1
Barkley Pediatric Acute Care Nurse Practitioner (PNP-
AC) Certification Exam | 175 Actual Questions and
Answers for Board Review
EXAM FORMAT & BLUEPRINT
The Pediatric Acute Care Nurse Practitioner (PNP-AC) certification exam is developed by the Pediatric Nursing Certification
Board (PNCB). The content is organized into three primary domains:
Domain Weight Key Content Areas
Assessment & Diagnosis 35% History taking, physical examination, diagnostic reasoning, differential diagnosis
Pharmacological & non-pharmacological interventions, acute illness & injury management,
Clinical Management 50%
chronic condition management
Professional Role & Health Ethics, legal issues, communication, patient/family education, quality improvement,
15%
Promotion evidence-based practice
The exam consists of 175 scored multiple-choice questions plus 25 unscored pretest items. Candidates have 3.5 hours to
complete the examination. A passing score is scaled to 500 (range 0–800), with the minimum passing score determined by
the PNCB.
DOMAIN 1 – CARDIOVASCULAR SYSTEM
Questions 1–25
Q1. A 2-week-old infant presents with poor feeding, tachypnea, and a murmur.
Examination reveals a systolic thrill at the left sternal border. A cyanotic spell
occurs with feeding. What is the most likely diagnosis?
A) Tetralogy of Fallot
B) Truncus arteriosus
C) Atrial septal defect
D) Patent ductus arteriosus
: Answer : B) Truncus arteriosus
pg. 1
,2
Rationale: Truncus arteriosus is a single great vessel arising from the heart,
usually associated with a VSD. It presents early with heart failure (tachypnea,
poor feeding) and sometimes a murmur. Cyanosis may not be prominent initially,
but can occur with feeding if pulmonary blood flow is restricted. PDA and ASD
typically present with murmurs but not early heart failure in the first weeks.
Tetralogy of Fallot typically presents with cyanotic spells, but not usually early
heart failure.
Q2. A 3-day-old infant has diminished femoral pulses, blood pressure 20 mmHg
higher in the upper extremities compared to the lower extremities. What is the
most likely diagnosis?
A) Coarctation of the aorta
B) Aortic stenosis
C) Patent ductus arteriosus
D) Truncus arteriosus
: Answer : A) Coarctation of the aorta
Rationale: Coarctation of the aorta presents with a blood pressure gradient
between the upper and lower extremities (arm BP higher than leg BP). Femoral
pulses are diminished or delayed. Infants may present with heart failure.
Q3. A 4-year-old with known tetralogy of Fallot suddenly becomes cyanotic and
hypoxic after crying. What is the most appropriate immediate action?
A) Administer supplemental oxygen
B) Place the child in the knee-chest position
C) Give intravenous fluids
D) Administer a beta-blocker
: Answer : B) Place the child in the knee-chest position
Rationale: Knee-chest positioning increases systemic vascular resistance, reducing
right-to-left shunting and improving pulmonary blood flow. This is the first-line
intervention for a hypercyanotic (tet) spell.
pg. 2
,3
Q4. A 12-year-old presents with fever, chest pain, and a friction rub. ECG shows
diffuse ST elevation. Which of the following is the most likely diagnosis?
A) Myocarditis
B) Cardiomyopathy
C) Bacterial endocarditis
D) Pericarditis
: Answer : D) Pericarditis
Rationale: Acute pericarditis often presents with chest pain, a friction rub, and
diffuse ST elevation on ECG. It can be viral, bacterial, or post-viral. Myocarditis
presents with heart failure signs rather than a friction rub. Bacterial endocarditis
presents with a murmur, fever, and positive blood cultures.
Q5. A newborn is diagnosed with transposition of the great arteries. Which of the
following is the most critical initial management?
A) Prostaglandin E1 infusion
B) Surgical repair within the first week of life
C) Balloon atrial septostomy
D) Oxygen therapy
: Answer : A) Prostaglandin E1 infusion
Rationale: Prostaglandin E1 maintains patency of the ductus arteriosus, allowing
mixing of oxygenated and deoxygenated blood and providing critical systemic
blood flow. Balloon atrial septostomy may be needed if there is inadequate
mixing.
Q6. A 6-year-old with Kawasaki disease is in the subacute phase. Which of the
following findings would be most concerning for coronary artery involvement?
A) Coronary artery dilation on echocardiogram
B) Persistent fever
pg. 3
, 4
C) Conjunctival injection
D) Swollen, erythematous hands and feet
: Answer : A) Coronary artery dilation on echocardiogram
Rationale: Kawasaki disease causes coronary artery aneurysms in up to 25% of
untreated children. Echocardiography is essential to assess coronary artery
involvement. Fever, rash, conjunctival injection, and peripheral changes are
acute-phase findings.
Q7. A 7-year-old presents with fatigue and exercise intolerance. On exam, there is
a midsystolic ejection murmur at the left sternal border that splits with
inspiration. What is the most likely diagnosis?
A) Ventricular septal defect
B) Atrial septal defect (ASD)
C) Aortic stenosis
D) Pulmonary stenosis
: Answer : B) Atrial septal defect (ASD)
Rationale: ASD classically produces a fixed splitting of S2 (split that does not vary
with respiration) and a midsystolic ejection murmur at the left sternal border.
VSD produces a holosystolic murmur.
Q8. A 6-month-old infant is brought to the emergency department with poor
feeding, sweating with feeds, and tachypnea. Cardiac exam reveals a grade 3/6
holosystolic murmur at the left lower sternal border. What is the most likely
diagnosis?
A) Atrial septal defect
B) Ventricular septal defect
C) Patent ductus arteriosus
D) Tetralogy of Fallot
: Answer : B) Ventricular septal defect
pg. 4
Barkley Pediatric Acute Care Nurse Practitioner (PNP-
AC) Certification Exam | 175 Actual Questions and
Answers for Board Review
EXAM FORMAT & BLUEPRINT
The Pediatric Acute Care Nurse Practitioner (PNP-AC) certification exam is developed by the Pediatric Nursing Certification
Board (PNCB). The content is organized into three primary domains:
Domain Weight Key Content Areas
Assessment & Diagnosis 35% History taking, physical examination, diagnostic reasoning, differential diagnosis
Pharmacological & non-pharmacological interventions, acute illness & injury management,
Clinical Management 50%
chronic condition management
Professional Role & Health Ethics, legal issues, communication, patient/family education, quality improvement,
15%
Promotion evidence-based practice
The exam consists of 175 scored multiple-choice questions plus 25 unscored pretest items. Candidates have 3.5 hours to
complete the examination. A passing score is scaled to 500 (range 0–800), with the minimum passing score determined by
the PNCB.
DOMAIN 1 – CARDIOVASCULAR SYSTEM
Questions 1–25
Q1. A 2-week-old infant presents with poor feeding, tachypnea, and a murmur.
Examination reveals a systolic thrill at the left sternal border. A cyanotic spell
occurs with feeding. What is the most likely diagnosis?
A) Tetralogy of Fallot
B) Truncus arteriosus
C) Atrial septal defect
D) Patent ductus arteriosus
: Answer : B) Truncus arteriosus
pg. 1
,2
Rationale: Truncus arteriosus is a single great vessel arising from the heart,
usually associated with a VSD. It presents early with heart failure (tachypnea,
poor feeding) and sometimes a murmur. Cyanosis may not be prominent initially,
but can occur with feeding if pulmonary blood flow is restricted. PDA and ASD
typically present with murmurs but not early heart failure in the first weeks.
Tetralogy of Fallot typically presents with cyanotic spells, but not usually early
heart failure.
Q2. A 3-day-old infant has diminished femoral pulses, blood pressure 20 mmHg
higher in the upper extremities compared to the lower extremities. What is the
most likely diagnosis?
A) Coarctation of the aorta
B) Aortic stenosis
C) Patent ductus arteriosus
D) Truncus arteriosus
: Answer : A) Coarctation of the aorta
Rationale: Coarctation of the aorta presents with a blood pressure gradient
between the upper and lower extremities (arm BP higher than leg BP). Femoral
pulses are diminished or delayed. Infants may present with heart failure.
Q3. A 4-year-old with known tetralogy of Fallot suddenly becomes cyanotic and
hypoxic after crying. What is the most appropriate immediate action?
A) Administer supplemental oxygen
B) Place the child in the knee-chest position
C) Give intravenous fluids
D) Administer a beta-blocker
: Answer : B) Place the child in the knee-chest position
Rationale: Knee-chest positioning increases systemic vascular resistance, reducing
right-to-left shunting and improving pulmonary blood flow. This is the first-line
intervention for a hypercyanotic (tet) spell.
pg. 2
,3
Q4. A 12-year-old presents with fever, chest pain, and a friction rub. ECG shows
diffuse ST elevation. Which of the following is the most likely diagnosis?
A) Myocarditis
B) Cardiomyopathy
C) Bacterial endocarditis
D) Pericarditis
: Answer : D) Pericarditis
Rationale: Acute pericarditis often presents with chest pain, a friction rub, and
diffuse ST elevation on ECG. It can be viral, bacterial, or post-viral. Myocarditis
presents with heart failure signs rather than a friction rub. Bacterial endocarditis
presents with a murmur, fever, and positive blood cultures.
Q5. A newborn is diagnosed with transposition of the great arteries. Which of the
following is the most critical initial management?
A) Prostaglandin E1 infusion
B) Surgical repair within the first week of life
C) Balloon atrial septostomy
D) Oxygen therapy
: Answer : A) Prostaglandin E1 infusion
Rationale: Prostaglandin E1 maintains patency of the ductus arteriosus, allowing
mixing of oxygenated and deoxygenated blood and providing critical systemic
blood flow. Balloon atrial septostomy may be needed if there is inadequate
mixing.
Q6. A 6-year-old with Kawasaki disease is in the subacute phase. Which of the
following findings would be most concerning for coronary artery involvement?
A) Coronary artery dilation on echocardiogram
B) Persistent fever
pg. 3
, 4
C) Conjunctival injection
D) Swollen, erythematous hands and feet
: Answer : A) Coronary artery dilation on echocardiogram
Rationale: Kawasaki disease causes coronary artery aneurysms in up to 25% of
untreated children. Echocardiography is essential to assess coronary artery
involvement. Fever, rash, conjunctival injection, and peripheral changes are
acute-phase findings.
Q7. A 7-year-old presents with fatigue and exercise intolerance. On exam, there is
a midsystolic ejection murmur at the left sternal border that splits with
inspiration. What is the most likely diagnosis?
A) Ventricular septal defect
B) Atrial septal defect (ASD)
C) Aortic stenosis
D) Pulmonary stenosis
: Answer : B) Atrial septal defect (ASD)
Rationale: ASD classically produces a fixed splitting of S2 (split that does not vary
with respiration) and a midsystolic ejection murmur at the left sternal border.
VSD produces a holosystolic murmur.
Q8. A 6-month-old infant is brought to the emergency department with poor
feeding, sweating with feeds, and tachypnea. Cardiac exam reveals a grade 3/6
holosystolic murmur at the left lower sternal border. What is the most likely
diagnosis?
A) Atrial septal defect
B) Ventricular septal defect
C) Patent ductus arteriosus
D) Tetralogy of Fallot
: Answer : B) Ventricular septal defect
pg. 4
