhythm
P-waves present before every QRS with a normal axis (Correct answer)
Heart rate above 180 bpm

Correct answer: P-waves present before every QRS with a normal axis

Sinus tachycardia shows upright P-waves with a normal axis preceding each QRS, unlike SVT which often shows absent or retrograde P-waves.

Question 45: Vasopressin is occasionally used in pediatric resuscitation as an alternative to epinephrine. Its mechanism is:

Non-adrenergic vasoconstriction via V1 receptors (Correct answer)
Beta-1 and beta-2 adrenergic agonism
Alpha-2 adrenergic agonism causing sedation
Calcium channel activation in cardiac muscle

Correct answer: Non-adrenergic vasoconstriction via V1 receptors

Vasopressin causes vasoconstriction through V1 receptor activation independent of adrenergic pathways, which may be effective when catecholamines fail.

Question 46: A 4-year-old is in cardiac arrest. An AED arrives. After delivering a shock, what is the IMMEDIATE next step?

Check for a pulse before resuming CPR
Give 2 rescue breaths before compressions
Reanalyze the rhythm before resuming CPR
Resume CPR immediately starting with chest compressions (Correct answer)

Correct answer: Resume CPR immediately starting with chest compressions

After AED shock delivery, immediately resume CPR starting with chest compressions without pausing for a pulse check.

Question 47: Which method is considered the gold standard for confirming correct endotracheal tube placement in a pediatric patient?

Bilateral auscultation over the lung fields
Direct observation of chest rise with ventilation
Continuous waveform capnography (end-tidal CO2) (Correct answer)
Chest radiograph showing tube at the carina

Correct answer: Continuous waveform capnography (end-tidal CO2)

Continuous waveform capnography is the gold standard for confirming and monitoring ET tube placement because it provides real-time evidence of CO2 exchange from the lungs.

Question 48: An infant is pulseless. Two rescuers are available. Which compression landmark is correct for the two thumb-encircling technique?

Just above the xiphoid process, on the lower sternum
Left lateral chest wall over the cardiac apex
Just below the nipple line, on the lower half of the sternum (Correct answer)
Center of the chest, on the upper half of the sternum

Correct answer: Just below the nipple line, on the lower half of the sternum

For infant CPR, place thumbs just below the nipple line on the lower half of the sternum, avoiding the xiphoid process.

Question 49: When performing bag-mask ventilation on a child with a pulse but absent respirations, what is the recommended ventilation rate?

12–20 breaths per minute (Correct answer)
30–40 breaths per minute
20–30 breaths per minute
8–10 breaths per minute

Correct answer: 12–20 breaths per minute

For a child with a pulse, deliver 1 breath every 3–5 seconds (12–20 breaths per minute) to support oxygenation without causing hyperventilation.

Question 50: Which of the following BEST describes the principle of 'constructive intervention' in PALS team dynamics?

Only the most senior clinician may intervene in another's actions
The team leader intervenes physically to correct a team member's technique mid-task
Any team member respectfully corrects an error or unsafe action observed during resuscitation (Correct answer)
Intervention is only appropriate after the resuscitation is complete

Correct answer: Any team member respectfully corrects an error or unsafe action observed during resuscitation

Constructive intervention empowers any team member to respectfully speak up when they observe an error or unsafe practice, regardless of hierarchy.

Question 51: In post-cardiac arrest care, which intervention has the strongest evidence for improving neurological outcomes in pediatric patients?

Magnesium sulfate infusion
Targeted temperature management (TTM) (Correct answer)
Early tracheostomy
High-dose corticosteroids

Correct answer: Targeted temperature management (TTM)

TTM (targeting 32–34°C or preventing fever at 36–37.5°C) has the strongest evidence base for neuroprotection in comatose post-arrest pediatric patients.

PALS Certification Exam

The AHA Pediatric Advanced Life Support (PALS) exam evaluates healthcare providers on systematic assessment, resuscitation algorithms, pharmacology, and team dynamics for critically ill pediatric patients.

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120 min

Time Limit

84%

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