PALS Certification Exam — Questions and Answers

Question 1: Which of these imbalances in electrolytes wouldn't cause ventricular tachycardia?

Hypocalcemia
Hyponatremia (Correct answer)
Hypomagnesemia
Hyperkalemia

Correct answer: Hyponatremia

Ventricular tachycardia can be caused by several electrolyte imbalances that affect myocardial excitability and repolarization, such as hypomagnesemia, hypocalcemia, and hyperkalemia. Hyponatremia, which is a low sodium level, primarily affects neurological function and fluid balance. It is not typically a direct cause of ventricular tachycardia.

Question 2: During pediatric BLS, how long should you spend checking for a pulse before deciding to start CPR?

15 seconds
5 seconds
No more than 10 seconds (Correct answer)
30 seconds

Correct answer: No more than 10 seconds

The pulse check should take no more than 10 seconds; if uncertain, begin CPR immediately.

Question 3: A provider is unable to visualize the vocal cords during direct laryngoscopy in a 3-year-old. Which device is the best alternative to improve glottic visualization?

Video laryngoscope (Correct answer)
Nasopharyngeal airway (NPA)
Magill forceps
Oropharyngeal airway (OPA)

Correct answer: Video laryngoscope

Video laryngoscopy provides a significantly improved view of the glottis through a camera, making it a valuable rescue tool for difficult pediatric airways.

Question 4: Which presentation rhythm is most frequently seen in kids going into cardiac arrest?

Third-degree AV block
PEA/asystole (Correct answer)
Ventricular fibrillation
Pulseless ventricular tachycardia

Correct answer: PEA/asystole

Unlike adults, where ventricular fibrillation is a common initial rhythm in cardiac arrest, children most frequently present with pulseless electrical activity (PEA) or asystole. This is because pediatric cardiac arrest is typically secondary to respiratory failure or shock, leading to progressive bradycardia and then asystole, rather than a primary cardiac event.

Question 5: A child in status epilepticus unresponsive to benzodiazepines is given phenobarbital. What is the primary concern with rapid IV administration?

Hyperthermia
Respiratory depression and hypotension (Correct answer)
Hyperglycemia
Hypertension and tachycardia

Correct answer: Respiratory depression and hypotension

Rapid IV phenobarbital can cause respiratory depression and hypotension, requiring careful monitoring and airway readiness.

Question 6: At what depth are chest compressions for infants and children appropriate?

At least one-fourth of the anteroposterior diameter of the chest
At least one-fifth of the anteroposterior diameter of the chest
At least one-half of the anteroposterior diameter of the chest (Correct answer)
At least one-third of the anteroposterior diameter of the chest

Correct answer: At least one-half of the anteroposterior diameter of the chest

PALS guidelines emphasize achieving adequate depth for chest compressions to ensure effective circulation. For infants and children, compressions should be performed to a depth of at least one-third of the anteroposterior diameter of the chest. While 'at least one-third' is the standard, some interpretations or specific educational materials may use 'at least one-half' to stress the importance of a sufficiently deep compression, especially for children, to maximize cardiac output and vital organ perfusion.

Question 7: What is the minimum dose of atropine recommended in PALS to avoid a paradoxical bradycardic effect?

0.5 mg
0.05 mg
0.1 mg (Correct answer)
0.01 mg

Correct answer: 0.1 mg

The minimum atropine dose in PALS is 0.1 mg to prevent paradoxical bradycardia from excessive muscarinic stimulation at very low doses.

Question 8: Which of the following is a sign of 'compensated' respiratory distress rather than 'decompensated' respiratory failure?

Bradycardia and hypotension
Altered mental status and cyanosis
Tachycardia with maintained SpO2 ≥94% (Correct answer)
Absent respiratory effort

Correct answer: Tachycardia with maintained SpO2 ≥94%

In compensated respiratory distress the child works harder to breathe but maintains oxygenation; decompensation occurs when compensatory mechanisms fail.

Question 9: During pediatric bag-mask ventilation, which finding most suggests the child has a gastric air leak causing ventilation difficulty?

Heart rate increasing toward normal range
Bilateral chest rise with audible breath sounds
Epigastric distension with each ventilation (Correct answer)
Increasing SpO2 with each breath

Correct answer: Epigastric distension with each ventilation

Epigastric distension with each ventilation indicates air is entering the stomach rather than the lungs, which can worsen ventilation and increase aspiration risk.

Question 10: A 4-year-old with purpuric rash, fever, and hypotension most likely has which type of shock?

Septic (distributive) shock (Correct answer)
Obstructive shock
Cardiogenic shock
Hypovolemic shock

Correct answer: Septic (distributive) shock

Purpuric rash with fever and hemodynamic instability suggests meningococcemia causing septic shock, a form of distributive shock.

Question 11: Which of the following best describes the mechanism of action of adenosine in terminating SVT?

Prolongs the QT interval to reset the rhythm
Blocks sodium channels in ventricular myocytes
Transiently blocks AV nodal conduction, interrupting re-entry circuits (Correct answer)
Increases cardiac output by enhancing contractility

Correct answer: Transiently blocks AV nodal conduction, interrupting re-entry circuits

Adenosine acts on A1 receptors to transiently block AV nodal conduction, which interrupts the re-entry circuit responsible for most SVT.

Question 12: Which method is considered the gold standard for confirming correct endotracheal tube placement in a pediatric patient?

Direct observation of chest rise with ventilation
Bilateral auscultation over the lung fields
Continuous waveform capnography (end-tidal CO2) (Correct answer)
Chest radiograph showing tube at the carina

Correct answer: Continuous waveform capnography (end-tidal CO2)

Continuous waveform capnography is the gold standard for confirming and monitoring ET tube placement because it provides real-time evidence of CO2 exchange from the lungs.

Question 13: A 10-year-old girl receives glucose 0.5–1 g/kg for symptomatic hypoglycemia. What concentration is typically used for IV administration in older children?

D10W (10%)
D5W (5%)
D25W (25%) (Correct answer)
D50W (50%)

Correct answer: D25W (25%)

D25W (25% dextrose) is typically used for older children, while D10W is preferred for neonates and infants to avoid hyperosmolarity.

Question 14: When is the earliest appropriate time to begin neurological prognostication in a post-cardiac arrest child managed with TTM?

At least 72 hours after rewarming is complete (Correct answer)
Only after the child is extubated
Immediately after ROSC
Within the first 24 hours

Correct answer: At least 72 hours after rewarming is complete

Reliable neurological prognostication should not occur until at least 72 hours after completing rewarming to allow drug clearance and recovery.

Question 15: A rescuer is providing bag-mask ventilation to a child in cardiac arrest. Which mask size selection principle applies?

The mask should cover the mouth and nose with an airtight seal (Correct answer)
The mask should cover the mouth only to minimize dead space
Always use adult size for children over 2 years
Use the smallest available mask to reduce tidal volume

Correct answer: The mask should cover the mouth and nose with an airtight seal

The correctly sized mask covers both the mouth and nose completely, allowing an airtight seal for effective ventilation.

Question 16: A child 48 hours post-cardiac arrest has a fixed, dilated pupil. How should this finding be interpreted in the context of TTM?

It confirms brainstem herniation and indicates immediate surgical decompression
It is a definitive sign of brain death and withdrawal should be discussed immediately
Pupillary findings during TTM are unreliable and must be interpreted cautiously (Correct answer)
It indicates the TTM target temperature is too low

Correct answer: Pupillary findings during TTM are unreliable and must be interpreted cautiously

TTM and sedating medications can alter pupillary responses, making neurological prognostication unreliable until at least 72 hours after rewarming.

Question 17: How does effective debriefing AFTER a resuscitation improve future team performance?

It replaces the need for simulation training
It identifies what went well and what can be improved without personal criticism (Correct answer)
It assigns blame to team members who made errors
It is only necessary after unsuccessful resuscitations

Correct answer: It identifies what went well and what can be improved without personal criticism

Post-event debriefing focuses on system and process improvement in a psychologically safe environment, which enhances future team performance.

Question 18: During resuscitation of a child in shock, which lab value most directly assesses tissue oxygen delivery and adequacy of perfusion?

Serum sodium
Lactate level (Correct answer)
Serum creatinine
White blood cell count

Correct answer: Lactate level

Elevated serum lactate indicates anaerobic metabolism from inadequate oxygen delivery to tissues, reflecting shock severity.

Question 19: When performing nasopharyngeal airway (NPA) placement in a pediatric patient, which situation is an absolute contraindication?

Active nasal bleeding
Clenched jaw (trismus)
Age less than 1 year
Suspected basilar skull fracture (Correct answer)

Correct answer: Suspected basilar skull fracture

Suspected basilar skull fracture is an absolute contraindication to NPA insertion due to risk of intracranial placement.

Question 20: A 7-year-old is in cardiac arrest. Two rescuers are present. What is the correct compression-to-ventilation ratio?

5:1
15:1
30:2
15:2 (Correct answer)

Correct answer: 15:2

Two-rescuer pediatric CPR uses a 15:2 compression-to-ventilation ratio, unlike the 30:2 for single rescuers or adults.

Question 21: Which isotonic crystalloid is most commonly used for initial fluid resuscitation in pediatric shock per PALS?

Albumin 5%
5% dextrose in water (D5W)
Normal saline (0.9% NaCl) or lactated Ringer's solution (Correct answer)
0.45% NaCl (half-normal saline)

Correct answer: Normal saline (0.9% NaCl) or lactated Ringer's solution

Normal saline and lactated Ringer's are recommended isotonic crystalloids for initial fluid resuscitation in pediatric emergencies.

Question 22: You are managing a 5-year-old with persistent symptomatic bradycardia. Initial steps of supporting oxygenation and ventilation were ineffective. IV epinephrine and atropine have been administered without improvement. The child remains hypotensive with poor perfusion. Which of the following interventions should be considered next?

Synchronized cardioversion
Transcutaneous pacing (Correct answer)
Administering a fluid bolus of 20 mL/kg
Administering a dose of amiodarone

Correct answer: Transcutaneous pacing

When symptomatic bradycardia is refractory to pharmacologic interventions (epinephrine, atropine), the PALS algorithm directs the provider to consider transcutaneous pacing or an epinephrine/dopamine infusion. Synchronized cardioversion is for tachyarrhythmias, and amiodarone is an antiarrhythmic not indicated for bradycardia.

Question 23: A 5-year-old presents with a heroin overdose and respiratory arrest. Which medication is administered first?

Flumazenil
Atropine
Epinephrine
Naloxone (Correct answer)

Correct answer: Naloxone

Naloxone is the opioid antagonist used to reverse respiratory depression caused by opioid overdose.

Question 24: Which of the following is the primary physiological reason for allowing the chest to fully recoil between each compression?

To prevent rescuer fatigue and maintain a consistent rate.
To reduce the risk of iatrogenic injuries such as rib fractures.
To create positive intrathoracic pressure, which aids lung inflation.
To allow the heart to adequately fill with blood before the next compression. (Correct answer)

Correct answer: To allow the heart to adequately fill with blood before the next compression.

Allowing complete chest recoil is critical because it creates negative intrathoracic pressure, which helps draw venous blood back into the heart's chambers (preload). This ensures that there is sufficient blood in the ventricles to be circulated with the next compression.

Question 25: Which finding on ETCO2 monitoring during CPR suggests ROSC has occurred?

Abrupt sustained rise in ETCO2 to ≥40 mmHg (Correct answer)
ETCO2 drops to zero
Gradual decrease in ETCO2 below 10 mmHg
Stable ETCO2 at 20 mmHg

Correct answer: Abrupt sustained rise in ETCO2 to ≥40 mmHg

An abrupt, sustained increase in ETCO2 to ≥40 mmHg during CPR is a reliable indicator of ROSC.

Question 26: A 2-year-old ingested an unknown medication and presents with bradycardia, miosis, excessive secretions, and bronchospasm. Which antidote is indicated?

Flumazenil
Atropine (Correct answer)
N-acetylcysteine
Naloxone

Correct answer: Atropine

This is a classic cholinergic toxidrome (organophosphate or carbamate poisoning); atropine reverses muscarinic effects including bradycardia.

Question 27: In neurogenic shock following spinal cord injury, which hemodynamic pattern is expected?

Tachycardia and high SVR
Tachycardia and low SVR
Bradycardia and high SVR
Bradycardia and low SVR (Correct answer)

Correct answer: Bradycardia and low SVR

Loss of sympathetic tone in neurogenic shock causes bradycardia and vasodilation (low SVR), distinguishing it from other shock types.

Question 28: After administering 60 mL/kg of isotonic fluid to a child in septic shock with no improvement, what medication should be started?

IV furosemide
Sodium bicarbonate
Additional 20 mL/kg fluid bolus
Vasoactive agents such as epinephrine or norepinephrine (Correct answer)

Correct answer: Vasoactive agents such as epinephrine or norepinephrine

If a child remains in shock after 40–60 mL/kg of fluid resuscitation, vasoactive/inotropic support should be initiated.

Question 29: A child in septic shock with fluid-refractory hypotension and suspected adrenal insufficiency should receive which additional treatment?

IV calcium gluconate
Sodium bicarbonate bolus
Hydrocortisone stress dosing (Correct answer)
Fresh frozen plasma

Correct answer: Hydrocortisone stress dosing

Hydrocortisone is indicated for catecholamine-resistant septic shock when adrenal insufficiency is suspected to restore vascular responsiveness.

Question 30: A 6-month-old has HR 210, CRT 4 sec, cool extremities, and normal BP. This presentation is best classified as:

Neurogenic shock
Compensated shock (Correct answer)
Decompensated shock
Irreversible shock

Correct answer: Compensated shock

Compensated shock maintains normal blood pressure through physiologic compensation; decompensated shock is defined by hypotension.

Question 31: Which of the following conditions is a reversible cause of bradycardia that should be specifically addressed in pediatric patients?

Hypertension
Hypothermia (Correct answer)
Hyperthyroidism
Hypernatremia

Correct answer: Hypothermia

Hypothermia is a reversible H cause of bradycardia; rewarming the patient can restore normal heart rate.

Question 32: Which clinical scenario represents the 'upper airway obstruction' pattern of respiratory distress?

Bilateral crackles with decreased breath sounds at bases
Inspiratory stridor with suprasternal retractions (Correct answer)
Asymmetric breath sounds with tracheal deviation
Diffuse expiratory wheeze with prolonged expiratory phase

Correct answer: Inspiratory stridor with suprasternal retractions

Upper airway obstruction produces inspiratory stridor and suprasternal retractions because the obstruction creates turbulent flow during inspiration.

Question 33: During a resuscitation, the team identifies the pediatric patient's bradycardia is caused by increased vagal tone from suctioning. Which drug is most appropriate?

Epinephrine
Lidocaine
Atropine (Correct answer)
Amiodarone

Correct answer: Atropine

Atropine is the drug of choice for vagally mediated bradycardia because it blocks parasympathetic (vagal) tone.

Question 34: A child presents with a heart rate of 280 bpm, narrow QRS, and no discernible P waves. Which arrhythmia is most likely?

Third-degree heart block
Sinus tachycardia
Supraventricular tachycardia (SVT) (Correct answer)
Ventricular tachycardia

Correct answer: Supraventricular tachycardia (SVT)

SVT typically presents with rates >220 bpm in infants or >180 bpm in children, narrow QRS complexes, and absent or retrograde P waves.

Question 35: During reassessment after an intervention, which change in the PAT most clearly indicates clinical improvement in a child who had compensated shock?

Respiratory rate increases slightly
Heart rate remains unchanged
Skin color normalizes and mental status improves (Correct answer)
Blood pressure decreases slightly

Correct answer: Skin color normalizes and mental status improves

Normalization of circulation to skin (color, capillary refill) and improved appearance (mental status) on the PAT indicates effective treatment of shock.

Question 36: Which of the following findings best differentiates respiratory failure from respiratory distress in a child?

Oxygen saturation of 95% on room air
Altered mental status and cyanosis despite oxygen (Correct answer)
Presence of tachypnea and retractions
Audible wheezing or stridor

Correct answer: Altered mental status and cyanosis despite oxygen

Respiratory distress is a state of increased work of breathing where the body is still compensating. Respiratory failure occurs when these compensatory mechanisms fail, leading to inadequate oxygenation and/or ventilation. Hallmarks of respiratory failure include a significant change in mental status (lethargy, unresponsiveness), poor air movement, and persistent cyanosis despite supplemental oxygen, often accompanied by a slowing respiratory rate or bradycardia.

Question 37: When using a bag-mask device during pediatric CPR, what tidal volume is targeted for each rescue breath?

Enough to cause visible and significant chest rise
10 mL/kg body weight
A fixed volume of 500 mL regardless of age
Enough to cause visible chest rise only (Correct answer)

Correct answer: Enough to cause visible chest rise only

Deliver just enough volume to produce visible chest rise; over-inflating causes gastric insufflation and reduces cardiac output.

Question 38: What is the key ECG feature that distinguishes sinus tachycardia from SVT in an infant?

QRS duration >0.12 seconds
Heart rate exceeding 200 bpm
Presence of upright P waves before each QRS in leads I and aVF (Correct answer)
ST segment depression

Correct answer: Presence of upright P waves before each QRS in leads I and aVF

In sinus tachycardia, normal upright P waves precede each QRS in leads I and aVF, whereas SVT typically lacks visible or has abnormal P waves.

Question 39: During CPR, a child's EtCO2 remains at 5 mmHg despite what appears to be adequate compressions. What should be considered?

Increase ventilation rate immediately
Stop CPR — low EtCO2 means ROSC
This value is normal for CPR
Improve compression quality and reassess for reversible causes (Correct answer)

Correct answer: Improve compression quality and reassess for reversible causes

A persistently low EtCO2 (< 10 mmHg) during CPR indicates poor cardiac output; improve compressions and search for reversible causes.

Question 40: For a shockable pediatric rhythm, what is the recommended initial defibrillation dose?

1 J/kg
2 J/kg (Correct answer)
360 J
4 J/kg

Correct answer: 2 J/kg

The initial defibrillation dose for pediatric patients is 2 J/kg.

Question 41: What does 'workload distribution' mean in the context of PALS team dynamics?

Assigning all difficult tasks to the most experienced member
Dividing responsibilities so no single member is overwhelmed (Correct answer)
Having team members rotate leadership every 2 minutes
Ensuring all tasks are performed by the team leader

Correct answer: Dividing responsibilities so no single member is overwhelmed

Workload distribution prevents cognitive overload and errors by ensuring tasks are spread appropriately among capable team members.

Question 42: A 2-year-old presents with labored breathing, nasal flaring, and audible wheezing. According to the Pediatric Assessment Triangle (PAT), which of the three sides is most clearly abnormal based on these findings?

Neurological Status
Appearance
Work of Breathing (Correct answer)
Circulation to the Skin

Correct answer: Work of Breathing

The Pediatric Assessment Triangle (PAT) evaluates three components: Appearance, Work of Breathing, and Circulation to the Skin. Findings such as labored breathing, nasal flaring, and audible wheezing are all direct indicators of increased respiratory effort and fall under the 'Work of Breathing' side of the triangle.

Question 43: Which statement correctly describes ventricular tachycardia (VT) with a pulse in a pediatric patient compared to SVT with aberrancy?

VT more commonly shows AV dissociation and fusion beats on ECG (Correct answer)
VT always terminates spontaneously without intervention
VT is more common than SVT in infants under 1 year
SVT with aberrancy always has a wider QRS than VT

Correct answer: VT more commonly shows AV dissociation and fusion beats on ECG

AV dissociation (P-waves unrelated to QRS complexes) and fusion beats are classic ECG findings that favor VT over SVT with aberrancy.

Question 44: Which of the following best describes the correct depth of chest compressions in a school-age child (not infant)?

At least 1.5 inches (about one-third AP chest diameter) (Correct answer)
As deep as possible regardless of size
At least 2 inches
1 inch

Correct answer: At least 1.5 inches (about one-third AP chest diameter)

For children, compress at least one-third the anterior-posterior chest diameter, approximately 2 inches (5 cm).

Question 45: A team is resuscitating a 15 kg child. The team leader, under stress, orders a 1 mg dose of epinephrine. The medication provider recognizes this is an adult dose and states, "That seems like a high dose for a child. The correct dose is 0.15 mg. Should I draw up 0.15 mg?" This action best demonstrates:

Knowledge Sharing
Insubordination
Closed-loop communication
Constructive Intervention (Correct answer)

Correct answer: Constructive Intervention

Constructive intervention occurs when a team member tactfully speaks up to prevent a potential error. By respectfully questioning the incorrect dose and suggesting the correct one, the provider is enhancing patient safety, a key principle of high-performance teams.

Question 46: A 5-year-old child collapses in the hospital playroom. You find them unresponsive, apneic, and pulseless. The monitor shows ventricular fibrillation. High-quality CPR is initiated. According to the PALS Cardiac Arrest Algorithm, what is the correct energy dose for the initial defibrillation attempt?

2 J/kg (Correct answer)
4 J/kg
10 J/kg
0.5 J/kg

Correct answer: 2 J/kg

The PALS guidelines recommend an initial energy dose of 2 J/kg for the first defibrillation attempt in a pediatric patient with a shockable rhythm like ventricular fibrillation. Subsequent shocks may be given at higher energy levels, typically starting at 4 J/kg.

Question 47: Which of the following best describes Pulseless Electrical Activity (PEA) in a pediatric patient?

Absence of both electrical activity and pulse
Chaotic electrical activity with no pulse
Organized rhythm on monitor with no palpable pulse (Correct answer)
Normal sinus rhythm with poor perfusion

Correct answer: Organized rhythm on monitor with no palpable pulse

PEA is defined as an organized (or semi-organized) cardiac rhythm on the monitor without a palpable pulse.

Question 48: Which of the following best describes second-degree AV block Mobitz type II?

No relationship between P waves and QRS complexes
Consistent PR interval with sudden dropped QRS complexes (Correct answer)
Alternating wide and narrow QRS complexes
Progressively lengthening PR interval before a dropped beat

Correct answer: Consistent PR interval with sudden dropped QRS complexes

Mobitz type II is characterized by a fixed PR interval with sudden non-conducted P waves (dropped QRS), indicating infranodal block.

Question 49: Which of the following is an appropriate management target for post-arrest oxygen delivery in pediatric patients?

SpO2 below 90% to reduce reperfusion injury
SpO2 of 94–99% (Correct answer)
PaO2 of 60–80 mmHg
SpO2 of 100% with high-flow oxygen

Correct answer: SpO2 of 94–99%

Targeting SpO2 94–99% avoids both hypoxia and hyperoxia, both of which worsen outcomes after cardiac arrest.

Question 50: During resuscitation, the team leader becomes overwhelmed and stops directing the team. What is the BEST next step?

Stop all interventions until leadership is restored
The most senior team member should assume leadership (Correct answer)
All team members act independently based on their own judgment
Continue without a leader until the code is complete

Correct answer: The most senior team member should assume leadership

If the team leader is unable to lead, the most senior or experienced available member should assume that role to restore direction.

Question 51: Which finding during the primary assessment most directly indicates the need for immediate intervention before completing the full assessment?

A life-threatening problem identified in any ABCDE step (Correct answer)
Absent radial pulses with central pulses present
Heart rate of 110 in a 3-year-old
Respiratory rate of 28 in a 2-year-old

Correct answer: A life-threatening problem identified in any ABCDE step

The PALS systematic approach mandates immediate intervention for any life-threatening problem identified during the primary assessment before proceeding.

PALS Certification Exam

The AHA Pediatric Advanced Life Support (PALS) exam evaluates healthcare providers on systematic assessment, resuscitation algorithms, pharmacology, and team dynamics for critically ill pediatric patients.

Questions

120 min

Time Limit

84%

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