Pediatric Primary Care PNCB 1 (PNP
Certification) Exam - Complete Study Guide with
Real Questions, Correct Answers and Detailed
Rationales || Latest Update 2026
Question 1
The child at highest risk for having an elevated blood lead level is a:
A. 3 month old exclusively breastfed infant
B. 6 month old who lives in a home built after 1970
C. 2 year old with iron deficiency anemia
D. 2 year old who is a picky eater
Correct Answer: C
Rationale: The amount of lead absorbed from the gut is increased in children with
nutritional deficiencies such as iron deficiency anemia (IDA). Iron deficiency anemia is
often a comorbidity of lead poisoning. The hand-to-mouth behavior of infants and
young children increases their lead exposure. However, living in a home built after 1970
reduces the risk since residential paint used in that era should not have been lead based.
Infants more than 4 months of age exclusively breastfed without supplemental iron are
at increased risk of IDA. A child who is a picky eater may or may not be at high risk for
IDA, depending on foods actually eaten.
Question 2
Which laboratory assessment is the BEST indicator of vitamin D deficiency?
A. 25(OH)-D (cholecalciferol)
B. 1,25(OH)-2-D (calcitriol)
C. PTH (parathyroid hormone)
D. Serum calcium and phosphorus
Correct Answer: A
Rationale: The best diagnostic study of vitamin D deficiency is the level of 25(OH)-D
(cholecalciferol). 1,25(OH)-2-D (calcitriol) is the active metabolite of 25(OH)-D, but due
to its short half-life it is not a good indicator of vitamin D sufficiency. The parathyroid
hormone releases calcium from bone. Rachitic changes can be seen at growth plates and
pg. 1
,decreased calcification leads to thickening of the growth plate. Serum calcium and
phosphorus are initial screening tests but not the best indicator of vitamin D deficiency.
Question 3
In a 2 month old with visible rib fractures on radiograph, the NEXT most critical
evaluation to obtain is a:
A. CT scan of the head
B. Long bone series
C. Coagulation profile
D. Retinal ophthalmologic exam
Correct Answer: A
Rationale: Posterior rib fractures associated with accidental trauma are rare. Posterior
fractures can be seen in infants who have been shaken as the perpetrator's hands are
typically wrapped around the infant's thorax during the shaking, with the vertebrae
acting as a fulcrum. These findings should alert the provider to consider shaken baby
syndrome (SBS). Subdural and subarachnoid hemorrhages are the most common acute
intracranial injuries seen in SBS and are associated with high rates of morbidity and
mortality. Thus, the most important study to do next is a CT scan. Studies have shown
that nearly one third of confirmed abusive head trauma cases were missed on initial
presentation, and many infants then sustain additional brain injury along with poorer
neurologic outcomes because of the delay in diagnosis.
Question 4
The MOST common barrier related to transitioning health care for an adolescent with
special needs or chronic illness is:
A. Finding an adult health care provider for transition
B. Resistance of the family and adolescent to transition of care
C. Lack of health care provider time to plan for transition of care
D. Difficulty in talking with patients about transitioning care
Correct Answer: A
Rationale: Finding an adult health care provider, one who is qualified to care for
young adults with special health care needs, is the most commonly perceived barrier to
the successful transition of health care as identified by family and young adults,
pediatric health care providers, and adult internists. Transitioning of care requires time
and communication with the parents and adolescents involved. Many families may be
pg. 2
,hesitant to leave the nurturing environment of pediatric care, and may perceive
differences in adult practices as a difficult adjustment. Internists may lack the training
and qualifications to address many of the complicated health care needs of adolescents
with chronic illnesses.
Question 5
A toddler is unable to use the right arm normally after the caregiver pulled her arm to
prevent the child from falling. Which finding would confirm the diagnosis of
subluxation of the radial head?
A. Severe swelling and bruising of the elbow
B. Elbow flexed with prorated forearm
C. Point tenderness at ulnar aspect of elbow
D. Elbow extended with supinated forearm
Correct Answer: B
Rationale: Subluxation of the radial head, also called nursemaid's elbow, must be
differentiated from a fracture prior to reducing the annular ligament of the elbow.
Radiographic examination is not necessary if the child's physical findings and history
are consistent with subluxation. The typical presentation of this injury includes the
following: age 2-5 years; history of a longitudinal traction injury, possible "pop" and
immediate pain, inability to use the arm normally, and arm splinted against the side. On
examination the elbow appears normal, is flexed with a prorated forearm against the
body, is tender laterally over the radial head, and has limited flexion with no supination.
Question 6
Education for caregivers whose child has sickle cell disease should include that the
majority of pain crises are triggered by which of the following?
A. No identifying cause
B. Temperature changes
C. Cigarette smoke exposure
D. Stressful situations
Correct Answer: A
Rationale: Sickle cell disease is a common genetic hematologic disorder. Pain is the
most common and disabling symptom of sickle cell disease. Environmental temperature
and second-hand smoke exposure have been studied as possible precipitating factors,
but have not been supported by the research. Negative emotions can facilitate the pain
pg. 3
, cycle. In general, pain episodes are erratic and unpredictable and occur for various,
unknown reasons.
Question 7
A 5 year old complains of a painful left eye after being accidentally scratched by a sibling
two hours ago. Fluorescein exam shows a small central corneal abrasion. The MOST
appropriate management during the first 24 hours is:
A. Frequent application of topical antibiotic
B. Observation of the injured eye
C. Frequent application of topical nonsteroidal anti-inflammatory drops
D. Occlusive patching of the injured eye
Correct Answer: A
Rationale: Accidental abrasion of the corneal epithelium causes pain, tearing, and
photophobia and is a common eye injury in children. An abrasion can be detected by
examining the eye with a Wood's lamp after instillation of fluorescein dye. The goal of
treatment is rapid healing of the abrasion. Until such healing occurs, the eye should be
protected from infection by the use of a topical ophthalmic antibiotic every 4-6 hours for
a few days. The repeated use of a topical anesthetic is not recommended, as these
medications can cause corneal toxicity and inhibit the blinking reflex. Topical steroids
are not recommended as they lower the eye's resistance to infection. Patching is no
longer recommended for most corneal abrasions, as it does not reduce discomfort or
speed healing and makes instillation of antibiotic medication more difficult.
Question 8
The parents of a 2 year old are concerned that their child is having temper tantrums in
public settings. Which is the BEST response?
A. The temper tantrum is an indication that the child is tired and needs to go home.
B. Make sure to ensure safety while ignoring the child's display of behavior.
C. The child should be removed from the situation and disciplined.
D. Temper tantrums are a sign of poor parenting.
Correct Answer: B
Rationale: Temper tantrums are a normal part of development in toddlers as they
struggle with autonomy and independence. The best approach is to ensure the child's
safety while ignoring the behavior. This is known as extinction—removing the
reinforcement for the behavior. Parents should be reassured that this is a normal
pg. 4
Certification) Exam - Complete Study Guide with
Real Questions, Correct Answers and Detailed
Rationales || Latest Update 2026
Question 1
The child at highest risk for having an elevated blood lead level is a:
A. 3 month old exclusively breastfed infant
B. 6 month old who lives in a home built after 1970
C. 2 year old with iron deficiency anemia
D. 2 year old who is a picky eater
Correct Answer: C
Rationale: The amount of lead absorbed from the gut is increased in children with
nutritional deficiencies such as iron deficiency anemia (IDA). Iron deficiency anemia is
often a comorbidity of lead poisoning. The hand-to-mouth behavior of infants and
young children increases their lead exposure. However, living in a home built after 1970
reduces the risk since residential paint used in that era should not have been lead based.
Infants more than 4 months of age exclusively breastfed without supplemental iron are
at increased risk of IDA. A child who is a picky eater may or may not be at high risk for
IDA, depending on foods actually eaten.
Question 2
Which laboratory assessment is the BEST indicator of vitamin D deficiency?
A. 25(OH)-D (cholecalciferol)
B. 1,25(OH)-2-D (calcitriol)
C. PTH (parathyroid hormone)
D. Serum calcium and phosphorus
Correct Answer: A
Rationale: The best diagnostic study of vitamin D deficiency is the level of 25(OH)-D
(cholecalciferol). 1,25(OH)-2-D (calcitriol) is the active metabolite of 25(OH)-D, but due
to its short half-life it is not a good indicator of vitamin D sufficiency. The parathyroid
hormone releases calcium from bone. Rachitic changes can be seen at growth plates and
pg. 1
,decreased calcification leads to thickening of the growth plate. Serum calcium and
phosphorus are initial screening tests but not the best indicator of vitamin D deficiency.
Question 3
In a 2 month old with visible rib fractures on radiograph, the NEXT most critical
evaluation to obtain is a:
A. CT scan of the head
B. Long bone series
C. Coagulation profile
D. Retinal ophthalmologic exam
Correct Answer: A
Rationale: Posterior rib fractures associated with accidental trauma are rare. Posterior
fractures can be seen in infants who have been shaken as the perpetrator's hands are
typically wrapped around the infant's thorax during the shaking, with the vertebrae
acting as a fulcrum. These findings should alert the provider to consider shaken baby
syndrome (SBS). Subdural and subarachnoid hemorrhages are the most common acute
intracranial injuries seen in SBS and are associated with high rates of morbidity and
mortality. Thus, the most important study to do next is a CT scan. Studies have shown
that nearly one third of confirmed abusive head trauma cases were missed on initial
presentation, and many infants then sustain additional brain injury along with poorer
neurologic outcomes because of the delay in diagnosis.
Question 4
The MOST common barrier related to transitioning health care for an adolescent with
special needs or chronic illness is:
A. Finding an adult health care provider for transition
B. Resistance of the family and adolescent to transition of care
C. Lack of health care provider time to plan for transition of care
D. Difficulty in talking with patients about transitioning care
Correct Answer: A
Rationale: Finding an adult health care provider, one who is qualified to care for
young adults with special health care needs, is the most commonly perceived barrier to
the successful transition of health care as identified by family and young adults,
pediatric health care providers, and adult internists. Transitioning of care requires time
and communication with the parents and adolescents involved. Many families may be
pg. 2
,hesitant to leave the nurturing environment of pediatric care, and may perceive
differences in adult practices as a difficult adjustment. Internists may lack the training
and qualifications to address many of the complicated health care needs of adolescents
with chronic illnesses.
Question 5
A toddler is unable to use the right arm normally after the caregiver pulled her arm to
prevent the child from falling. Which finding would confirm the diagnosis of
subluxation of the radial head?
A. Severe swelling and bruising of the elbow
B. Elbow flexed with prorated forearm
C. Point tenderness at ulnar aspect of elbow
D. Elbow extended with supinated forearm
Correct Answer: B
Rationale: Subluxation of the radial head, also called nursemaid's elbow, must be
differentiated from a fracture prior to reducing the annular ligament of the elbow.
Radiographic examination is not necessary if the child's physical findings and history
are consistent with subluxation. The typical presentation of this injury includes the
following: age 2-5 years; history of a longitudinal traction injury, possible "pop" and
immediate pain, inability to use the arm normally, and arm splinted against the side. On
examination the elbow appears normal, is flexed with a prorated forearm against the
body, is tender laterally over the radial head, and has limited flexion with no supination.
Question 6
Education for caregivers whose child has sickle cell disease should include that the
majority of pain crises are triggered by which of the following?
A. No identifying cause
B. Temperature changes
C. Cigarette smoke exposure
D. Stressful situations
Correct Answer: A
Rationale: Sickle cell disease is a common genetic hematologic disorder. Pain is the
most common and disabling symptom of sickle cell disease. Environmental temperature
and second-hand smoke exposure have been studied as possible precipitating factors,
but have not been supported by the research. Negative emotions can facilitate the pain
pg. 3
, cycle. In general, pain episodes are erratic and unpredictable and occur for various,
unknown reasons.
Question 7
A 5 year old complains of a painful left eye after being accidentally scratched by a sibling
two hours ago. Fluorescein exam shows a small central corneal abrasion. The MOST
appropriate management during the first 24 hours is:
A. Frequent application of topical antibiotic
B. Observation of the injured eye
C. Frequent application of topical nonsteroidal anti-inflammatory drops
D. Occlusive patching of the injured eye
Correct Answer: A
Rationale: Accidental abrasion of the corneal epithelium causes pain, tearing, and
photophobia and is a common eye injury in children. An abrasion can be detected by
examining the eye with a Wood's lamp after instillation of fluorescein dye. The goal of
treatment is rapid healing of the abrasion. Until such healing occurs, the eye should be
protected from infection by the use of a topical ophthalmic antibiotic every 4-6 hours for
a few days. The repeated use of a topical anesthetic is not recommended, as these
medications can cause corneal toxicity and inhibit the blinking reflex. Topical steroids
are not recommended as they lower the eye's resistance to infection. Patching is no
longer recommended for most corneal abrasions, as it does not reduce discomfort or
speed healing and makes instillation of antibiotic medication more difficult.
Question 8
The parents of a 2 year old are concerned that their child is having temper tantrums in
public settings. Which is the BEST response?
A. The temper tantrum is an indication that the child is tired and needs to go home.
B. Make sure to ensure safety while ignoring the child's display of behavior.
C. The child should be removed from the situation and disciplined.
D. Temper tantrums are a sign of poor parenting.
Correct Answer: B
Rationale: Temper tantrums are a normal part of development in toddlers as they
struggle with autonomy and independence. The best approach is to ensure the child's
safety while ignoring the behavior. This is known as extinction—removing the
reinforcement for the behavior. Parents should be reassured that this is a normal
pg. 4
