PALS Exam 2026/2027 (PDF) | Pediatric Advanced Life Support | AHA, Exams of Pediatrics
Comprehensive Assessment
Year: 2026-2027 | Question Count: 100 Questions | 100% VERIFIED
Introduction
The PALS Exam Comprehensive Assessment provides a rigorous, application-based evaluation of
the knowledge, clinical reasoning, and operational judgment required to recognize and manage
critically ill and injured infants and children. The examination is organized around the domains of
the American Heart Association Pediatric Advanced Life Support blueprint, including Pediatric
Assessment and Recognition of Respiratory Distress, Pediatric Basic and Advanced Life Support
Algorithms, Cardiac Arrhythmia Identification and Management, Vascular Access and Fluid
Resuscitation, Pharmacological Interventions in Pediatric Emergencies, Post-Resuscitation Care and
Stabilization, Effective Resuscitation Team Dynamics, and Neonatal and Infant-Specific
Considerations. Competence across these domains governs how quickly a deteriorating child is
identified, whether the correct algorithm and weight-based dose are executed without error,
whether airway and vascular access are secured safely, whether the resuscitation team
communicates and coordinates under pressure, and whether post-arrest neuroprotective care is
delivered. Mastery of this material is essential for professional certification and recertification, for
credentialing within pediatric emergency and critical care operations, and for the dependable
clinical execution of pediatric advanced life support in the emergency department, the intensive
care unit, the prehospital environment, and the inpatient ward. Each item presents a clinical
scenario requiring analysis and professional judgment rather than recall, and each concise rationale
identifies the governing principle and explains why the remaining options are incorrect.
Question 1
A 6-month-old arrives in February with 3 days of rhinorrhea, poor feeding, and increasing effort to
breathe. He is alert and cries vigorously, with audible expiratory wheeze, nasal flaring, and
moderate intercostal and subcostal retractions. Skin is pink and warm, capillary refill is under 2
seconds, and pulse oximetry reads 92% on room air. Using the Pediatric Assessment Triangle, how
should this infant be categorized?
A. Physiologically stable, because the pulse oximetry value remains above 90%
B. Cardiopulmonary failure, because two sides of the triangle are abnormal
C. Compensated shock, because capillary refill and skin findings determine the categorization
D. Respiratory distress, because work of breathing is abnormal while appearance and circulation to
skin remain normal
Correct Answer: D. Respiratory distress, because work of breathing is abnormal while
appearance and circulation to skin remain normal
Rationale: The Pediatric Assessment Triangle sorts acuity by appearance, work of breathing, and
circulation to skin; isolated abnormal work of breathing with normal appearance and perfusion
defines respiratory distress. Cardiopulmonary failure requires abnormal appearance together with
abnormal work of breathing or perfusion, and this infant has normal tone, interactiveness, and
consolability. Skin findings and capillary refill are normal, so shock is not supported. An oxygen
,saturation of 92% accompanied by retractions is not stability, because increased work of breathing
precedes desaturation and decompensation.
Question 2
A 2-year-old presents at night with a 2-day history of low-grade fever, hoarse voice, and barking
cough. He has inspiratory stridor at rest and mild suprasternal retractions, no cyanosis, and he is
alert and consolable. Which intervention should be prioritized?
A. Nebulized racemic epinephrine plus a single dose of dexamethasone 0.6 mg/kg with a 16 mg
maximum, followed by observation for 2 to 4 hours for rebound symptoms
B. Oral amoxicillin and discharge with instructions to return if the stridor worsens
C. Nebulized albuterol and intravenous methylprednisolone
D. Immediate endotracheal intubation in the emergency department before any pharmacologic
treatment
Correct Answer: A. Nebulized racemic epinephrine plus a single dose of dexamethasone 0.6
mg/kg with a 16 mg maximum, followed by observation for 2 to 4 hours for rebound
symptoms
Rationale: Moderate croup, defined by stridor at rest with retractions, is treated with nebulized
racemic or L-epinephrine to reduce subglottic edema rapidly plus dexamethasone 0.6 mg/kg, and
observation is mandatory because symptoms may rebound within 2 to 3 hours. Intubation is
reserved for impending respiratory failure, which an alert and consolable child does not have.
Albuterol does not reduce upper airway edema and has no role in croup. Croup is viral, so
antibiotics are unwarranted, and discharge without observation after epinephrine risks
unrecognized rebound obstruction.
Question 3
A 9-year-old with severe persistent asthma presents in status asthmaticus after 6 hours of home
nebulizers. He is lethargic, speaks in single words, and has minimal air movement without audible
wheeze; pulse oximetry is 88% on a non-rebreather mask. Arterial blood gas shows pH 7.28, PaCO2
58 mmHg, and PaO2 52 mmHg. What is the most appropriate next action?
A. Continue hourly albuterol nebulizers and reassess in 60 minutes
B. Initiate high-flow nasal cannula at 2 L/min and obtain a chest radiograph before further
intervention
C. Administer intravenous magnesium sulfate and observe with continuous pulse oximetry alone
D. Begin assisted ventilation with a bag-mask device and 100% oxygen and prepare for advanced
airway management while continuing bronchodilator and corticosteroid therapy
Correct Answer: D. Begin assisted ventilation with a bag-mask device and 100% oxygen and
prepare for advanced airway management while continuing bronchodilator and
corticosteroid therapy
Rationale: A silent chest with lethargy and a rising PaCO2 signals impending respiratory arrest
from muscle fatigue, and hypercapnia in asthma is a pre-terminal finding that requires immediate
ventilatory support with bag-mask assistance and preparation for an advanced airway. Hourly
nebulizers alone are insufficient once the child is tiring and retaining carbon dioxide. Magnesium
sulfate is a valid adjunct but never a substitute for ventilation in an obtunded, fatigued patient.
,Low-flow oxygen at 2 L/min is an inadequate dose for a 9-year-old, and imaging must not delay
airway management.
Question 4
A 3-week-old infant grunts with each exhalation and has nasal flaring and intercostal retractions.
Which statement best explains the physiologic purpose of grunting?
A. Grunting lowers intrathoracic pressure to increase venous return during inspiration
B. Grunting increases dead space ventilation so that carbon dioxide is retained to stimulate
respiration
C. Exhalation against a partially closed glottis generates auto-PEEP, which helps maintain functional
residual capacity and prevents alveolar collapse
D. Grunting is a voluntary behavior indicating pain rather than a sign of respiratory compromise
Correct Answer: C. Exhalation against a partially closed glottis generates auto-PEEP, which
helps maintain functional residual capacity and prevents alveolar collapse
Rationale: Grunting is expiration against a partially closed glottis, producing positive end-
expiratory pressure that splints alveoli open, preserves functional residual capacity, and improves
oxygenation in bronchiolitis, pneumonia, and pulmonary edema. It is never a benign pain behavior
in an infant. It does not increase dead space to retain carbon dioxide, and it raises rather than
lowers end-expiratory intrathoracic pressure; any resulting carbon dioxide retention is a
consequence of disease, not a therapeutic goal.
Question 5
A 6-year-old arrives after 3 days of vomiting and diarrhea. He is tachycardic at 160, capillary refill is
5 seconds, extremities are cool and mottled, and he is obtunded. Blood pressure is 74/40 mmHg.
How should this blood pressure be interpreted?
A. Normal for age, because a systolic pressure above 70 mmHg is adequate for every child older
than 1 year
B. Compensated, because tachycardia proves the cardiovascular system is maintaining perfusion
C. Hypotensive, because the minimum systolic threshold for a child 1 to 10 years old is 70 plus
twice the age in years, or 82 mmHg, so this child is in decompensated shock
D. Isolated diastolic hypotension requiring no intervention because the systolic value exceeds 60
mmHg
Correct Answer: C. Hypotensive, because the minimum systolic threshold for a child 1 to 10
years old is 70 plus twice the age in years, or 82 mmHg, so this child is in decompensated
shock
Rationale: The age-based hypotension thresholds are less than 70 mmHg for term neonates to 1
month, less than 70 plus twice the age in years for children 1 to 10 years, and less than 90 mmHg
for children older than 10 years; for a 6-year-old the threshold is 82 mmHg, so 74 mmHg is
hypotensive and defines decompensated shock. A value above 70 mmHg is not automatically
normal for a 6-year-old. Tachycardia with obtundation, delayed refill, and hypotension is
decompensated rather than compensated shock. Both systolic and diastolic pressures matter, and
perfusion failure is already established.
Question 6
, An 8-month-old with fever and poor intake has a heart rate of 195, respiratory rate of 52, capillary
refill of 4 seconds, cool mottled extremities, weak peripheral pulses, and irritable but consolable
behavior. Blood pressure is 88/50 mmHg. Which classification and initial management are most
appropriate?
A. Compensated shock; give a 20 mL/kg isotonic crystalloid bolus over 5 to 20 minutes and reassess
perfusion after each bolus
B. Normal infant physiology; provide oral rehydration and discharge with follow-up
C. Respiratory failure; proceed directly to endotracheal intubation
D. Hypotensive shock; begin a norepinephrine infusion before any fluid administration
Correct Answer: A. Compensated shock; give a 20 mL/kg isotonic crystalloid bolus over 5 to
20 minutes and reassess perfusion after each bolus
Rationale: In compensated shock, tachycardia and vasoconstriction maintain blood pressure, so a
normal pressure never excludes shock; delayed capillary refill, cool mottled skin, weak pulses, and
altered behavior establish the diagnosis. A 20 mL/kg isotonic crystalloid bolus with reassessment
after each dose is first-line therapy for hypovolemic and distributive shock. Vasoactive agents are
added only after fluid-refractory shock is documented, and hypotension is absent here. Intubation
addresses respiratory failure, not perfusion failure, and these findings are never normal in an
infant.
Question 7
A 5-year-old ejected from a vehicle arrives with a Glasgow Coma Scale score of 9. Twenty minutes
later his heart rate falls from 120 to 52, blood pressure rises from 90/58 to 152/94 mmHg, and
respirations become irregular. Which interpretation and management are correct?
A. Symptomatic bradycardia; give atropine 0.02 mg/kg and begin chest compressions
B. Nonconvulsive seizure activity; give lorazepam 0.1 mg/kg and obtain an electroencephalogram
C. Cushing triad indicating increased intracranial pressure and impending herniation; elevate the
head of the bed, maintain normotension and normoxia, provide controlled ventilation, and give
hyperosmolar therapy such as hypertonic saline or mannitol
D. Neurogenic shock; give a large crystalloid bolus and begin a dopamine infusion
Correct Answer: C. Cushing triad indicating increased intracranial pressure and impending
herniation; elevate the head of the bed, maintain normotension and normoxia, provide
controlled ventilation, and give hyperosmolar therapy such as hypertonic saline or mannitol
Rationale: Bradycardia with hypertension and irregular respirations is the Cushing triad, a late sign
of increased intracranial pressure and impending herniation; therapy targets cerebral perfusion
pressure through head-of-bed elevation, avoidance of hypotonic fluids and hypoxemia, controlled
ventilation to normocapnia, hyperosmolar therapy, and neurosurgical consultation. Neurogenic
shock produces hypotension with bradycardia rather than hypertension. The bradycardia is a reflex
response to intracranial hypertension, so atropine and compressions treat the wrong mechanism
and may worsen hypertension. Nothing in the examination suggests seizure activity.
Question 8
A 10-month-old suddenly develops a silent cough, cannot cry, and shows universal distress while
eating grapes. He is conscious with an ineffective cough and no air movement. What is the correct
sequence?
Comprehensive Assessment
Year: 2026-2027 | Question Count: 100 Questions | 100% VERIFIED
Introduction
The PALS Exam Comprehensive Assessment provides a rigorous, application-based evaluation of
the knowledge, clinical reasoning, and operational judgment required to recognize and manage
critically ill and injured infants and children. The examination is organized around the domains of
the American Heart Association Pediatric Advanced Life Support blueprint, including Pediatric
Assessment and Recognition of Respiratory Distress, Pediatric Basic and Advanced Life Support
Algorithms, Cardiac Arrhythmia Identification and Management, Vascular Access and Fluid
Resuscitation, Pharmacological Interventions in Pediatric Emergencies, Post-Resuscitation Care and
Stabilization, Effective Resuscitation Team Dynamics, and Neonatal and Infant-Specific
Considerations. Competence across these domains governs how quickly a deteriorating child is
identified, whether the correct algorithm and weight-based dose are executed without error,
whether airway and vascular access are secured safely, whether the resuscitation team
communicates and coordinates under pressure, and whether post-arrest neuroprotective care is
delivered. Mastery of this material is essential for professional certification and recertification, for
credentialing within pediatric emergency and critical care operations, and for the dependable
clinical execution of pediatric advanced life support in the emergency department, the intensive
care unit, the prehospital environment, and the inpatient ward. Each item presents a clinical
scenario requiring analysis and professional judgment rather than recall, and each concise rationale
identifies the governing principle and explains why the remaining options are incorrect.
Question 1
A 6-month-old arrives in February with 3 days of rhinorrhea, poor feeding, and increasing effort to
breathe. He is alert and cries vigorously, with audible expiratory wheeze, nasal flaring, and
moderate intercostal and subcostal retractions. Skin is pink and warm, capillary refill is under 2
seconds, and pulse oximetry reads 92% on room air. Using the Pediatric Assessment Triangle, how
should this infant be categorized?
A. Physiologically stable, because the pulse oximetry value remains above 90%
B. Cardiopulmonary failure, because two sides of the triangle are abnormal
C. Compensated shock, because capillary refill and skin findings determine the categorization
D. Respiratory distress, because work of breathing is abnormal while appearance and circulation to
skin remain normal
Correct Answer: D. Respiratory distress, because work of breathing is abnormal while
appearance and circulation to skin remain normal
Rationale: The Pediatric Assessment Triangle sorts acuity by appearance, work of breathing, and
circulation to skin; isolated abnormal work of breathing with normal appearance and perfusion
defines respiratory distress. Cardiopulmonary failure requires abnormal appearance together with
abnormal work of breathing or perfusion, and this infant has normal tone, interactiveness, and
consolability. Skin findings and capillary refill are normal, so shock is not supported. An oxygen
,saturation of 92% accompanied by retractions is not stability, because increased work of breathing
precedes desaturation and decompensation.
Question 2
A 2-year-old presents at night with a 2-day history of low-grade fever, hoarse voice, and barking
cough. He has inspiratory stridor at rest and mild suprasternal retractions, no cyanosis, and he is
alert and consolable. Which intervention should be prioritized?
A. Nebulized racemic epinephrine plus a single dose of dexamethasone 0.6 mg/kg with a 16 mg
maximum, followed by observation for 2 to 4 hours for rebound symptoms
B. Oral amoxicillin and discharge with instructions to return if the stridor worsens
C. Nebulized albuterol and intravenous methylprednisolone
D. Immediate endotracheal intubation in the emergency department before any pharmacologic
treatment
Correct Answer: A. Nebulized racemic epinephrine plus a single dose of dexamethasone 0.6
mg/kg with a 16 mg maximum, followed by observation for 2 to 4 hours for rebound
symptoms
Rationale: Moderate croup, defined by stridor at rest with retractions, is treated with nebulized
racemic or L-epinephrine to reduce subglottic edema rapidly plus dexamethasone 0.6 mg/kg, and
observation is mandatory because symptoms may rebound within 2 to 3 hours. Intubation is
reserved for impending respiratory failure, which an alert and consolable child does not have.
Albuterol does not reduce upper airway edema and has no role in croup. Croup is viral, so
antibiotics are unwarranted, and discharge without observation after epinephrine risks
unrecognized rebound obstruction.
Question 3
A 9-year-old with severe persistent asthma presents in status asthmaticus after 6 hours of home
nebulizers. He is lethargic, speaks in single words, and has minimal air movement without audible
wheeze; pulse oximetry is 88% on a non-rebreather mask. Arterial blood gas shows pH 7.28, PaCO2
58 mmHg, and PaO2 52 mmHg. What is the most appropriate next action?
A. Continue hourly albuterol nebulizers and reassess in 60 minutes
B. Initiate high-flow nasal cannula at 2 L/min and obtain a chest radiograph before further
intervention
C. Administer intravenous magnesium sulfate and observe with continuous pulse oximetry alone
D. Begin assisted ventilation with a bag-mask device and 100% oxygen and prepare for advanced
airway management while continuing bronchodilator and corticosteroid therapy
Correct Answer: D. Begin assisted ventilation with a bag-mask device and 100% oxygen and
prepare for advanced airway management while continuing bronchodilator and
corticosteroid therapy
Rationale: A silent chest with lethargy and a rising PaCO2 signals impending respiratory arrest
from muscle fatigue, and hypercapnia in asthma is a pre-terminal finding that requires immediate
ventilatory support with bag-mask assistance and preparation for an advanced airway. Hourly
nebulizers alone are insufficient once the child is tiring and retaining carbon dioxide. Magnesium
sulfate is a valid adjunct but never a substitute for ventilation in an obtunded, fatigued patient.
,Low-flow oxygen at 2 L/min is an inadequate dose for a 9-year-old, and imaging must not delay
airway management.
Question 4
A 3-week-old infant grunts with each exhalation and has nasal flaring and intercostal retractions.
Which statement best explains the physiologic purpose of grunting?
A. Grunting lowers intrathoracic pressure to increase venous return during inspiration
B. Grunting increases dead space ventilation so that carbon dioxide is retained to stimulate
respiration
C. Exhalation against a partially closed glottis generates auto-PEEP, which helps maintain functional
residual capacity and prevents alveolar collapse
D. Grunting is a voluntary behavior indicating pain rather than a sign of respiratory compromise
Correct Answer: C. Exhalation against a partially closed glottis generates auto-PEEP, which
helps maintain functional residual capacity and prevents alveolar collapse
Rationale: Grunting is expiration against a partially closed glottis, producing positive end-
expiratory pressure that splints alveoli open, preserves functional residual capacity, and improves
oxygenation in bronchiolitis, pneumonia, and pulmonary edema. It is never a benign pain behavior
in an infant. It does not increase dead space to retain carbon dioxide, and it raises rather than
lowers end-expiratory intrathoracic pressure; any resulting carbon dioxide retention is a
consequence of disease, not a therapeutic goal.
Question 5
A 6-year-old arrives after 3 days of vomiting and diarrhea. He is tachycardic at 160, capillary refill is
5 seconds, extremities are cool and mottled, and he is obtunded. Blood pressure is 74/40 mmHg.
How should this blood pressure be interpreted?
A. Normal for age, because a systolic pressure above 70 mmHg is adequate for every child older
than 1 year
B. Compensated, because tachycardia proves the cardiovascular system is maintaining perfusion
C. Hypotensive, because the minimum systolic threshold for a child 1 to 10 years old is 70 plus
twice the age in years, or 82 mmHg, so this child is in decompensated shock
D. Isolated diastolic hypotension requiring no intervention because the systolic value exceeds 60
mmHg
Correct Answer: C. Hypotensive, because the minimum systolic threshold for a child 1 to 10
years old is 70 plus twice the age in years, or 82 mmHg, so this child is in decompensated
shock
Rationale: The age-based hypotension thresholds are less than 70 mmHg for term neonates to 1
month, less than 70 plus twice the age in years for children 1 to 10 years, and less than 90 mmHg
for children older than 10 years; for a 6-year-old the threshold is 82 mmHg, so 74 mmHg is
hypotensive and defines decompensated shock. A value above 70 mmHg is not automatically
normal for a 6-year-old. Tachycardia with obtundation, delayed refill, and hypotension is
decompensated rather than compensated shock. Both systolic and diastolic pressures matter, and
perfusion failure is already established.
Question 6
, An 8-month-old with fever and poor intake has a heart rate of 195, respiratory rate of 52, capillary
refill of 4 seconds, cool mottled extremities, weak peripheral pulses, and irritable but consolable
behavior. Blood pressure is 88/50 mmHg. Which classification and initial management are most
appropriate?
A. Compensated shock; give a 20 mL/kg isotonic crystalloid bolus over 5 to 20 minutes and reassess
perfusion after each bolus
B. Normal infant physiology; provide oral rehydration and discharge with follow-up
C. Respiratory failure; proceed directly to endotracheal intubation
D. Hypotensive shock; begin a norepinephrine infusion before any fluid administration
Correct Answer: A. Compensated shock; give a 20 mL/kg isotonic crystalloid bolus over 5 to
20 minutes and reassess perfusion after each bolus
Rationale: In compensated shock, tachycardia and vasoconstriction maintain blood pressure, so a
normal pressure never excludes shock; delayed capillary refill, cool mottled skin, weak pulses, and
altered behavior establish the diagnosis. A 20 mL/kg isotonic crystalloid bolus with reassessment
after each dose is first-line therapy for hypovolemic and distributive shock. Vasoactive agents are
added only after fluid-refractory shock is documented, and hypotension is absent here. Intubation
addresses respiratory failure, not perfusion failure, and these findings are never normal in an
infant.
Question 7
A 5-year-old ejected from a vehicle arrives with a Glasgow Coma Scale score of 9. Twenty minutes
later his heart rate falls from 120 to 52, blood pressure rises from 90/58 to 152/94 mmHg, and
respirations become irregular. Which interpretation and management are correct?
A. Symptomatic bradycardia; give atropine 0.02 mg/kg and begin chest compressions
B. Nonconvulsive seizure activity; give lorazepam 0.1 mg/kg and obtain an electroencephalogram
C. Cushing triad indicating increased intracranial pressure and impending herniation; elevate the
head of the bed, maintain normotension and normoxia, provide controlled ventilation, and give
hyperosmolar therapy such as hypertonic saline or mannitol
D. Neurogenic shock; give a large crystalloid bolus and begin a dopamine infusion
Correct Answer: C. Cushing triad indicating increased intracranial pressure and impending
herniation; elevate the head of the bed, maintain normotension and normoxia, provide
controlled ventilation, and give hyperosmolar therapy such as hypertonic saline or mannitol
Rationale: Bradycardia with hypertension and irregular respirations is the Cushing triad, a late sign
of increased intracranial pressure and impending herniation; therapy targets cerebral perfusion
pressure through head-of-bed elevation, avoidance of hypotonic fluids and hypoxemia, controlled
ventilation to normocapnia, hyperosmolar therapy, and neurosurgical consultation. Neurogenic
shock produces hypotension with bradycardia rather than hypertension. The bradycardia is a reflex
response to intracranial hypertension, so atropine and compressions treat the wrong mechanism
and may worsen hypertension. Nothing in the examination suggests seizure activity.
Question 8
A 10-month-old suddenly develops a silent cough, cannot cry, and shows universal distress while
eating grapes. He is conscious with an ineffective cough and no air movement. What is the correct
sequence?
