Nursery outbreaks US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Nursery outbreaks. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Nursery outbreaks US Medical PG Question 1: A 6-year-old boy and his parents present to the emergency department with high-grade fever, headache, and projectile vomiting. The boy was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. Past medical history is noncontributory. He has had no sick contacts at school or at home. The family has not traveled out of the area recently. He likes school and playing videogames with his younger brother. Today, his blood pressure is 115/76 mm Hg, heart rate is 110/min, respiratory rate is 22/min, and temperature is 38.4°C (101.2°F). On physical exam, the child is disoriented. Kernig’s sign is positive. A head CT was performed followed by a lumbar puncture. Several aliquots of CSF were distributed throughout the lab. Cytology showed high counts of polymorphs, biochemistry showed low glucose and elevated protein levels, and a gram smear shows gram-positive lanceolate-shaped cocci alone and in pairs. A smear is prepared on blood agar in an aerobic environment and grows mucoid colonies with clearly defined edges and alpha hemolysis. On later evaluation they develop a ‘draughtsman’ appearance. Which one of the following is the most likely pathogen?
- A. Streptococcus pneumoniae (Correct Answer)
- B. Staphylococcus aureus
- C. Neisseria meningitidis
- D. Staphylococcus epidermidis
- E. Streptococcus agalactiae
Nursery outbreaks Explanation: ***Streptococcus pneumoniae***
- The CSF findings of **high polymorphs**, **low glucose**, and **elevated protein** are classic for bacterial meningitis. The Gram stain showing **Gram-positive, lanceolate-shaped cocci in pairs** is highly characteristic of *Streptococcus pneumoniae*.
- The growth of **mucoid colonies** with **alpha hemolysis** on blood agar in an aerobic environment, which later develop a **'draughtsman' appearance**, are further confirmatory characteristics of *S. pneumoniae*.
*Staphylococcus aureus*
- *Staphylococcus aureus* is a Gram-positive coccus but typically presents in **clusters** on Gram stain, not lanceolate pairs.
- While it can cause meningitis, it usually exhibits **beta-hemolysis** and is catalase-positive, unlike *S. pneumoniae*.
*Neisseria meningitidis*
- *Neisseria meningitidis* is a **Gram-negative diplococcus**, which would appear distinctly different on Gram stain compared to the described Gram-positive lanceolate cocci.
- Although it is a common cause of bacterial meningitis, its colonial morphology and Gram stain characteristics do not match the case.
*Staphylococcus epidermidis*
- *Staphylococcus epidermidis* is a **Gram-positive coccus in clusters**, similar to *S. aureus*, and is commonly a **skin commensal** or found in infections related to indwelling devices.
- It typically exhibits **gamma-hemolysis** (non-hemolytic) and is usually **coagulase-negative**, differentiating it from the alpha-hemolytic, 'draughtsman' appearing colonies described.
*Streptococcus agalactiae*
- *Streptococcus agalactiae* (**Group B Streptococcus**) is a Gram-positive coccus that typically grows in **chains** and causes **beta-hemolysis**, particularly in neonates.
- While it can cause meningitis, its characteristic hemolytic pattern and arrangement on Gram stain differ from the alpha-hemolytic, lanceolate-shaped cocci in pairs described.
Nursery outbreaks US Medical PG Question 2: A 12-month-old girl is brought to her pediatrician for a checkup and vaccines. The patient’s mother wants to send her to daycare but is worried about exposure to unvaccinated children and other potential sources of infection. The toddler was born at 39 weeks gestation via spontaneous vaginal delivery. She is up to date on all vaccines. She does not walk yet but stands in place and can say a few words. The toddler drinks formula and eats a mixture of soft vegetables and pureed meals. She has no current medications. On physical exam, the vital signs include: temperature 37.0°C (98.6°F), blood pressure 95/50 mm Hg, pulse 130/min, and respiratory rate 28/min. The patient is alert and responsive. The remainder of the exam is unremarkable. Which of the following is most appropriate for this patient at this visit?
- A. Meningococcal vaccine
- B. Gross motor workup and evaluation
- C. Rotavirus vaccine
- D. Referral for speech pathology
- E. MMR vaccine (Correct Answer)
Nursery outbreaks Explanation: ***MMR vaccine***
- The **measles, mumps, and rubella (MMR) vaccine** is recommended for administration at **12-15 months of age**.
- This timing offers protection against these common childhood diseases, which is especially important for children attending **daycare**.
*Meningococcal vaccine*
- The routine **meningococcal vaccine (MenACWY)** is typically recommended for adolescents at **11-12 years of age**, with a booster at 16 years.
- While there are specific circumstances for earlier vaccination (e.g., high-risk conditions), it is **not routine** for a 12-month-old.
*Gross motor workup and evaluation*
- The patient's motor development, standing in place but not yet walking, is **within the normal range** for a 12-month-old.
- A definitive **gross motor workup** would generally be considered if there were more significant delays or regressions.
*Rotavirus vaccine*
- The **rotavirus vaccine** series is typically given at **2, 4, and 6 months of age**, with the final dose administered no later than **8 months of age**.
- A 12-month-old is **outside the recommended age range** for initiating or completing this vaccine series.
*Referral for speech pathology*
- Saying "a few words" at 12 months is **within the normal developmental milestone** for expressive language at this age.
- A referral for **speech pathology** would generally be indicated for more significant language delays.
Nursery outbreaks US Medical PG Question 3: A 15-year-old boy is brought to the Emergency department by ambulance from school. He started the day with some body aches and joint pain but then had several episodes of vomiting and started complaining of a terrible headache. The school nurse called for emergency services. The boy was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. Past medical history is noncontributory. He is a good student and enjoys sports. At the hospital, his blood pressure is 120/80 mm Hg, heart rate is 105/min, respiratory rate is 21/min, and his temperature is 38.9°C (102.0°F). On physical exam, he appears drowsy with neck stiffness and sensitivity to light. Kernig’s sign is positive. An ophthalmic exam is performed followed by a lumbar puncture. An aliquot of cerebrospinal fluid is sent to microbiology. A gram stain shows gram-negative diplococci. A smear is prepared on blood agar and grows round, smooth, convex colonies with clearly defined edges. Which of the following would identify the described pathogen?
- A. Oxidase-positive and ferments glucose and maltose (Correct Answer)
- B. Oxidase-positive test and ferments glucose only
- C. Catalase-negative and oxidase-positive
- D. No growth on Thayer-Martin medium
- E. Growth in anaerobic conditions
Nursery outbreaks Explanation: ***Oxidase-positive and ferments glucose and maltose***
- The patient's symptoms (fever, headache, neck stiffness, sensitivity to light, positive Kernig's sign) are classic for **meningitis**, and the CSF showing **gram-negative diplococci** points to *Neisseria meningitidis*.
- *Neisseria meningitidis* is identified by its positive **oxidase test** and its ability to ferment both **glucose and maltose**.
*Oxidase-positive test and ferments glucose only*
- This description corresponds to *Neisseria gonorrhoeae*, which primarily causes **gonorrhea** and occasionally meningitis due to disseminated infection but is less common in this age group and presentation.
- While *Neisseria gonorrhoeae* is also an **oxidase-positive gram-negative diplococcus**, it specifically ferments only *glucose*, not maltose.
*Catalase-negative and oxidase-positive*
- While *Neisseria meningitidis* is **oxidase-positive**, stating it is "catalase-negative" is incorrect; *Neisseria* species are actually **catalase-positive**.
- This option incorrectly describes a general metabolic property that would rule out *Neisseria meningitidis*.
*No growth on Thayer-Martin medium*
- Thayer-Martin medium is a **selective medium** specifically designed to isolate pathogenic *Neisseria species* by inhibiting the growth of commensal bacteria and fungi.
- Therefore, *Neisseria meningitidis* would **grow well** on Thayer-Martin medium, making "no growth" an incorrect identifier.
*Growth in anaerobic conditions*
- *Neisseria meningitidis* is an **obligate aerobe**, meaning it requires oxygen for growth.
- It would **not grow** in anaerobic conditions, making this statement false for identifying the described pathogen.
Nursery outbreaks US Medical PG Question 4: A 20-week-old infant is brought to an urgent care clinic by her mother because she has not been eating well for the past 2 days. The mother said her daughter has also been "floppy" since yesterday morning and has been unable to move or open her eyes since the afternoon of the same day. The child has recently started solid foods, like cereals sweetened with honey. There is no history of loose, watery stools. On examination, the child is lethargic with lax muscle tone. She does not have a fever or apparent respiratory distress. What is the most likely mode of transmission of the pathogen responsible for this patient’s condition?
- A. Vertical transmission
- B. Vector-borne disease
- C. Direct contact
- D. Contaminated food (Correct Answer)
- E. Airborne transmission
Nursery outbreaks Explanation: ***Contaminated food***
- The infant's symptoms of **lethargy**, widespread **flaccid paralysis** (floppy, unable to move or open eyes), and recent ingestion of **honey** (a known source of **Clostridium botulinum** spores) strongly suggest **infant botulism**.
- **Infant botulism** is acquired through the ingestion of **Clostridium botulinum spores**, typically from environmental sources or contaminated food like honey, which then germinate in the infant's immature gut.
*Vertical transmission*
- **Vertical transmission** refers to the passage of a pathogen from mother to offspring during pregnancy, birth, or breastfeeding.
- The clinical picture of **flaccid paralysis** and association with **honey ingestion** in this case does not align with typical vertically transmitted infections.
*Vector-borne disease*
- **Vector-borne diseases** are transmitted by an arthropod vector, such as mosquitoes or ticks.
- There is no clinical or epidemiological evidence in the scenario to suggest an **arthropod vector** as the source of this infant's illness.
*Direct contact*
- Diseases transmitted by **direct contact** typically require close physical interaction with an infected individual or their body fluids.
- The onset of **neurological symptoms** and the specific history of **honey ingestion** do not point to direct contact as the mode of transmission for botulism.
*Airborne transmission*
- **Airborne transmission** occurs when pathogens are spread through respiratory droplets or aerosols.
- The symptoms of **flaccid paralysis** and the history of recent **honey ingestion** are not consistent with an airborne pathogen.
Nursery outbreaks US Medical PG Question 5: An 8-year-old boy is brought to the physician because of worsening confusion and lethargy for the last hour. He has had high-grade fever, productive cough, fatigue, and malaise for 2 days. He was diagnosed with sickle cell anemia at the age of 2 years but has not seen a physician in over a year. His temperature is 38.9°C (102°F), pulse is 133/min, respirations are 33/min, and blood pressure is 86/48 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. The patient does not respond to verbal commands. Examination shows conjunctival pallor and scleral icterus. Inspiratory crackles are heard at the left lung base. Laboratory studies show:
Hemoglobin 8.1 g/dL
Leukocyte count 17,000/mm3
Platelet count 200,000/mm3
Which of the following is most likely to have prevented this patient's condition?
- A. Chronic transfusion therapy
- B. Pneumococcal vaccination (Correct Answer)
- C. Folic acid
- D. Low molecular weight heparin
- E. Hydroxyurea
Nursery outbreaks Explanation: ***Pneumococcal vaccination***
- This patient with **sickle cell anemia** is presenting with symptoms suggestive of severe **bacterial sepsis and pneumonia** (fever, altered mental status, hypotension, hypoxemia, leukocytosis, crackles). Patients with sickle cell disease are at high risk for **encapsulated bacterial infections**, particularly with *Streptococcus pneumoniae*, due to **functional asplenia** (autosplenectomy from recurrent infarctions).
- **Pneumococcal vaccines** (both **PCV13 conjugate vaccine** and **PPSV23 polysaccharide vaccine**) are crucial for preventing such severe infections in this population. Children with sickle cell disease should receive PCV13 in infancy followed by PPSV23 at age 2 years, with boosters as recommended.
- The neglect of medical care for over a year, including missed vaccinations, likely contributed to this life-threatening presentation.
*Chronic transfusion therapy*
- While chronic transfusion therapy can reduce **stroke risk** and prevent recurrent **vaso-occlusive crises**, it is not primarily used to prevent infectious complications like the one described.
- Transfusions do not directly improve immune function against encapsulated bacteria.
*Folic acid*
- **Folic acid supplementation** is essential in sickle cell anemia to support increased erythropoiesis due to chronic hemolysis.
- It helps prevent **megaloblastic anemia** but does not prevent bacterial infections.
*Low molecular weight heparin*
- **Low molecular weight heparin** is an anticoagulant used to prevent or treat **venous thromboembolism**.
- It has no role in preventing bacterial infections associated with functional asplenia in sickle cell disease.
*Hydroxyurea*
- **Hydroxyurea** increases **fetal hemoglobin (HbF)**, which reduces sickling, vaso-occlusive crises, and acute chest syndrome.
- While it improves overall health and can indirectly reduce infection risk by decreasing hospitalization and improving splenic function in some patients, it does not directly confer protection against encapsulated bacterial infections like vaccination does.
Nursery outbreaks US Medical PG Question 6: A 4-year-old boy is brought to the emergency department with difficulty breathing. His mother reports that he developed a fever last night and began to have trouble breathing this morning. The boy was born at 39 weeks gestation via spontaneous vaginal delivery. He is unvaccinated (conscientious objection by the family) and is meeting all developmental milestones. At the hospital, his vitals are temperature 39.8°C (103.6°F), pulse 122/min, respiration rate 33/min, blood pressure 110/66 mm Hg, and SpO2 93% on room air. On physical examination, he appears ill with his neck hyperextended and chin protruding. His voice is muffled and is drooling. The pediatrician explains that there is one particular bacteria that commonly causes these symptoms. At what age should the patient have first received vaccination to prevent this condition from this particular bacteria?
- A. At birth
- B. At 2-months-old (Correct Answer)
- C. Between 9- and 12-months-old
- D. At 6-months-old
- E. Between 12- and 15-months-old
Nursery outbreaks Explanation: ***At 2-months-old***
- The clinical presentation with **high fever**, **difficulty breathing**, **neck hyperextension**, **muffled voice**, and **drooling** in an unvaccinated child strongly suggests **epiglottitis**, likely caused by *Haemophilus influenzae type b* (Hib).
- The **Hib vaccine** is routinely given starting at **2 months of age** as part of the multi-dose primary series to protect against this life-threatening condition.
*At birth*
- While some vaccines like **Hepatitis B** are given at birth, the Hib vaccine is not typically administered at this age.
- Vaccinating at birth would not align with the standard immunization schedule for *Haemophilus influenzae type b*.
*Between 9- and 12-months-old*
- This age range typically corresponds to the **measles, mumps, and rubella (MMR)** and **varicella** vaccines, or a booster dose of other vaccines, not the initial primary series for Hib.
- Delaying the first Hib vaccination until this age would leave infants vulnerable during a critical period.
*At 6-months-old*
- By 6 months, a child should have already received at least **two doses** of the Hib vaccine if following the recommended schedule.
- Administering the first dose at 6 months would significantly delay protection against invasive Hib disease.
*Between 12- and 15-months-old*
- This age range is typically when the **final booster dose** of the Hib vaccine is given, not the initial vaccination.
- The primary series for Hib should have been completed much earlier to provide timely protection.
Nursery outbreaks US Medical PG Question 7: A 24-year-old newly immigrated mother arrives to the clinic to discuss breastfeeding options for her newborn child. Her medical history is unclear as she has recently arrived from Sub-Saharan Africa. You tell her that unfortunately she will not be able to breastfeed until further testing is performed. Which of the following infections is an absolute contraindication to breastfeeding?
- A. Human Immunodeficiency Virus (HIV) (Correct Answer)
- B. Latent tuberculosis
- C. Hepatitis B
- D. Hepatitis C
- E. All of the options
Nursery outbreaks Explanation: ***Human Immunodeficiency Virus (HIV)***
- In developed countries where safe alternatives are available, **HIV-positive mothers** are advised against breastfeeding due to the risk of **vertical transmission** through breast milk.
- This is considered an **absolute contraindication** in settings where formula feeding is accessible and safe.
*Latent tuberculosis*
- **Latent tuberculosis** is not a contraindication to breastfeeding; mothers can breastfeed while receiving treatment.
- Active, untreated tuberculosis, however, generally requires temporary separation of mother and child until the mother is no longer infectious, but pumping and feeding expressed milk is often still an option.
*Hepatitis B*
- **Hepatitis B** infection in the mother is not a contraindication to breastfeeding, especially if the infant receives **hepatitis B vaccine** and **Hepatitis B Immune Globulin (HBIG)** at birth.
- Breastfeeding is considered safe and does not increase the risk of transmission to the infant.
*Hepatitis C*
- **Hepatitis C** is generally **not a contraindication** to breastfeeding, as studies have shown a very low risk of transmission through breast milk.
- Breastfeeding is supported unless the mother has **cracked or bleeding nipples**, which could potentially allow viral transmission.
*All of the options*
- This option is incorrect because **only HIV** is considered an absolute contraindication to breastfeeding in settings where safe alternatives are available.
- Latent TB, Hepatitis B, and Hepatitis C alone do not preclude breastfeeding.
Nursery outbreaks US Medical PG Question 8: A 3-year-old boy is brought to the physician because of a 3-day history of a pruritic skin rash on his chest. His mother says that he has no history of dermatological problems. He was born at term and has been healthy except for recurrent episodes of otitis media. His immunizations are up-to-date. He appears pale. His temperature is 37°C (98.6°F), pulse is 110/min, respirations are 26/min, and blood pressure is 102/62 mm Hg. Examination shows vesicles and flaccid bullae with thin brown crusts on the chest. Lateral traction of the surrounding skin leads to sloughing. Examination of the oral mucosa shows no abnormalities. Complete blood count is within the reference range. Which of the following is the most likely diagnosis?
- A. Bullous pemphigoid
- B. Dermatitis herpetiformis
- C. Bullous impetigo (Correct Answer)
- D. Pemphigus vulgaris
- E. Stevens-Johnson syndrome
Nursery outbreaks Explanation: ***Bullous impetigo***
- The presence of **flaccid bullae with thin brown crusts** and the positive **Nikolsky's sign** (sloughing with lateral traction), in the absence of mucosal involvement, are classic signs of bullous impetigo, a **Staphylococcus aureus** infection.
- This condition is common in children and can present with localized lesions, as seen on the chest.
*Bullous pemphigoid*
- Typically presents with **tense bullae** in older adults, often with **urticarial plaques**, unlike the flaccid bullae and crusts seen here.
- **Nikolsky's sign is negative** in bullous pemphigoid, which helps distinguish it from bullous impetigo and pemphigus conditions.
*Dermatitis herpetiformis*
- Characterized by intensely **pruritic papules and vesicles** found symmetrically on extensor surfaces, often associated with **celiac disease**.
- The lesions are usually small and grouped, not flaccid bullae with positive Nikolsky's sign.
*Pemphigus vulgaris*
- Presents with **flaccid bullae** and a positive Nikolsky's sign, but characteristically also involves the **oral mucosa**, which is normal in this patient.
- It usually affects older individuals and can be more widespread than the localized rash described.
*Stevens-Johnson syndrome*
- A severe mucocutaneous reaction typically characterized by **widespread epidermal necrosis**, **target lesions**, and often involves **mucous membranes** (oral, ocular, genital) extensively.
- This patient's localized rash without mucosal involvement, target lesions, or systemic toxicity does not fit the criteria for SJS.
Nursery outbreaks US Medical PG Question 9: A 16-month-old male patient, with no significant past medical history, is brought into the emergency department for the second time in 5 days with tachypnea, expiratory wheezes and hypoxia. The patient presented to the emergency department initially due to rhinorrhea, fever and cough. He was treated with nasal suctioning and discharged home. The mother states that, over the past 5 days, the patient has started breathing faster with chest retractions. His vital signs are significant for a temperature of 100.7 F, respiratory rate of 45 and oxygen saturation of 90%. What is the most appropriate treatment for this patient?
- A. Albuterol, ipratropium and IV methylprednisolone
- B. IV cefotaxime and IV vancomycin
- C. Intubation and IV cefuroxime
- D. Humidified oxygen, racemic epinephrine and intravenous (IV) dexamethasone
- E. Nasal suctioning, oxygen therapy and IV fluids (Correct Answer)
Nursery outbreaks Explanation: ***Nasal suctioning, oxygen therapy and IV fluids***
- This patient's presentation with rhinorrhea, fever, cough, tachypnea, expiratory wheezes, and hypoxia, particularly a 16-month-old, strongly suggests **bronchiolitis**, likely caused by **RSV**.
- Management of bronchiolitis is primarily **supportive care**, including maintaining airway patency via nasal suctioning, providing oxygen for hypoxia, and ensuring adequate hydration with IV fluids.
*Albuterol, ipratropium and IV methylprednisolone*
- **Bronchodilators** like albuterol and ipratropium are generally **not recommended** for routine management of bronchiolitis due to lack of consistent efficacy in infants.
- **Corticosteroids** (e.g., methylprednisolone) are also **not routinely indicated** for bronchiolitis and have not been shown to improve outcomes.
*IV cefotaxime and IV vancomycin*
- These are **broad-spectrum antibiotics** used to treat **bacterial infections**, such as severe pneumonia or sepsis.
- The clinical presentation is more consistent with a **viral respiratory infection** (bronchiolitis), and there is no evidence of a bacterial co-infection or sepsis.
*Intubation and IV cefuroxime*
- **Intubation** is an invasive procedure reserved for patients with impending respiratory failure and is not indicated at this stage given the current oxygen saturation of 90% with supportive measures.
- **Cefuroxime** is an antibiotic, and like other antibiotics, is not indicated for a viral illness like bronchiolitis.
*Humidified oxygen, racemic epinephrine and intravenous (IV) dexamethasone*
- **Racemic epinephrine** may be considered for severe bronchiolitis with significant bronchospasm, but its use is not routine and its efficacy is debated.
- **IV dexamethasone** is a corticosteroid, which is not recommended for routine bronchiolitis management. Humidified oxygen is helpful, but the overall regimen is not standard for bronchiolitis.
Nursery outbreaks US Medical PG Question 10: A 2-month-old girl is brought to the physician for a well-child examination. She was born at 32 weeks' gestation and weighed 1616 g (3 lb 9 oz); she currently weighs 2466 g (5 lb 7 oz). She is exclusively breastfed and receives vitamin D supplementation. Physical examination shows no abnormalities apart from low height and weight. This patient is at increased risk for which of the following complications?
- A. Iron deficiency anemia (Correct Answer)
- B. Hemorrhage
- C. Scurvy
- D. Subacute combined degeneration
- E. Intussusception
Nursery outbreaks Explanation: ***Iron deficiency anemia***
- Preterm infants have **lower iron stores** at birth due to reduced placental transfer in the third trimester.
- Their rapid growth rate and exclusive breastfeeding (breast milk has low iron content) further increase their risk of **iron deficiency anemia**.
*Hemorrhage*
- While preterm infants are at higher risk for certain hemorrhages (e.g., intraventricular hemorrhage), this typically occurs in the **immediate neonatal period** and risk significantly decreases by 2 months of age.
- Hemorrhage is not a common long-term complication unique to a 2-month-old preterm infant without additional risk factors.
*Scurvy*
- Scurvy is caused by **vitamin C deficiency**, which is typically not a concern in breastfed infants as breast milk provides adequate vitamin C.
- The primary deficiency risk addressed by supplementation in breastfed infants is vitamin D, not vitamin C.
*Subacute combined degeneration*
- This condition is caused by **vitamin B12 deficiency**, leading to demyelination of the spinal cord.
- While possible in infants of vegan mothers, it is unlikely in a breastfed infant without specific dietary restrictions in the mother.
*Intussusception*
- Intussusception is a condition where one segment of the intestine telescopes into another, usually occurring between **3 months and 3 years of age**.
- It is not specifically linked to prematurity or low birth weight as an increased long-term risk.
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