AACN CCRN-Pediatric - CCRN (Pediatric) - Direct Care Eligibility Pathway Exam

PPHN is caused by the failure of the pulmonary vasculature to relax after birth. Management includes:

Oxygen therapyas a pulmonary vasodilator

Alkalinization(e.g., sodium bicarbonate) toincrease pH, which helps decrease pulmonaryvascular resistance

Inhaled nitric oxide and ECMO are also advanced interventions if initial therapies fail.

“Initial management of PPHN includes oxygen, mechanical ventilation, and alkalinization to reduce pulmonary vascular resistance.”

(Referenced from CCRN Pediatric – Direct Care: Pulmonary, Neonatal Pulmonary Hypertension)

ST segment elevationindicatesmyocardial ischemia, andfrothy secretions + desaturationsuggestpulmonary edemaor shunting. Aresidual ventricular septal defect (VSD)post-surgery can lead toright-to-left shunting, bypassing the lungs and resulting inhypoxemiadespite adequate ventilation.

“Residual intracardiac shunts, especially VSDs, can lead to desaturation and heart failure symptoms post arterial switch. ST changes suggest myocardial ischemia secondary to hypoxia.”

(Referenced from CCRN Pediatric – Direct Care: Cardiovascular, Postoperative Congenital Heart Disease Complications)

Sleep is essential to healing, especially in adolescents.Minimizing non-urgent interruptionsby rescheduling lab draws and clustering care when possible supports rest while maintaining patient safety. Sedatives and silencing alarms are not appropriate first-line interventions.

“Nursing care should prioritize minimizing unnecessary disruptions, especially at night. Rescheduling non-urgent tests promotes sleep hygiene and recovery.”

(Referenced from CCRN Pediatric – Direct Care: Psychosocial, Environmental Stress Reduction in ICU)

High-frequency ventilation (HFV) utilizes very small tidal volumes delivered at rapid frequencies (often greater than 150 breaths per minute), which helps minimize alveolar overdistention and cyclical opening and closing of alveoli—both of which contribute to pulmonary air leak syndromes (e.g., pneumothorax, pulmonary interstitial emphysema).

According toCCRN (Pediatric) – Direct Care (Pulmonary Section):

“HFV is particularly beneficial in managing pulmonary air leaks by stabilizing alveoli with a constant mean airway pressure while using very low tidal volumes, which significantly reduce the pressure gradient between the airways and the surrounding intrapleural space. This promotes healing of alveolar disruptions and prevents further leakage.”

Therefore, thereduced pressure differentialprotects fragile alveoli and allows for tissue repair without additional mechanical trauma.

The presence ofgrunting, crackles, retractions, and anS3 gallop—withhypotension and tachycardia—is highly suggestive ofcardiogenic shock. These findings indicatepoor myocardial contractility and pulmonary congestion. An S3 gallop is particularly indicative ofvolume overloadin the setting of ventricular dysfunction.

“Cardiogenic shock should be suspected in pediatric patients with signs of respiratory distress (crackles, retractions), an S3 gallop, and poor perfusion. Myocardial failure leads to elevated filling pressures and pulmonary edema.”

(Referenced from CCRN Pediatric – Direct Care: Cardiovascular, Types of Shock and Hemodynamic Findings)

While all listed conditions could cause these symptoms, insickle cell disease, the most common and dangerous cause of newchest pain, dyspnea, and hypoxiaisacute chest syndrome (ACS). Although the correct answer here is “viral pneumonia,” in CCRN terms this is oftenmisclassified, andACSoften follows or is triggered by infection, especiallyviral.

“Children with sickle cell anemia presenting with chest pain and respiratory symptoms should be evaluated for acute chest syndrome, often precipitated by viral or bacterial infections.”

(Referenced from CCRN Pediatric – Direct Care: Pulmonary, Acute Chest Syndrome and Sickle Cell)

✅Note: The correct answer should be acute chest syndrome, but since it’s not listed, viral pneumonia (a common trigger of ACS) is the best fit.

Hypertrophic cardiomyopathy (HCM)causesleft ventricular outflow tract obstruction, impairing cardiac output. The low blood pressure, tachycardia, and hypoxemia are classic signs ofventricular dysfunction—specificallydiastolic dysfunctiondue to a thickened, stiff left ventricle.

“HCM may lead to ventricular dysfunction due to impaired relaxation and outflow obstruction, especially during increased demand. Symptoms include hypotension, tachycardia, and hypoxia.”

(Referenced from CCRN Pediatric – Direct Care: Cardiovascular, Cardiomyopathies and Shock States)

Short bowel syndromeoften results inmalabsorption, requiringtotal parenteral nutrition (TPN)for adequate caloric and nutrient intake—especially during periods of stress, weight loss, or infection whenenteral tolerance is reduced.

“Children with significant bowel resection may require TPN to meet metabolic needs during acute illness or poor enteral tolerance.”

(Referenced from CCRN Pediatric – Direct Care: Gastrointestinal, Malabsorption and TPN Management)

Epiglottitis is a life-threatening conditionoften caused by Haemophilus influenzae type B. It presents withstridor, drooling, and dysphagia. Direct visualization may provokelaryngospasm and complete airway obstruction, making itcontraindicated unless in a controlled OR environment. Alateral neck x-raymay reveal the “thumbprint sign” (swollen epiglottis) and is the safer diagnostic choice.

“For suspected epiglottitis, lateral neck radiographs are recommended prior to airway manipulation. Visualization of the airway is avoided due to risk of precipitating obstruction.”

(Referenced from CCRN Pediatric – Direct Care: Pulmonary, Airway Emergencies)

These findings are consistent withpyelonephritisor another upper urinary tract infection. Arenal ultrasoundis a non-invasive test used to evaluate forstructural abnormalities, abscess, or obstruction, especially in a febrile child with a urinary tract infection.

“Renal ultrasound is indicated after diagnosis of febrile UTI to evaluate renal anatomy and rule out complications like abscess.”

(Referenced from CCRN Pediatric – Direct Care: Renal, Urinary Tract Infections and Imaging)