1
Barkley PNP-AC Review | Pediatric Acute Care Nurse
Practitioner Exam | 175 Actual Questions and Answers
SECTION 1 – CARDIOVASCULAR & HEMODYNAMICS (1–20)
1. A 3-month-old infant with a large ventricular septal defect (VSD) presents
with tachypnea, diaphoresis during feeds, and poor weight gain. On exam, a
harsh holosystolic murmur is heard at the left lower sternal border. The PMHNP
recognizes that the direction of the shunt is primarily:
A. Right-to-left
B. Left-to-right
C. Bidirectional with equal flow
D. No shunt; the murmur is innocent
: Correct Answer : B
Rationale: A large VSD initially creates a left-to-right shunt because left ventricular
pressure is higher than right. This leads to increased pulmonary blood flow,
causing the symptoms described. Over time, if pulmonary vascular resistance
increases, the shunt may reverse (Eisenmenger syndrome).
2. A 10-year-old with tetralogy of Fallot (TOF) experiences a hypercyanotic "tet
spell" while crying. The PMHNP should immediately place the child in which
position?
A. Supine with legs elevated
B. Knee-to-chest position
C. Trendelenburg
D. Left lateral decubitus
: Correct Answer : B
Rationale: The knee-to-chest position increases systemic vascular resistance,
which reduces right-to-left shunting through the VSD and promotes pulmonary
blood flow. Other interventions include oxygen, morphine, and intravenous fluids.
pg. 1
,2
3. A 4-week-old infant presents with poor feeding, tachypnea, and
hepatomegaly. A chest x-ray shows cardiomegaly with pulmonary venous
congestion. The most likely diagnosis is:
A. Transposition of the great arteries
B. Coarctation of the aorta
C. Dilated cardiomyopathy
D. Total anomalous pulmonary venous return (TAPVR)
: Correct Answer : C? Wait, the presentation of an infant with heart failure,
cardiomegaly, and no murmur could be dilated cardiomyopathy. However, TAPVR
with obstruction also causes cyanosis and pulmonary edema. The question
doesn't mention cyanosis. So cardiomyopathy is plausible. Let's think: A 4-week-
old with poor feeding, tachypnea, hepatomegaly, and x-ray showing cardiomegaly
with pulmonary venous congestion is classic for dilated cardiomyopathy or
myocarditis. TAPVR often has cyanosis. Coarctation (B) would present with
differential blood pressures. I'll select dilated cardiomyopathy (C).
: Correct Answer : C
Rationale: Dilated cardiomyopathy in infancy presents with signs of congestive
heart failure, cardiomegaly on chest x-ray, and no significant murmur. Common
etiologies include viral myocarditis, metabolic disorders, or genetic causes.
4. A child with history of Kawasaki disease (KD) is being followed. Which
coronary artery complication is most concerning?
A. Coronary artery vasospasm
B. Coronary artery aneurysm
C. Coronary artery dissection
D. Coronary artery calcification
: Correct Answer : B
Rationale: Kawasaki disease can cause coronary artery aneurysms in up to 25% of
untreated cases, leading to risk of thrombosis, myocardial infarction, and sudden
death. Treatment with IVIG and aspirin reduces this risk.
pg. 2
,3
5. A 14-year-old presents with syncope during a basketball game. Family history
is positive for sudden cardiac death in a cousin at age 16. ECG shows left
ventricular hypertrophy with deep Q waves in lateral leads. The most likely
diagnosis is:
A. Long QT syndrome
B. Hypertrophic cardiomyopathy (HCM)
C. Arrhythmogenic right ventricular cardiomyopathy
D. Brugada syndrome
: Correct Answer : B
Rationale: HCM presents with exertional syncope, LVH on ECG, and a family
history of sudden death. It is the most common cause of sudden cardiac death in
young athletes. The ECG pattern with deep Q waves and LVH is characteristic.
6. A 2-day-old newborn presents with cyanosis unresponsive to oxygen.
Echocardiogram shows the aorta arising from the right ventricle and the
pulmonary artery from the left ventricle. What is the diagnosis?
A. Tetralogy of Fallot
B. Transposition of the great arteries (TGA)
C. Truncus arteriosus
D. Tricuspid atresia
: Correct Answer : B
Rationale: D-TGA is a cyanotic congenital heart disease where the aorta and
pulmonary artery are switched. Mixing of blood is necessary for survival, typically
via a patent ductus arteriosus (PDA). Prostaglandin E1 is given to keep the PDA
open until surgical repair.
7. A child with acute myocarditis develops hypotension, cool extremities, and a
weak pulse despite fluid resuscitation. The PMHNP recognizes this as:
A. Hypovolemic shock
B. Distributive shock
C. Cardiogenic shock
D. Obstructive shock
pg. 3
, 4
: Correct Answer : C
Rationale: Myocarditis impairs the heart's pumping ability, leading to cardiogenic
shock. Management includes inotropic support (milrinone, dobutamine), diuresis
for volume overload, and afterload reduction.
8. A 6-month-old with unrepaired tetralogy of Fallot has a hypercyanotic spell.
After placing the infant in knee-to-chest position and administering oxygen, the
PMHNP's next pharmacological intervention is:
A. Intravenous epinephrine
B. Intravenous morphine sulfate
C. Oral propranolol
D. Inhaled nitric oxide
: Correct Answer : B
Rationale: Morphine reduces respiratory drive and decreases sympathetic
stimulation, which helps relax the infundibular spasm and reduces right-to-left
shunting. Intravenous propranolol can also be used, but morphine is first-line in
acute management. Beta-blockers (propranolol) are used for prophylaxis.
9. A child with a history of ventricular septal defect repair develops new-onset
heart block on ECG. Which defect is most associated with this complication?
A. Ostium primum ASD
B. Membranous VSD
C. Muscular VSD
D. Patent ductus arteriosus
: Correct Answer : B
Rationale: Membranous (perimembranous) VSDs are located near the conduction
system. Surgical or device closure can damage the bundle of His, leading to
complete heart block.
10. A 10-year-old with a history of rheumatic fever develops mitral stenosis.
Which findings would the PMHNP expect to see?
pg. 4
Barkley PNP-AC Review | Pediatric Acute Care Nurse
Practitioner Exam | 175 Actual Questions and Answers
SECTION 1 – CARDIOVASCULAR & HEMODYNAMICS (1–20)
1. A 3-month-old infant with a large ventricular septal defect (VSD) presents
with tachypnea, diaphoresis during feeds, and poor weight gain. On exam, a
harsh holosystolic murmur is heard at the left lower sternal border. The PMHNP
recognizes that the direction of the shunt is primarily:
A. Right-to-left
B. Left-to-right
C. Bidirectional with equal flow
D. No shunt; the murmur is innocent
: Correct Answer : B
Rationale: A large VSD initially creates a left-to-right shunt because left ventricular
pressure is higher than right. This leads to increased pulmonary blood flow,
causing the symptoms described. Over time, if pulmonary vascular resistance
increases, the shunt may reverse (Eisenmenger syndrome).
2. A 10-year-old with tetralogy of Fallot (TOF) experiences a hypercyanotic "tet
spell" while crying. The PMHNP should immediately place the child in which
position?
A. Supine with legs elevated
B. Knee-to-chest position
C. Trendelenburg
D. Left lateral decubitus
: Correct Answer : B
Rationale: The knee-to-chest position increases systemic vascular resistance,
which reduces right-to-left shunting through the VSD and promotes pulmonary
blood flow. Other interventions include oxygen, morphine, and intravenous fluids.
pg. 1
,2
3. A 4-week-old infant presents with poor feeding, tachypnea, and
hepatomegaly. A chest x-ray shows cardiomegaly with pulmonary venous
congestion. The most likely diagnosis is:
A. Transposition of the great arteries
B. Coarctation of the aorta
C. Dilated cardiomyopathy
D. Total anomalous pulmonary venous return (TAPVR)
: Correct Answer : C? Wait, the presentation of an infant with heart failure,
cardiomegaly, and no murmur could be dilated cardiomyopathy. However, TAPVR
with obstruction also causes cyanosis and pulmonary edema. The question
doesn't mention cyanosis. So cardiomyopathy is plausible. Let's think: A 4-week-
old with poor feeding, tachypnea, hepatomegaly, and x-ray showing cardiomegaly
with pulmonary venous congestion is classic for dilated cardiomyopathy or
myocarditis. TAPVR often has cyanosis. Coarctation (B) would present with
differential blood pressures. I'll select dilated cardiomyopathy (C).
: Correct Answer : C
Rationale: Dilated cardiomyopathy in infancy presents with signs of congestive
heart failure, cardiomegaly on chest x-ray, and no significant murmur. Common
etiologies include viral myocarditis, metabolic disorders, or genetic causes.
4. A child with history of Kawasaki disease (KD) is being followed. Which
coronary artery complication is most concerning?
A. Coronary artery vasospasm
B. Coronary artery aneurysm
C. Coronary artery dissection
D. Coronary artery calcification
: Correct Answer : B
Rationale: Kawasaki disease can cause coronary artery aneurysms in up to 25% of
untreated cases, leading to risk of thrombosis, myocardial infarction, and sudden
death. Treatment with IVIG and aspirin reduces this risk.
pg. 2
,3
5. A 14-year-old presents with syncope during a basketball game. Family history
is positive for sudden cardiac death in a cousin at age 16. ECG shows left
ventricular hypertrophy with deep Q waves in lateral leads. The most likely
diagnosis is:
A. Long QT syndrome
B. Hypertrophic cardiomyopathy (HCM)
C. Arrhythmogenic right ventricular cardiomyopathy
D. Brugada syndrome
: Correct Answer : B
Rationale: HCM presents with exertional syncope, LVH on ECG, and a family
history of sudden death. It is the most common cause of sudden cardiac death in
young athletes. The ECG pattern with deep Q waves and LVH is characteristic.
6. A 2-day-old newborn presents with cyanosis unresponsive to oxygen.
Echocardiogram shows the aorta arising from the right ventricle and the
pulmonary artery from the left ventricle. What is the diagnosis?
A. Tetralogy of Fallot
B. Transposition of the great arteries (TGA)
C. Truncus arteriosus
D. Tricuspid atresia
: Correct Answer : B
Rationale: D-TGA is a cyanotic congenital heart disease where the aorta and
pulmonary artery are switched. Mixing of blood is necessary for survival, typically
via a patent ductus arteriosus (PDA). Prostaglandin E1 is given to keep the PDA
open until surgical repair.
7. A child with acute myocarditis develops hypotension, cool extremities, and a
weak pulse despite fluid resuscitation. The PMHNP recognizes this as:
A. Hypovolemic shock
B. Distributive shock
C. Cardiogenic shock
D. Obstructive shock
pg. 3
, 4
: Correct Answer : C
Rationale: Myocarditis impairs the heart's pumping ability, leading to cardiogenic
shock. Management includes inotropic support (milrinone, dobutamine), diuresis
for volume overload, and afterload reduction.
8. A 6-month-old with unrepaired tetralogy of Fallot has a hypercyanotic spell.
After placing the infant in knee-to-chest position and administering oxygen, the
PMHNP's next pharmacological intervention is:
A. Intravenous epinephrine
B. Intravenous morphine sulfate
C. Oral propranolol
D. Inhaled nitric oxide
: Correct Answer : B
Rationale: Morphine reduces respiratory drive and decreases sympathetic
stimulation, which helps relax the infundibular spasm and reduces right-to-left
shunting. Intravenous propranolol can also be used, but morphine is first-line in
acute management. Beta-blockers (propranolol) are used for prophylaxis.
9. A child with a history of ventricular septal defect repair develops new-onset
heart block on ECG. Which defect is most associated with this complication?
A. Ostium primum ASD
B. Membranous VSD
C. Muscular VSD
D. Patent ductus arteriosus
: Correct Answer : B
Rationale: Membranous (perimembranous) VSDs are located near the conduction
system. Surgical or device closure can damage the bundle of His, leading to
complete heart block.
10. A 10-year-old with a history of rheumatic fever develops mitral stenosis.
Which findings would the PMHNP expect to see?
pg. 4
