Question 1

The primary care pediatric nurse practitioner is examining a 5-year-old child who has had recurrent fevers, bone pain, and a recent loss of weight. The physical exam reveals scattered petechiae, lymphadenopathy, and bruising. A complete blood count shows thrombocytopenia, anemia, and an elevated white cell blood count. The nurse practitioner will refer this child to a specialist for what diagnostic testing?

Accepted Answer

The presentation of fevers, bone pain, weight loss, petechiae, lymphadenopathy, bruising, thrombocytopenia, anemia, and an elevated white cell blood count suggest a possible diagnosis of leukemia or other hematologic malignancy. A bone marrow biopsy is necessary to confirm the diagnosis and determine the type of leukemia or malignancy. Corticosteroids and IVIG may be used in the treatment of certain types of leukemia, but a definitive diagnosis must be made first. Hemoglobin electrophoresis is not indicated in this case, as it is used to diagnose hemoglobinopathies such as sickle cell anemia. Immunoglobulin testing may be useful in the diagnosis of immunodeficiency disorders, but it is not indicated in this case.

Question 2

The primary care pediatric nurse practitioner is managing care for a child diagnosed with iron-deficiency anemia who had an initial hemoglobin of 8.8 g/dL and hematocrit of 32% who has been receiving ferrous sulfate as 3 mg/kg/day of elemental iron for 4 weeks. The child's current lab work reveals elevations in Hgb/Hct and reticulocytes with a hemoglobin of 10.5 g/dL and a hematocrit of 36%. What is the next step in management of this patient?

Accepted Answer

The improvement in hemoglobin (Hgb) and hematocrit (Hct) levels, along with an increase in reticulocytes, indicates a positive response to the current iron supplementation. Continuing the current dose and rechecking labs in 1 to 2 months is appropriate to ensure continued improvement towards normal levels.

Question 3

The primary care pediatric nurse practitioner reviews a child's complete blood count with differential white blood cell values and recognizes a "left shift" because of what event?

Accepted Answer

A left shift in the differential white blood cell count occurs when there is an increase in the number of immature neutrophils, such as bands or metamyelocytes, in the bloodstream. This is usually a response to an acute bacterial infection, and an elevated neutrophil count is commonly seen with this type of response.

Question 4

The primary care pediatric nurse practitioner sees a 12-month-old infant who is being fed goat's milk and a vegetarian diet. The child is pale and has a beefy-red, sore tongue and oral mucous membranes. Which tests will the nurse practitioner order to evaluate this child's condition?

Accepted Answer

The child's presentation is consistent with a B vitamin deficiency, which may occur with a vegetarian diet lacking in certain nutrients, such as vitamin B12. The sore tongue and oral mucous membranes suggest a deficiency in folate and/or vitamin B12. Testing for RBC folate, iron, and B levels would help confirm this suspicion and guide treatment. Hemoglobin electrophoresis and reticulocyte levels would not be necessary in this case, as there is no indication of a hemoglobinopathy or anemia. Serum lead levels may be indicated if there is a suspicion of lead poisoning, but this is not the likely cause of the child's symptoms.

Question 5

A toddler who presents with anemia and reticulocytopenia has a history of a gradual decrease in energy and increase in pallor beginning after a recent viral infection. How will the primary care pediatric nurse practitioner treat this child?

Accepted Answer

The answer of A toddler who presents with anemia and...

Question 6

The primary care pediatric nurse practitioner reviews hematology reports on a child with beta-thalassemia minor and notes an Hgb level of 8 g/dL. What will the nurse practitioner do?

Accepted Answer

The nurse practitioner should evaluate serum ferritin to determine if there is concurrent iron deficiency anemia, as beta-thalassemia minor typically does not cause severe anemia and does not require transfusions or iron supplementation unless iron deficiency is present.

Question 7

The primary care pediatric nurse practitioner evaluates a 5-year-old child who presents with pallor and obtains labs revealing a hemoglobin of 8.5 g/dL and a hematocrit of 31%. How will the nurse practitioner manage this patient?

Accepted Answer

The child has anemia, likely iron deficiency anemia, given the age and presentation. Prescribing elemental iron and rechecking labs in 1 month is a standard management approach to confirm improvement and ensure the treatment is effective.

Question 8

A school-age child comes to the clinic for evaluation of excessive bruising. The primary care pediatric nurse practitioner notes a history of an upper respiratory infection 2 weeks prior. The physical exam is negative for hepatosplenomegaly and lymphadenopathy. Blood work reveals a platelet count of 60,000/mm3 with normal PT and aPTT. How will the nurse practitioner manage this child's condition?

Accepted Answer

The child's presentation is consistent with immune thrombocytopenia (ITP), which often follows a viral infection and presents with isolated thrombocytopenia (low platelet count) but normal coagulation studies (PT and aPTT). Management for mild cases, as indicated by the absence of significant bleeding and a platelet count above 30,000/mm3, includes observation and advising to avoid activities or medications (like NSAIDs) that could increase bleeding risk. Hospital admission, corticosteroid therapy, or referral to a hematologist might be considered in more severe cases or if the condition does not improve.

Question 9

The primary care pediatric nurse practitioner performs a well baby examination on a 4-month-old infant who is exclusively breastfed and whose mother plans to introduce only small amounts of fruits and vegetables in addition to breastfeeding. To ensure that the infant gets adequate amounts of iron, what will the nurse practitioner recommend?

Accepted Answer

CElemental iron supplementation of 1 mg/kg/day until cereals are added is recommended for exclusively breastfed infants starting at around 4 months of age to prevent iron deficiency until iron-rich solid foods are introduced. Monitoring the infant's hemoglobin and hematocrit at every well-baby checkup is also a good practice to ensure the infant maintains adequate iron levels and to detect any signs of anemia early.

Question 10

A 2-year-old child who has sickle cell anemia (SCA) comes to the clinic with a cough and a fever of 101.5°C. The child currently takes penicillin V prophylaxis 125 mg orally twice daily. What will the primary care pediatric nurse practitioner do?

Accepted Answer

A fever in a child with SCA could be a sign of a serious infection such as sepsis. Therefore, the child should be admitted to the hospital for further evaluation and treatment. In addition, the child should receive intravenous antibiotics and fluids to manage the infection and prevent dehydration. The penicillin V dose does not need to be increased at this time, as the child is already receiving prophylaxis. A chest radiograph may be ordered as part of the evaluation for pneumonia, but admission to the hospital is the priority.

Question 11

A complete blood count on a 12-month-old infant reveals microcytic, hypochromic anemia with a hemoglobin of 9.5 g/dL. The infant has mild pallor with no hepatosplenomegaly. The primary care pediatric nurse practitioner suspects what disorder?

Accepted Answer

The microcytic, hypochromic anemia with normal-sized red blood cells and mild pallor are consistent with iron-deficiency anemia, which is the most common type of anemia seen in infants and young children due to inadequate dietary iron intake or loss of iron through blood loss. Hereditary spherocytosis would have a normal mean corpuscular volume (MCV) and normal hemoglobin. Lead intoxication and sickle-cell anemia may have anemia but would present with other symptoms and signs such as abdominal pain, jaundice, bone pain, and organomegaly.

Question 12

The pediatric nurse practitioner provides primary care for a 30-month-old child who has sickle cell anemia who has had one dose of 23-valent pneumococcal vaccine. Which is an appropriate action for health maintenance in this child?

Accepted Answer

Children with sickle cell anemia are at increased risk for infections, including those caused by Neisseria meningitidis. Administering an initial meningococcal vaccine is appropriate for health maintenance to help protect against meningococcal disease.

Question 13

The primary care pediatric nurse practitioner is performing a well child examination on a school-age child who has a history of cancer treated with cranial irradiation. What will the nurse practitioner monitor in this child?

Accepted Answer

Cranial irradiation in children can lead to leukoencephalopathy, a condition affecting the white matter of the brain. Monitoring for cognitive and neurological effects is important in these patients.

Quiz 39: Hematologic Disorders