PALS Pediatric Emergency Resuscitation | Pediatric
Advanced Life Support Study Guide & Certification
Exam Prep 2026/2027 | PALS Pediatric Emergency
Care, BLS & High-Quality CPR, Systematic Pediatric
Assessment, Airway Management, Respiratory
Distress & Failure, Shock Recognition, Cardiac
Arrest, Bradycardia, Tachycardia, ECG Rhythm
Recognition, Defibrillation, Cardioversion,
Emergency Medications, Post-Cardiac Arrest Care,
Team Dynamics, Practice Questions, Answers &
Detailed Rationales
Question 1: A 2-year-old child presents with a heart rate of 220/min, a blood
pressure of 72/48 mmHg, and poor perfusion. The ECG shows a narrow
complex tachycardia with no visible P waves. The child is lethargic but has a
palpable pulse. What is the most appropriate immediate intervention?
A. Administer adenosine 0.1 mg/kg IV rapid push
B. Perform immediate synchronized cardioversion
C. Administer a 20 mL/kg isotonic fluid bolus
D. Administer amiodarone 5 mg/kg IV over 20-60 minutes
CORRECT ANSWER: B. Perform immediate synchronized cardioversion
Rationale: This child presents with unstable supraventricular tachycardia (SVT)
indicated by a narrow complex tachycardia, absent P waves, and signs of poor perfusion
(hypotension and lethargy). For an unstable child with a palpable pulse and a
tachyarrhythmia, synchronized cardioversion is the treatment of choice. Adenosine is an
appropriate treatment for stable SVT, but for a patient in compensated or hypotensive
shock from tachycardia, immediate synchronized cardioversion is recommended to
prevent further hemodynamic deterioration .
Question 2: A 5-year-old child in the PICU suddenly becomes unresponsive.
The cardiac monitor shows a wide-complex rhythm at a rate of 300/min. No
pulse is palpable. What is the initial energy dose for defibrillation in this child?
A. 1 J/kg
B. 2 J/kg
C. 4 J/kg
D. 10 J/kg
CORRECT ANSWER: B. 2 J/kg
Rationale: For a child with pulseless ventricular tachycardia (VT), the first defibrillation
attempt should be 2 J/kg. If this fails to terminate the rhythm, the dose can be increased
to 4 J/kg and subsequently to a maximum of 10 J/kg for subsequent shocks. The 2
,J/kg dose is consistent with AHA PALS guidelines for the initial shock in shockable
pediatric cardiac arrest rhythms .
Question 3: An 8-year-old child is brought to the emergency department with a
heart rate of 45/min and a blood pressure of 78/42 mmHg. The child is
lethargic and has cool, mottled extremities. The rhythm is sinus bradycardia.
Which of the following is the most appropriate first step in management?
A. Administer atropine 0.02 mg/kg IV
B. Prepare for transcutaneous pacing
C. Administer epinephrine 0.01 mg/kg IV
D. Ensure a patent airway and provide 100% oxygen
CORRECT ANSWER: D. Ensure a patent airway and provide 100% oxygen
Rationale: The most common cause of bradycardia in children is hypoxia. The initial
management of symptomatic bradycardia includes supporting the airway, breathing, and
circulation. This includes ensuring a patent airway and providing high-flow oxygen. If
the bradycardia persists despite oxygenation and ventilation, medications such as
epinephrine or atropine may then be considered .
Question 4: A 6-year-old child with a history of asthma is in respiratory
distress. His work of breathing is increased, with wheezing audible. His SpO2
is 88% on room air. What is the FIRST-line treatment?
A. Immediate endotracheal intubation
B. Albuterol via nebulization
C. IV magnesium sulfate
D. IM epinephrine
CORRECT ANSWER: B. Albuterol via nebulization
Rationale: For a child in respiratory distress with wheezing, the first-line treatment is an
inhaled bronchodilator such as albuterol. This addresses the bronchospasm that is likely
the cause of the distress. Intubation is a last resort for impending or actual respiratory
failure. IV magnesium sulfate and IM epinephrine are reserved for severe or refractory
cases of asthma or anaphylaxis .
Question 5: A 3-year-old child is in pulseless cardiac arrest. High-quality CPR
is in progress. The rhythm is asystole. An IO line is placed. What is the correct
dose and route for epinephrine?
A. 0.01 mg/kg IV/IO of 1:10,000 concentration
B. 0.1 mg/kg IV/IO of 1:1,000 concentration
C. 0.01 mg/kg IM of 1:1,000 concentration
D. 0.1 mg/kg IO of 1:10,000 concentration
CORRECT ANSWER: A. 0.01 mg/kg IV/IO of 1:10,000 concentration
,Rationale: During pediatric cardiac arrest, the recommended dose of epinephrine is 0.01
mg/kg IV/IO, given every 3-5 minutes. The concentration typically used is 1:10,000 (0.1
mg/mL). The 1:1,000 (1 mg/mL) concentration is used for IM administration in
anaphylaxis. The dosing regimen is a critical part of the PALS cardiac arrest algorithm .
Question 6: A 1-year-old infant is in septic shock. He has received 40 mL/kg of
isotonic crystalloid boluses but remains hypotensive with poor perfusion.
What is the MOST appropriate next step?
A. Administer another 20 mL/kg fluid bolus
B. Begin vasoactive therapy with dopamine or epinephrine
C. Obtain a portable chest X-ray
D. Administer sodium bicarbonate
CORRECT ANSWER: B. Begin vasoactive therapy with dopamine or
epinephrine
Rationale: In septic shock, if the child remains hypotensive after 40-60 mL/kg of fluid
resuscitation, it is time to initiate vasoactive therapy to support blood pressure and
perfusion. Dopamine or epinephrine are commonly used first-line agents. While further
fluids might be indicated in some cases, the failure to respond to initial fluid boluses
suggests a need for inotropic and vasopressor support .
Question 7: A child is in respiratory failure and is being ventilated with a bag-
mask device. Which of the following is the MOST reliable method for
confirming endotracheal tube placement after intubation?
A. Auscultation of bilateral breath sounds
B. Observation of chest rise
C. Continuous waveform capnography
D. Pulse oximetry improvement
CORRECT ANSWER: C. Continuous waveform capnography
Rationale: The most reliable method for confirming proper endotracheal tube placement
is continuous waveform capnography. This technology confirms that the tube is in the
trachea by detecting exhaled carbon dioxide. While clinical signs like breath sounds and
chest rise are useful, they are not as definitive as capnography, especially in a poorly
perfused state .
Question 8: An 11-year-old child is in respiratory distress with a respiratory
rate of 50/min and SpO2 of 85%. He is anxious and leaning forward, drooling.
This presentation is MOST consistent with which condition?
A. Asthma
B. Epiglottitis
C. Pneumonia
D. Foreign body aspiration
CORRECT ANSWER: B. Epiglottitis
, Rationale: The classic presentation of epiglottitis includes a child who appears toxic, is
anxious, leans forward in the "tripod" position to open the airway, and is drooling due to
inability to swallow. This represents a life-threatening upper airway obstruction. Asthma
and pneumonia typically present with wheezing or crackles and are not associated with
the classic tripod position and drooling.
Question 9: A child has a stable narrow-complex tachycardia. A 12-lead ECG
shows a heart rate of 220/min. The child is alert and has good perfusion. What
is the initial medication of choice?
A. Amiodarone
B. Adenosine
C. Lidocaine
D. Atropine
CORRECT ANSWER: B. Adenosine
Rationale: Adenosine is the first-line medication for the treatment of stable
supraventricular tachycardia (SVT) in children. It works by slowing conduction through
the AV node to interrupt the reentrant circuit. Amiodarone is used for ventricular
arrhythmias or if adenosine is unsuccessful, while atropine is for bradycardia and
lidocaine is primarily for ventricular arrhythmias .
Question 10: During a pediatric resuscitation, after delivering a defibrillation
shock for pulseless VT, what is the next immediate action?
A. Check rhythm and pulse immediately
B. Administer epinephrine 0.01 mg/kg IV
C. Resume CPR immediately for 2 minutes
D. Deliver a second shock at double the joules
CORRECT ANSWER: C. Resume CPR immediately for 2 minutes
Rationale: After delivering a defibrillation shock, the AHA PALS guidelines recommend
resuming CPR immediately for 2 minutes without pausing to check the rhythm or pulse.
After the 2-minute cycle is complete, a pulse and rhythm check is performed. This
approach minimizes interruptions to chest compressions and increases the likelihood of
successful conversion .
Question 11: A 4-year-old child presents with a history of fever, coughing, and
stridor. The child is in respiratory distress. What is the most likely cause of
this upper airway obstruction?
A. Bronchiolitis
B. Croup
C. Epiglottitis
D. Asthma
CORRECT ANSWER: B. Croup
Advanced Life Support Study Guide & Certification
Exam Prep 2026/2027 | PALS Pediatric Emergency
Care, BLS & High-Quality CPR, Systematic Pediatric
Assessment, Airway Management, Respiratory
Distress & Failure, Shock Recognition, Cardiac
Arrest, Bradycardia, Tachycardia, ECG Rhythm
Recognition, Defibrillation, Cardioversion,
Emergency Medications, Post-Cardiac Arrest Care,
Team Dynamics, Practice Questions, Answers &
Detailed Rationales
Question 1: A 2-year-old child presents with a heart rate of 220/min, a blood
pressure of 72/48 mmHg, and poor perfusion. The ECG shows a narrow
complex tachycardia with no visible P waves. The child is lethargic but has a
palpable pulse. What is the most appropriate immediate intervention?
A. Administer adenosine 0.1 mg/kg IV rapid push
B. Perform immediate synchronized cardioversion
C. Administer a 20 mL/kg isotonic fluid bolus
D. Administer amiodarone 5 mg/kg IV over 20-60 minutes
CORRECT ANSWER: B. Perform immediate synchronized cardioversion
Rationale: This child presents with unstable supraventricular tachycardia (SVT)
indicated by a narrow complex tachycardia, absent P waves, and signs of poor perfusion
(hypotension and lethargy). For an unstable child with a palpable pulse and a
tachyarrhythmia, synchronized cardioversion is the treatment of choice. Adenosine is an
appropriate treatment for stable SVT, but for a patient in compensated or hypotensive
shock from tachycardia, immediate synchronized cardioversion is recommended to
prevent further hemodynamic deterioration .
Question 2: A 5-year-old child in the PICU suddenly becomes unresponsive.
The cardiac monitor shows a wide-complex rhythm at a rate of 300/min. No
pulse is palpable. What is the initial energy dose for defibrillation in this child?
A. 1 J/kg
B. 2 J/kg
C. 4 J/kg
D. 10 J/kg
CORRECT ANSWER: B. 2 J/kg
Rationale: For a child with pulseless ventricular tachycardia (VT), the first defibrillation
attempt should be 2 J/kg. If this fails to terminate the rhythm, the dose can be increased
to 4 J/kg and subsequently to a maximum of 10 J/kg for subsequent shocks. The 2
,J/kg dose is consistent with AHA PALS guidelines for the initial shock in shockable
pediatric cardiac arrest rhythms .
Question 3: An 8-year-old child is brought to the emergency department with a
heart rate of 45/min and a blood pressure of 78/42 mmHg. The child is
lethargic and has cool, mottled extremities. The rhythm is sinus bradycardia.
Which of the following is the most appropriate first step in management?
A. Administer atropine 0.02 mg/kg IV
B. Prepare for transcutaneous pacing
C. Administer epinephrine 0.01 mg/kg IV
D. Ensure a patent airway and provide 100% oxygen
CORRECT ANSWER: D. Ensure a patent airway and provide 100% oxygen
Rationale: The most common cause of bradycardia in children is hypoxia. The initial
management of symptomatic bradycardia includes supporting the airway, breathing, and
circulation. This includes ensuring a patent airway and providing high-flow oxygen. If
the bradycardia persists despite oxygenation and ventilation, medications such as
epinephrine or atropine may then be considered .
Question 4: A 6-year-old child with a history of asthma is in respiratory
distress. His work of breathing is increased, with wheezing audible. His SpO2
is 88% on room air. What is the FIRST-line treatment?
A. Immediate endotracheal intubation
B. Albuterol via nebulization
C. IV magnesium sulfate
D. IM epinephrine
CORRECT ANSWER: B. Albuterol via nebulization
Rationale: For a child in respiratory distress with wheezing, the first-line treatment is an
inhaled bronchodilator such as albuterol. This addresses the bronchospasm that is likely
the cause of the distress. Intubation is a last resort for impending or actual respiratory
failure. IV magnesium sulfate and IM epinephrine are reserved for severe or refractory
cases of asthma or anaphylaxis .
Question 5: A 3-year-old child is in pulseless cardiac arrest. High-quality CPR
is in progress. The rhythm is asystole. An IO line is placed. What is the correct
dose and route for epinephrine?
A. 0.01 mg/kg IV/IO of 1:10,000 concentration
B. 0.1 mg/kg IV/IO of 1:1,000 concentration
C. 0.01 mg/kg IM of 1:1,000 concentration
D. 0.1 mg/kg IO of 1:10,000 concentration
CORRECT ANSWER: A. 0.01 mg/kg IV/IO of 1:10,000 concentration
,Rationale: During pediatric cardiac arrest, the recommended dose of epinephrine is 0.01
mg/kg IV/IO, given every 3-5 minutes. The concentration typically used is 1:10,000 (0.1
mg/mL). The 1:1,000 (1 mg/mL) concentration is used for IM administration in
anaphylaxis. The dosing regimen is a critical part of the PALS cardiac arrest algorithm .
Question 6: A 1-year-old infant is in septic shock. He has received 40 mL/kg of
isotonic crystalloid boluses but remains hypotensive with poor perfusion.
What is the MOST appropriate next step?
A. Administer another 20 mL/kg fluid bolus
B. Begin vasoactive therapy with dopamine or epinephrine
C. Obtain a portable chest X-ray
D. Administer sodium bicarbonate
CORRECT ANSWER: B. Begin vasoactive therapy with dopamine or
epinephrine
Rationale: In septic shock, if the child remains hypotensive after 40-60 mL/kg of fluid
resuscitation, it is time to initiate vasoactive therapy to support blood pressure and
perfusion. Dopamine or epinephrine are commonly used first-line agents. While further
fluids might be indicated in some cases, the failure to respond to initial fluid boluses
suggests a need for inotropic and vasopressor support .
Question 7: A child is in respiratory failure and is being ventilated with a bag-
mask device. Which of the following is the MOST reliable method for
confirming endotracheal tube placement after intubation?
A. Auscultation of bilateral breath sounds
B. Observation of chest rise
C. Continuous waveform capnography
D. Pulse oximetry improvement
CORRECT ANSWER: C. Continuous waveform capnography
Rationale: The most reliable method for confirming proper endotracheal tube placement
is continuous waveform capnography. This technology confirms that the tube is in the
trachea by detecting exhaled carbon dioxide. While clinical signs like breath sounds and
chest rise are useful, they are not as definitive as capnography, especially in a poorly
perfused state .
Question 8: An 11-year-old child is in respiratory distress with a respiratory
rate of 50/min and SpO2 of 85%. He is anxious and leaning forward, drooling.
This presentation is MOST consistent with which condition?
A. Asthma
B. Epiglottitis
C. Pneumonia
D. Foreign body aspiration
CORRECT ANSWER: B. Epiglottitis
, Rationale: The classic presentation of epiglottitis includes a child who appears toxic, is
anxious, leans forward in the "tripod" position to open the airway, and is drooling due to
inability to swallow. This represents a life-threatening upper airway obstruction. Asthma
and pneumonia typically present with wheezing or crackles and are not associated with
the classic tripod position and drooling.
Question 9: A child has a stable narrow-complex tachycardia. A 12-lead ECG
shows a heart rate of 220/min. The child is alert and has good perfusion. What
is the initial medication of choice?
A. Amiodarone
B. Adenosine
C. Lidocaine
D. Atropine
CORRECT ANSWER: B. Adenosine
Rationale: Adenosine is the first-line medication for the treatment of stable
supraventricular tachycardia (SVT) in children. It works by slowing conduction through
the AV node to interrupt the reentrant circuit. Amiodarone is used for ventricular
arrhythmias or if adenosine is unsuccessful, while atropine is for bradycardia and
lidocaine is primarily for ventricular arrhythmias .
Question 10: During a pediatric resuscitation, after delivering a defibrillation
shock for pulseless VT, what is the next immediate action?
A. Check rhythm and pulse immediately
B. Administer epinephrine 0.01 mg/kg IV
C. Resume CPR immediately for 2 minutes
D. Deliver a second shock at double the joules
CORRECT ANSWER: C. Resume CPR immediately for 2 minutes
Rationale: After delivering a defibrillation shock, the AHA PALS guidelines recommend
resuming CPR immediately for 2 minutes without pausing to check the rhythm or pulse.
After the 2-minute cycle is complete, a pulse and rhythm check is performed. This
approach minimizes interruptions to chest compressions and increases the likelihood of
successful conversion .
Question 11: A 4-year-old child presents with a history of fever, coughing, and
stridor. The child is in respiratory distress. What is the most likely cause of
this upper airway obstruction?
A. Bronchiolitis
B. Croup
C. Epiglottitis
D. Asthma
CORRECT ANSWER: B. Croup
