CPN Croup & Epiglottitis Practice Questions

This child demonstrates stridor and hoarseness, classic signs of upper airway edema in anaphylaxis requiring immediate epinephrine. The correct action is to inject intramuscular epinephrine into the anterolateral thigh (A), which rapidly reverses laryngeal edema and bronchoconstriction. Albuterol (B) is a bronchodilator for lower airway symptoms and would not relieve stridor; its use delays definitive therapy. Calling 9-1-1 before giving epinephrine (C) is dangerous because any delay increases mortality; guidelines emphasize giving epinephrine at the first sign of anaphylaxis, then activating EMS. The deltoid muscle (D) is not recommended due to slower absorption compared with the thigh. The NIAID and AAP both state that IM epinephrine into the thigh is the first-line treatment for pediatric anaphylaxis, regardless of setting. Prompt recognition and immediate administration are the cornerstones of management.

Grunting is a compensatory mechanism where the infant exhales against a partially closed glottis. This generates positive end-expiratory pressure to maintain functional residual capacity and prevent alveolar collapse. Option B is incorrect because upper airway obstruction typically presents with inspiratory stridor, not expiratory grunting. Option C describes the pathophysiology of croup, which presents with a barking cough and stridor, not grunting. Option D is incorrect because while grunting indicates severe distress, it is an active compensatory mechanism rather than a direct sign of muscle fatigue, which would present as apnea or a weakening respiratory effort.

A 6-month-old infant presenting with biphasic stridor at rest and worsening retractions has a critical, severe upper airway obstruction that requires immediate escalation of care. Transferring to the pediatric intensive care unit ensures advanced airway management is readily available. Option A is incorrect because biphasic stridor at rest is never benign; it signals severe narrowing. Option B is incorrect because cool mist is insufficient for severe obstruction with retractions. Option C is incorrect because routine outpatient evaluation delays life-saving care for an acute, potentially life-threatening airway compromise.

For a child with moderate croup who is actively vomiting and lacks IV access, the intramuscular route is the most reliable method for administering dexamethasone to ensure full dose delivery. Giving the medication orally (Option B) is contraindicated due to the high risk of immediate expulsion and uncertain dosing. Inserting an IV (Option C) causes unnecessary pain and agitation, which can acutely worsen respiratory distress and increase airway turbulence in a child with croup. Withholding the corticosteroid (Option D) delays essential treatment that reduces laryngeal edema and prevents disease progression.

An inspiratory high-pitched sound that is worse when crying or supine and improves when prone is the classic presentation of laryngomalacia, caused by supraglottic collapse. Option A is incorrect because lower airway obstructions typically produce expiratory wheezing, not inspiratory stridor, and do not change significantly with prone positioning. Option B is incorrect because a vascular ring usually presents with biphasic stridor or expiratory wheezing that does not improve simply by placing the infant prone. Option D is incorrect because vocal cord paralysis typically presents with a weak cry, hoarseness, or continuous stridor that is not strictly position-dependent.

This child presents with mild croup, indicated by the barking cough but no stridor at rest. The standard of care for mild croup is a single dose of oral dexamethasone, which effectively reduces airway inflammation and decreases the likelihood of return visits. Racemic epinephrine (Option B) is reserved for moderate to severe croup characterized by resting stridor or severe retractions. A multi-day course of prednisolone (Option C) is unnecessary because dexamethasone has a long biologic half-life (36 to 72 hours) that covers the typical duration of acute croup symptoms. Transferring to the ED (Option D) is unwarranted for a stable child with mild symptoms who can be safely managed in urgent care.

This infant demonstrates signs of impending respiratory failure, indicated by lethargy, severe retractions, and poor air entry despite maximum medical therapy. The priority is to prepare for advanced airway management because the child is exhausting their respiratory reserve. Administering a third nebulizer (Option A) inappropriately delays securing a definitive airway in a rapidly deteriorating patient. Placing the infant supine (Option B) can exacerbate the airway obstruction and increase respiratory distress; children with airway compromise should be allowed to assume a position of comfort. While corticosteroids are essential, switching to IV methylprednisolone (Option C) does not address the immediate, life-threatening need for mechanical ventilation.

When a child is undergoing compassionate extubation, managing terminal secretions is a primary comfort goal. The gurgling sounds indicate pooled secretions in the oropharynx. Administering an anticholinergic like glycopyrrolate helps dry these secretions effectively without crossing the blood-brain barrier. Deep nasopharyngeal suctioning is invasive, causes significant discomfort, and contradicts the goals of comfort care. Increasing the fentanyl infusion is excellent for pain or air hunger but does not reduce airway secretions. Administering dexamethasone is useful for reducing airway edema or stridor but will not manage the immediate issue of pooled terminal secretions. By choosing a drying agent, the nurse minimizes distressing sounds for the family while keeping the child comfortable.

The combination of sudden onset of inspiratory stridor and unilateral wheezing in a toddler is highly suspicious for foreign body aspiration. Preparing for rigid bronchoscopy is the definitive diagnostic and therapeutic step. Option A is incorrect because racemic epinephrine treats viral croup, which typically has a gradual onset and lacks unilateral findings. Option C is incorrect because epiglottitis presents with drooling, high fever, and a toxic appearance, not unilateral wheezing. Option D is incorrect because corticosteroids are indicated for inflammatory conditions like asthma or croup, not for mechanical obstruction caused by a foreign body.

In the management of anaphylaxis, a biphasic reaction or refractory symptoms can occur. If a patient experiences worsening stridor or other progressive symptoms five to fifteen minutes after the initial dose, a second dose of epinephrine is the standard of care. Because EMS is delayed, administering a second auto-injector is the most critical intervention to stabilize the airway and circulation. Option A is incorrect because oral diphenhydramine is an adjunctive therapy that only addresses cutaneous symptoms; it does not relieve life-threatening airway edema. Option B is incorrect because while upright positioning might subjectively ease breathing, it does not halt the systemic allergic cascade and risks cardiovascular collapse. Option D is incorrect because although oxygen is supportive, it does not reverse the underlying bronchoconstriction and mucosal edema.

Croup is a viral illness characterized by subglottic inflammation, making antibiotics ineffective and inappropriate. Dexamethasone is a potent corticosteroid with a long half-life that provides prolonged reduction of this swelling with just a single dose, matching the typical duration of the acute illness. It does not eradicate bacterial infections (Option A) because the etiology is viral. Corticosteroids do not prevent secondary bacterial infections (Option C) and can sometimes mildly suppress the local immune response. Furthermore, dexamethasone is a systemic anti-inflammatory agent, not a rapid bronchodilator (Option D); racemic epinephrine fills the role of rapid topical vasoconstriction to temporarily relieve airway edema.

The return of audible stridor at rest after an initial observation period indicates rebound stridor, requiring further immediate intervention. The most appropriate next step is to administer another racemic epinephrine nebulizer to rapidly reduce subglottic edema and stabilize the airway. Discharging the child (Option A) is highly unsafe due to impending respiratory compromise. A second dose of dexamethasone (Option B) is not indicated because the initial dose provides prolonged anti-inflammatory coverage and takes several hours to reach peak effect. A lateral neck radiograph (Option D) delays critical airway management and is unnecessary when the clinical diagnosis of croup is already established and the patient is symptomatic.

Because the child remains fully conscious during the event, this is classified as a focal aware seizure. The unilateral facial twitching and drooling indicate a motor onset, specifically associated with benign epilepsy with centrotemporal spikes, previously known as benign rolandic epilepsy. These seizures characteristically happen at night and preserve awareness, though the child cannot speak due to the motor involvement of the facial muscles. Option A is incorrect because the seizure is focal in onset, not generalized, and lacks a loss of tone. Option B is incorrect because awareness is fully preserved throughout the episode, distinguishing it from an impaired awareness event. Option D is incorrect as it describes a generalized onset without motor activity, whereas this scenario clearly involves localized motor symptoms.

The presence of a chronic moist cough and recurrent otitis media alongside poor growth strongly suggests an underlying organic failure to thrive, such as cystic fibrosis or severe gastroesophageal reflux disease. These chronic systemic illnesses increase metabolic demands and impair nutrient retention. Severe psychosocial deprivation and improper feeding techniques are non-organic causes that do not typically present with chronic respiratory or ear infections. While congenital airway anomalies are organic, they typically present with stridor or acute choking rather than chronic moist coughs and recurrent ear infections.