A 2-month-old girl is found to have a small, hard mass on her scalp. The mass increases in size over the next 4 weeks. A biopsy is performed that confirms a diagnosis of embryonal rhabdomyosarcoma. You initiate chemotherapy with vincristine, dactinomycin, and cyclophosphamide. The child presents to clinic for day 1 of cycle 3 of chemotherapy, and the mass on her scalp is smaller. She is afebrile, absolute neutrophil count is 1,405 cells/mcL, platelet count is 154,000/mcL, and total bilirubin is 0.8 mg/dL. Her mother reports she looks very tired because her eyelids have been 'very droopy,' and she thinks she has a sore throat because her cry is hoarse. Her last bowel movement was 2 days ago. What is the most appropriate chemotherapy plan?

Correct Answer: C

Rationale: The correct answer is C because the child is showing signs of vincristine-induced neurotoxicity, which can manifest as droopy eyelids (ptosis) and hoarse cry. Holding vincristine and reevaluating weekly allows for monitoring of symptoms. If resolved, vincristine can be resumed with a dose reduction to prevent further neurotoxicity. Dactinomycin and cyclophosphamide are continued to maintain treatment efficacy. Continuing full-dose vincristine (choice A) can worsen neurotoxicity. With rhabdomyosarcoma responding to the current regimen, stopping all chemotherapy (choice B) is not appropriate. Discontinuing vincristine permanently (choice D) may compromise the treatment plan.

Correct Answer: C

Rationale: The correct answer is C: Fresh frozen plasma (20 mL/kg), which will raise her factor XI level to 20%. Fresh frozen plasma contains various clotting factors, including factor XI. In patients with severe factor XI deficiency, like this 16-year-old female, fresh frozen plasma can provide factor XI replacement and improve hemostasis. The dose of 20 mL/kg is appropriate to achieve a factor XI level of around 20%, which is sufficient for hemostasis during surgery. Now, let's analyze the other choices: A: Cryoprecipitate (five units), which will likely raise her factor XI level to 20% - Cryoprecipitate contains factor VIII and fibrinogen, but the amount of factor XI in cryoprecipitate is minimal and may not significantly raise factor XI levels to the required 20%. B: Factor XI concentrate (20 units/kg), which will raise her factor XI level to 20% - While factor XI concentrate is

Correct Answer: C

Rationale: The correct answer is C: Rib tenderness. Rib tenderness is a symptom more commonly associated with musculoskeletal issues rather than pulmonary embolism. Pulmonary embolism typically presents with symptoms such as chest pain, shortness of breath, and sometimes cough. Fever is not a typical symptom of pulmonary embolism. Shortness of breath is a common symptom but not specific enough to substantially decrease suspicion for pulmonary embolism.

Correct Answer: B

Rationale: The correct answer is B because starting chemotherapy before resection at week 12 can help shrink the tumor, making it more manageable for surgery. A is incorrect because preoperative chemotherapy can improve outcomes. C is incorrect because radiotherapy may not be necessary if the tumor is completely resected. D is incorrect because radiotherapy may still be necessary even if the tumor is resected before chemotherapy.

Correct Answer: A

Rationale: The correct answer is A: Assess the conjunctiva of the eye. Pallor is difficult to detect in dark-skinned individuals due to the lack of contrast. The conjunctiva of the eye provides a reliable area to assess for pallor as it is mucous membrane with blood vessels that can show changes in color. It is not accurate to assess for pallor by having the patient open the hand widely (B) as skin color on hands may vary. Looking at the roof of the mouth (C) may not accurately reflect pallor. Palpating for areas of mild swelling (D) does not assess for pallor, but rather for edema.