Pediatric CCRN Exam Pediatric CCRN Neurological 2 — Questions and Answers
Question 1: A child with bacterial meningitis develops the sudden onset of a fixed dilated pupil and posturing. The nurse should FIRST:
- Administer a scheduled antibiotic dose
- Notify the physician immediately and prepare for emergent ICP management (Correct answer)
- Position the child flat and obtain a STAT CT scan
- Increase the IV fluid rate
Correct answer: Notify the physician immediately and prepare for emergent ICP management
A fixed dilated pupil with posturing signals cerebral herniation — an immediate life-threatening emergency requiring physician notification and emergent ICP management before any other action.
Question 2: Which CSF finding is MOST consistent with bacterial meningitis in a child?
- Clear CSF, WBC 10 (lymphocytic), glucose 60, protein 30
- Cloudy CSF, WBC 2,000 (neutrophilic), glucose 25, protein 200 (Correct answer)
- Xanthochromic CSF, RBC 10,000, WBC 50
- Clear CSF, WBC 300 (lymphocytic), glucose 55, protein 80
Correct answer: Cloudy CSF, WBC 2,000 (neutrophilic), glucose 25, protein 200
Bacterial meningitis produces cloudy CSF with a high neutrophilic pleocytosis, very low glucose (<40 mg/dL or CSF:serum ratio <0.4), and elevated protein due to purulent inflammation.
Question 3: What is the mechanism of neurological injury in neonatal hypoxic-ischemic encephalopathy (HIE)?
- Direct viral invasion of neurons
- Excitotoxicity from glutamate release during reperfusion after hypoxia (Correct answer)
- Autoimmune destruction of myelin
- Vascular thrombosis from hypercoagulability
Correct answer: Excitotoxicity from glutamate release during reperfusion after hypoxia
During reperfusion after hypoxia-ischemia, massive glutamate release triggers excitotoxicity, calcium influx, mitochondrial dysfunction, and programmed cell death in the vulnerable neonatal brain.
Question 4: Therapeutic hypothermia for HIE is initiated at 33.5°C for 72 hours. It is CONTRAINDICATED in which scenario?
- Gestational age ≥36 weeks with moderate encephalopathy
- Birth weight >1,800 g
- Gestational age <36 weeks (Correct answer)
- Presence of coagulopathy
Correct answer: Gestational age <36 weeks
Therapeutic hypothermia is currently recommended only for neonates ≥36 weeks gestation; premature infants <36 weeks are excluded due to insufficient evidence and increased risk of complications.
Question 5: A 7-year-old with a VP shunt presents with headache, vomiting, and a bulging fontanelle. Assessment reveals upward gaze palsy. What does upward gaze palsy indicate in this context?
- Cortical blindness from occipital ischemia
- Parinaud syndrome from dorsal midbrain compression due to hydrocephalus (Correct answer)
- Optic nerve compression
- Cerebellar herniation
Correct answer: Parinaud syndrome from dorsal midbrain compression due to hydrocephalus
Parinaud syndrome (paralysis of upward gaze) results from dorsal midbrain compression by an enlarged third ventricle in obstructive hydrocephalus — a classic sign of shunt failure.
Question 6: Which anticonvulsant is PREFERRED for a neonate with seizures due to hypoglycemia?
- Phenobarbital
- Treat the underlying hypoglycemia with IV dextrose first (Correct answer)
- Fosphenytoin
- Levetiracetam
Correct answer: Treat the underlying hypoglycemia with IV dextrose first
Neonatal seizures caused by hypoglycemia are metabolic in origin — correcting the glucose abnormality is the definitive treatment and should precede any anticonvulsant therapy.
Pediatric CCRN Exam Pediatric CCRN Neurological 2
A child with bacterial meningitis develops the sudden onset of a fixed dilated pupil and posturing.
The nurse should FIRST: