Question 1

A child diagnosed with Group A beta-hemolytic streptococci (GABHS) 2 weeks prior is in the clinic with periorbital edema, dyspnea, and elevated blood pressure. A urinalysis reveals tea-colored urine with hematuria and mild proteinuria. What will the primary care pediatric nurse practitioner do to manage this condition?

Accepted Answer

The child is showing symptoms of post-streptococcal glomerulonephritis, which is a rare but serious complication of GABHS infection. The child needs urgent referral to a pediatric nephrologist for hospitalization and management of the condition. Antibiotics and steroids are not indicated in this case. Reassurance is also not appropriate as the condition requires immediate intervention.

Question 2

A 9-month-old infant is brought to the clinic with scrotal swelling and fussiness. The primary care pediatric nurse practitioner notes a tender mass in the affected scrotum that is difficult to reduce. What is the correct action?

Accepted Answer

Scrotal swelling in infants can be due to a variety of causes, including inguinal hernias or hydroceles. However, the presence of a tender and difficult-to-reduce mass suggests the possibility of an incarcerated hernia, which can lead to serious complications such as bowel obstruction and necrosis. Therefore, referral to a pediatric surgeon for prompt evaluation and treatment is the most appropriate action. Obtaining an abdominal radiograph or scheduling an appointment with a pediatric urologist may be considered as additional steps in the management of the condition, but the immediate priority is to address the potential surgical emergency. Teaching the parents signs of incarceration is also important but should not delay the referral to a specialist.

Question 3

The clean catch urine specimen of a child with dysuria, frequency, and fever has a colony count between 50,000 and 100,000 of E. coli. What is the treatment for this child?

Accepted Answer

A colony count between 50,000 and 100,000 of E. coli in a clean catch urine specimen indicates a urinary tract infection. Treatment with antibiotics is necessary to clear the infection and prevent complications such as pyelonephritis. Sensitivity testing can be done to guide antibiotic choice, but treatment should not be delayed while waiting for results. Obtaining a complete blood count and C-reactive protein may provide additional information, but they are not necessary for the diagnosis and management of a urinary tract infection. Repeat culture may be considered if symptoms persist or worsen despite appropriate treatment, but it is not necessary for initial management.

Question 4

A 3-year-old child has just completed a 7-day course of amoxicillin for a second febrile urinary tract infection and currently has a negative urine culture. What is the next course of action?

Accepted Answer

A renal and bladder ultrasound is recommended after a second febrile UTI in young children to assess for any anatomical abnormalities that may predispose to recurrent infections.

Question 5

A child is diagnosed with nephrotic syndrome, and the pediatric nurse practitioner provides primary care in consultation with a pediatric nephrologist. The child was treated with steroids and responded well to this treatment. What will the nurse practitioner tell the child's parents about this disease?

Accepted Answer

Nephrotic syndrome is a relapsing condition, and steroids are the first-line treatment for a relapse. While a complete cure is not possible, most children with nephrotic syndrome have a good long-term outlook, with 80-90% achieving remission after steroid therapy. However, relapses are common, and steroid treatment will be needed each time a relapse occurs. It is not necessary to use steroids indefinitely. Future outcomes are highly variable but are not likely to be worse with adequate follow-up and management.

Question 6

During a well child examination of a 2-year-old child, the primary care pediatric nurse practitioner palpates a unilateral, smooth, firm abdominal mass which does not cross the midline. What is the next course of action that?

Accepted Answer

The presence of a unilateral, smooth, firm abdominal mass in a child that does not cross the midline is suggestive of a Wilms' tumor. Immediate referral to an oncologist is necessary for further evaluation and management.

Question 7

A healthy 14-year-old female has a dipstick urinalysis that is positive for 5-6 RBCs per hpf but otherwise normal. What is the first question the primary care pediatric nurse practitioner will ask this patient?

Accepted Answer

The presence of RBCs in the urine can be indicative of various conditions, including kidney stones, urinary tract infections, or menstrual bleeding. Given that this patient is a 14-year-old female, it is important to first ask about her menstrual history to determine if the presence of RBCs could be related to her menstrual cycle. The other questions may also be important to ask, but determining menstrual history is the priority in this case.

Question 8

An adolescent male comes to the clinic reporting unilateral scrotal pain, nausea, and vomiting that began that morning. The primary care pediatric nurse practitioner palpates a painful, swollen testis and elicits increased pain with slight elevation of the testis (a negative Phren's sign). What will the nurse practitioner do?

Accepted Answer

The presentation of unilateral scrotal pain, swelling, and tenderness with nausea and vomiting is strongly suggestive of testicular torsion, a urologic emergency that requires immediate surgical intervention to prevent testicular loss. A negative Phren's sign suggests the same diagnosis. Antibiotics, rest, and scrotal support are not appropriate management in this case. Referral to a pediatric urologist or surgeon is essential for prompt diagnosis and treatment.

Question 9

An adolescent has 2+ proteinuria in a random dipstick urinalysis. A subsequent first-morning voided specimen is negative. What will the primary care pediatric nurse practitioner do to manage this condition?

Accepted Answer

A finding of 2+ proteinuria on a random dipstick urinalysis in an adolescent may be a benign finding. However, it is recommended to monitor for proteinuria at each annual well child examination. If the proteinuria persists or if there are any other concerning symptoms or findings, further evaluation by a pediatric nephrologist may be necessary. A 24-hour timed urine collection for creatinine and protein excretion may be ordered if the initial finding is persistent or if there are other concerning symptoms or findings, but is not necessary in this case. Reassuring the parents without further evaluation or monitoring is not recommended.

Question 10

The mother of a 12-month-old uncircumcised male infant reports that the child seems to have pain associated with voiding. A physical examination reveals a tight, pinpoint opening of the foreskin, which thickened and inflamed. What will the primary care pediatric nurse practitioner do?

Accepted Answer

The infant may be experiencing symptoms of balanitis or balanoposthitis, inflammation of the penis or inflammation of the penis and foreskin, respectively. In infants, these conditions may be caused by poor hygiene, but can also indicate an underlying anatomical issue. Attempting to retract the foreskin in this case may cause further injury or pain to the infant, so this option should be avoided. Treatment with corticosteroid cream can be appropriate for some cases of balanitis or balanoposthitis, but referral to a pediatric urologist is indicated when there is significant or recurrent inflammation, especially if the infant is having difficulty urinating, as in this case. The pediatric urologist can assess for underlying anatomical abnormalities, provide guidance on whether and when to try retracting the foreskin, and discuss options for medical or surgical management.

Question 11

A 30-month-old girl who has been toilet trained for 6 months has daytime enuresis and dysuria and a low-grade fever. A dipstick urinalysis is negative for leukocyte esterase and nitrites. What is the next step?

Accepted Answer

The negative dipstick urinalysis does not rule out a urinary tract infection (UTI) in a young child. The symptoms of dysuria, fever, and daytime enuresis are suggestive of UTI. Therefore, sending the urine to the lab for culture is the next appropriate step in the management of this child. Empiric treatment with antibiotics should not be initiated without confirming the diagnosis of UTI with a urine culture. Behavioral interventions for toilet training would not be helpful in this case.

Question 12

A preschool-age child with no previous history has mild flank pain and fever but no abdominal pain or vomiting. A urinalysis is positive for leukocyte esterase and nitrites. A culture is pending. Which is the correct course of treatment for this child?

Accepted Answer

Amoxicillin clavulanate is the first-line treatment for uncomplicated urinary tract infections in children.

Question 13

The parent of a toddler diagnosed with grade V vesicoureteral reflux asks the primary care pediatric nurse practitioner how the disease will be treated. What will the nurse practitioner tell this parent?

Accepted Answer

Grade V vesicoureteral reflux is a severe form of this condition and may require surgical intervention to correct the anatomical abnormalities causing the reflux. Long-term antibiotic prophylaxis may be necessary to prevent further infections, but it will not correct the underlying issue. Kidney transplant is not typically necessary for this condition. The condition is unlikely to resolve spontaneously without intervention.

Question 14

A 6-month-old infant has a retractile testis that was noted at the 2-month well baby exam. What will the primary care pediatric nurse practitioner do to manage this condition?

Accepted Answer

A retractile testis is one that can move up and down within the scrotum and is relatively common in infants and young boys. However, it is important to distinguish it from an undescended testis, which is fixed in an abnormal position and requires treatment. In this case, since the testis has not descended by 6 months, the primary care pediatric nurse practitioner should refer the infant to a pediatric urologist or surgeon for possible orchiopexy, which involves surgical fixation of the testis in the scrotum. This is because the longer the testis remains undescended or retractile, the higher the risk of complications such as impaired fertility and testicular cancer later in life. The other options are not appropriate management strategies for a retractile testis.

Question 15

A child has gross hematuria, abdominal pain, and arthralgia as well as a rash. What diagnosis is most likely?

Accepted Answer

The presentation of gross hematuria, abdominal pain, arthralgia, and rash is classic for Henoch-Schönlein purpura, which is a systemic vasculitis that affects small vessels. Rhabdomyosarcoma is a type of soft tissue sarcoma that presents with a solid mass, not the symptoms mentioned. Sickle cell disease is a genetic blood disorder and is not associated with the symptoms mentioned. Systemic lupus erythematosus can cause a rash and joint pain but is less likely to present with gross hematuria and abdominal pain.

Question 16

An adolescent has right-sided flank pain without fever. A dipstick urinalysis reveals gross hematuria without signs of infection or bacteriuria, and the primary care pediatric nurse practitioner diagnoses possible nephrolithiasis. What is the initial treatment for this condition?

Accepted Answer

Increasing fluid intake up to 2 L daily is the initial treatment for nephrolithiasis. This helps to flush out small stones and prevent the formation of new ones. ESWL, percutaneous removal of renal calculi, and referral to a pediatric nephrologist may be considered if the stones do not pass on their own or if complications arise.

Question 17

A dipstick urinalysis is positive for leukocyte esterase and nitrites in a school-age child with dysuria and foul-smelling urine but no fever who has not had previous urinary tract infections. A culture is pending. What will the pediatric nurse practitioner do to treat this child?

Accepted Answer

The presence of leukocyte esterase and nitrites on a dipstick urinalysis is highly indicative of a urinary tract infection. In the absence of fever, a shorter course of antibiotics (3-5 days) can be used. Trimethoprim-sulfamethoxazole (TMP) is a commonly used first-line agent for uncomplicated urinary tract infections in children. Waiting for culture results is not necessary if the child has symptoms consistent with a UTI, and ciprofloxacin ER is not recommended as a first-line agent in younger children. Asymptomatic bacteriuria is possible in certain populations, but this child has symptoms and a positive dipstick, making a UTI more likely.

Question 18

A child who has nephrotic syndrome is on a steroids and a salt-restricted diet for a relapse of symptoms. A dipstick urinalysis shows 1+ protein, down from 3+ at the beginning of the episode. In consultation with the child's nephrologist, what is the correct course of treatment considering this finding?

Accepted Answer

Continuing with steroids and salt restrictions until the urine is negative for protein is the correct course of treatment. This approach ensures that the underlying condition causing proteinuria is fully addressed before making changes to the treatment regimen. Relaxing treatment prematurely could lead to a relapse or incomplete resolution of the nephrotic syndrome.

Quiz 41: Genitourinary Disorders