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Quiz Session - Attempts With Random Questions

AACN CCRN (Neonatal) Exam Questions

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1.

Factors that increase the risk of injury from IV extravasations include all the following, EXCEPT: 

  • Hypotonic solutions

  • Length of time between extravasation and treatment

  • Medications that are irritating to veins

  • Use of mechanical pumps for infusions

Correct answer: Hypotonic solutions

Infiltrated IV solutions can cause skin injury and occasionally deep tissue necrosis with muscle and/or nerve damage. Factors that increase the risk of injury from IV extravasations include:

  • length of time between extravasation and treatment
  • hypertonic solutions (those with high calcium, potassium, amino acid, or glucose solutions)
  • medications such as nafcillin that are irritating to veins (vesicant properties)
  • the use of mechanical pumps for infusions (mechanical compression caused by electronic infusion pumps)

In addition, there may be an added risk of injury for patients with poor perfusion to extremities and limbs that have been secured with restricting adhesives that obstruct venous return. 

2.

A full-term infant is born to a mother with systemic lupus erythematosus (SLE). A strong correlation has been established between maternal SLE antibodies and which neonatal condition?

  • Congenital heart block

  • Respiratory distress syndrome

  • Pulmonary hypertension

  • Polycythemia

Correct answer: Congenital heart block 

Maternal SLE has been strongly linked to neonatal congenital heart block, a rare manifestation of neonatal lupus syndrome. Neonatal manifestations of SLE are rare and are attributed to the placental transfer of maternal antibodies to the fetus. Other findings may include a transient lupus-like rash, hemolysis, and thrombocytopenia. These findings are transient and typically clear in a few months. Fetal heart block may be detected with antenatal testing.

All infants born to mothers with SLE should receive an electrocardiogram at birth, and those infants diagnosed with complete heart block are treated with cardiac pacemakers after delivery. Approximately one-third of affected infants die within the first three years of life.

3.

What are the expected laboratory values for a preterm infant with disseminated intravascular coagulation (DIC)?

  • Low fibrinogen level, elevated D-dimer level, low platelet count

  • Increased fibrinogen level, decreased D-dimer level, increased platelet count

  • Low fibrinogen level, low D-dimer level, low platelet count

  • Elevated fibrinogen level, elevated D-dimer level, low platelet count

Correct answer: Low fibrinogen level, elevated D-dimer level, low platelet count 

In DIC, the activation of blood clotting proteins is initiated by tissue factors from bacterial products (endotoxin) or inflammation or through the contact system. The activation of clotting proteins leads to a hypercoagulable state, and thromboses form. Liver and bone marrow partially compensate by releasing platelets and clotting factors into the bloodstream. However, since the regulatory system of coagulation is immature in preterm neonates, their capacity to neutralize activated clotting proteins is quickly depleted, and the resulting deficiencies in platelets and clotting factors are called consumptive coagulopathy. The depletion of procoagulant proteins leads to bleeding and paradoxical bleeding, and simultaneous thrombosis can occur. 

DIC predisposes a preterm infant to intracranial hemorrhage, and bleeding is seen in the skin, around catheters, ET tubes, and chest tubes. Lab results for DIC involve low platelet counts, prolonged prothrombin and partial thromboplastin times, low fibrinogen levels, and increased D-dimer levels. 

4.

For HEALTHY term and preterm infants, what is the normal range of platelet counts? 

  • 150,000 to 400,000 platelets/mm3

  • 100,000 to 250,000 platelets/mm3

  • 250,000 to 500,000 platelets/mm3

  • 200,000 to 450,000 platelets/mm3

Correct answer: 150,000 to 400,000 platelets/mm3

In general, healthy term and preterm infants have platelet counts within the normal adult range, which is 150,000 to 400,000 platelets/mm3, and mean platelet counts ranging from 200,000 to 250,000 platelets/mm3 that increase slightly with gestational age. 

Counts are 20% to 25% lower in infants who are small for gestational age (SGA). 

5.

What does a positive direct antiglobulin test (DAT), or direct Coombs test, indicate?

  • The presence of maternal IgG antibodies on the surface of an infant's red blood cells

  • The presence of IgG antibodies in maternal blood

  • A decreased incidence of hyperbilirubinemia in an infant

  • A newborn's blood type

Correct answer: The presence of maternal IgG antibodies on the surface of an infant's red blood cells 

A direct Coombs' positive result indicates the presence of maternal IgG antibodies on the surface of an infant's red blood cells. Some of these infants have clinically significant hemolysis and hyperbilirubinemia.

6.

Meconium aspiration syndrome (MAS) is associated with which of the following pathophysiologic mechanisms?

  • Uneven aeration, risk of air trapping and impaired gas exchange, and inactivation of surfactant

  • Lungs prone to atelectasis becoming susceptible to volutrauma

  • Hemodynamic impairment and restricted chest and diaphragmatic movement

  • Gas interstitium compressing the alveoli, airways, and pulmonary venules

Correct answer: Uneven aeration, risk of air trapping and impaired gas exchange, and inactivation of surfactant

With MAS, a hypoxic event in utero stimulates intestinal peristalsis and relaxation of the anal sphincter, resulting in the expelling of meconium into the amniotic fluid. Respirations after birth draw meconium into the major and then smaller airways, causing uneven aeration, obstruction, atelectasis, air trapping, and pneumothorax. Meconium can also cause the inactivation of surfactant, further impairing gas exchange and potentiating barotrauma and promoting an inflammatory response known as chemical pneumonitis.

Respiratory distress syndrome (RDS) is characterized by atelectasis-prone lungs susceptible to volutrauma. Hemodynamic impairment and restricted chest and diaphragmatic movement may occur with severe NEC or impaired gastroschisis. Pneumothorax and pulmonary interstitial emphysema result from gas interstitium compressing the alveoli, airways, and pulmonary venules.

7.

Critical findings associated with a diagnosis of meconium ileus include all the following, EXCEPT: 

  • Enterocolitis

  • Bilious emesis

  • Abdominal distention

  • "Soap bubble" appearance of the bowel on abdominal x-ray

Correct answer: Enterocolitis

Meconium ileus is an intestinal obstruction caused by meconium that creates a sticky plug obstructing the lumen of the bowel. Critical assessment findings include the following: 

  • abdominal distention at birth
  • bilious vomiting
  • a "soap bubble" appearance of the bowel on abdominal radiography (caused by trapped gas within the meconium)
  • microcolon on barium enema

Enterocolitis is more indicative of Hirschsprung's disease.

8.

Positive end-expiratory pressure (PEEP) may cause an increase in which of the following?

  • Pulmonary vascular resistance (PVR)

  • Systemic vascular resistance (SVR)

  • Mean airway pressure (MAP)

  • Pulmonary artery occlusion pressure (PAOP)

Correct answer: Pulmonary vascular resistance (PVR)

Effects of changes in PEEP depend on the severity of lung disease and degree of lung inflation. High PEEP in the presence of relatively compliant lungs will cause overdistention, worsening PaO2, and an increase in PVR. In addition, overdistention may increase the risk of barotrauma. 

However, levels of PEEP that are too low contribute to hypoxia and pulmonary hypertension because of low lung volumes. Acute lung injury is worsened by the failure to recruit adequate lung volume by using insufficient PEEP.

9.

When a neonate becomes overwhelmed by external stimuli, they will MOST likely exhibit:

  • Bradycardia and apnea

  • Hypoxia and hypotension

  • Hypertension and tachypnea

  • Increased intracranial pressure (ICP) and tachycardia

Correct answer: Bradycardia and apnea 

Once overwhelmed by external stimuli, a newborn's global response to stress is generally apnea and bradycardia. For preterm infants, "routine" procedures such as bathing result in tachycardia, increased blood pressure, motor stress behaviors, hypoxia, and increased ICP.

10.

A mother comes into the emergency department in active late-stage labor. She reports being positive for group B streptococcus (GBS). The infant arrives precipitously via vaginal delivery before intrapartum IV antibiotics can be initiated and is exposed to GBS in the birth canal.

The NICU nurse knows to watch for which of the following symptoms in the infant?

  • Fever and poor feeding

  • Fever and anemia

  • Fever and heart murmur

  • Fever and leukopenia

Correct answer: Fever and poor feeding 

Fever and poor feeding are often the first signs and symptoms of a GBS infection. The infant may be ill-appearing and exhibit a high white blood cell count (not leukopenia). If GBS is suspected, cultures should be taken, and antibiotic therapy should be initiated.

11.

What is the definition of central apnea in neonates?

  • Absence of breathing effort and airflow

  • Presence of breathing effort and absence of airflow

  • Pauses in breathing for up to 10 seconds followed by a series of rapid, shallow breaths and then normal breathing returns without intervention

  • A condition with neurologic and obstructive components

Correct answer: Absence of respiratory effort and airflow

Causes of apnea in premature infants consist of:

  • central apnea, in which there is an absence of breathing effort (without respiratory effort, airflow is zero)
  • obstructive apnea, in which breathing efforts occur but the airway is blocked
  • mixed apnea, in which an initial central apnea occurs followed by obstruction of the airway

Periodic breathing is defined as pauses in breathing followed by a series of rapid, shallow breaths and then resuming normal breathing without intervention. This periodic breathing may be observed in infants during non-REM sleep.

12.

What is a measure to decrease the incidence of necrotizing enterocolitis (NEC) in preterm infants?

  • Enteral feedings with human breast milk

  • Kangaroo care

  • Total parenteral nutrition

  • Enteral feedings with an elemental formula containing medium-chain triglycerides 

Correct answer: Enteral feedings with human breast milk

NEC is an inflammatory condition of the bowel of uncertain cause and is primarily a disease of premature infants. There have been significant efforts to prevent the onset of NEC by modifying the feeding regimens in premature infants. One simple measure to decrease the incidence of NEC is feeding with breast milk instead of formula. Breastfed infants have been found to have a lower incidence of NEC compared to formula-fed infants. In addition to breast milk, the addition of probiotics (Lactobacillus acidophilus and Bifidobacterium infantis) to the feeding regimen seems to decrease the incidence of NEC in recent randomized trials.

Total parenteral nutrition is used until sufficient enteral intake (via either human milk or formula) is established to sustain adequate growth. 

13.

Which of the following MOST accurately assesses brain growth?

  • Weekly head circumference measurements

  • Daily weight measurements

  • Weekly head ultrasound

  • Weekly Ballard assessments

Correct answer: Weekly head circumference measurements

In the absence of pathologic findings such as hydrocephalus or craniosynostosis, head circumference is used as an indicator of brain growth and is a good predictor of neurodevelopmental outcome. It is obtained using a paper or soft tape measure. An RN records the largest measurement obtained with the tape placed over the frontal, parietal, and occipital prominences. 

Daily weight is a measure of overall growth and is not specific to the brain. An ultrasound of the head details the patient's structure and measures ventricular size, but it is not used to measure brain growth or size. The Ballard examination assesses gestational age at birth only.

14.

A nurse is providing education to the caregiver of an infant who was drug-exposed in utero and exhibiting withdrawal symptoms. Regarding abuse prevention, the nurse recognizes it is MOST important to include which of the following? 

  • Techniques for the caregiver to calm themselves when the infant becomes difficult to console 

  • Infant cardiopulmonary resuscitation (CPR) training 

  • Car seat safety and safe sleeping practices 

  • Basic infant care practices such as diapering, feeding, and bathing 

Correct answer: Techniques for the caregiver to calm themselves when the infant becomes difficult to console 

Symptoms of withdrawal may persist for 2 to 6 months, and health care professionals should discuss this possibility with an infant's caregivers well before discharge so they can begin building the skills they will need with supportive staff. 

An infant who is difficult to console is at increased risk for abuse, including shaken baby syndrome. Teach caregiver(s) techniques to assist in calming themselves when the infant is irritable and difficult to console. 

15.

What is the desired therapeutic level of caffeine citrate for a neonate with diagnosed apnea of prematurity? 

  •  5-25 mcg/mL

  • 26-40 mcg/mL

  • 1-4 mcg/mL

  • 10-15 mcg/mL

Correct answer: 5-25 mcg/mL

Apnea of prematurity is treated with methylxanthines (e.g., caffeine, theophylline, aminophylline), which are potent cardiac, respiratory, and CNS stimulants and smooth muscle relaxers. Caffeine citrate is considered the drug of choice for apnea of prematurity because (1) administration is once a day; (2) there is an earlier onset of action; (3) it has a wide therapeutic range, requiring fewer serum blood level evaluations; (4) there is no alteration of CBF; and (5) there are fewer side effects than with theophylline.  

The therapeutic level for management of apnea of prematurity is 5 to 25 mcg/mL. Toxic levels are above 40-50 mcg/mL. 

16.

Which of the following is NOT a cause of hypovolemic shock for neonates?  

  • Congenital heart lesion with subsequent myocardial failure 

  • Umbilical cord rupture at birth 

  • Postnatal intracranial hemorrhage 

  • Erythroblastosis fetalis 

Correct answer: Congenital heart lesion with subsequent myocardial failure 

There is a large differential for blood loss in neonates, which (if profound) can lead to hypovolemic shock. Blood loss from placental abnormalities (umbilical cord rupture at birth, abruptio placentae, placenta previa, twin-to-twin transfusion syndrome), acute blood loss postnatally (such as pulmonary or intracranial hemorrhage), acute or chronic blood loss postsurgically, and plasma and fluid losses are all causes of hypovolemic shock. 

Erythroblastosis fetalis is an alloimmune condition that develops when maternal IgG antibodies pass through the placenta to the fetus and attack antigens on the red blood cells in the fetal circulation (breaking down and destroying cells). The fetus can develop anemia and reticulocytosis. 

Cardiogenic shock can be caused by myocardial failure due to severe hypoxemia, hypoglycemia, hypocalcemia, or acidosis. Examples of cardiogenic shock include congenital heart lesions, cardiac arrhythmias (e.g., sustained SVTs, complete atrioventricular block), cardiac function restriction (tamponade, tension pneumothorax, excessive levels of ventilatory distending pressures), and myocarditis (which is often associated with sepsis).  

17.

Which of the following is a psychological task with which parents of premature infants must cope?

  • Resumption of the relationship with the infant that had been disrupted

  • Participating in the infant's care

  • Discussing the infant with other family members

  • Allowing family and friends to hold and care for the infant

Correct answer: Resumption of the relationship with the infant that had been disrupted 

Six psychological tasks can be applied to parents of premature and/or sick infants:

  • anticipatory grieving and withdrawal from the relationship established during pregnancy
  • resumption of the relationship with the infant that had been disrupted
  • parental acknowledgment of feelings of guilt and failure
  • preparation to take the infant home
  • adaption to the intensive care environment
  • crisis events related to labor and delivery

Participating in the infant's care is a task that all parents must cope with, not just parents of sick or premature infants. Discussing the infant with other family members and allowing friends and family to hold and care for the infant are not psychological tasks related to coping with a premature or sick infant.

18.

Analyze the following arterial blood gases of a term infant whose delivery was complicated by meconium aspiration:

  • pH: 7.36
  • CO2: 63
  • HCO3: 28

Which, if any, acid-base disorder do these values represent?

  • Compensated respiratory acidosis

  • Uncompensated respiratory alkalosis

  • Compensated metabolic acidosis

  • Uncompensated metabolic alkalosis

Correct answer: Compensated respiratory acidosis 

This arterial blood gas result indicates compensated respiratory acidosis. The pH is between 7.35 and 7.45, so the value is compensated. Because it is closer to 7.35, the value is considered acidotic. 

To determine whether acidosis is respiratory or metabolic, find the value that represents acidosis. In this scenario, it would be CO2 at 63 mm Hg (normal values are 35 to 45). The most common pulmonary cause of respiratory acidosis in term newborns is obstructive lung disease, such as meconium aspiration and transient tachypnea of the newborn (TTN).

19.

Which condition is a type of pregnancy-induced hypertension that is accompanied by edema and proteinuria and generally develops during the second half of pregnancy?

  • Preeclampsia

  • Eclampsia

  • Gestational hypertension

  • Chronic hypertension in pregnancy

Correct answer: Preeclampsia

Preeclampsia is a condition occurring in pregnancy characterized by high blood pressure, proteinuria, and edema, occurring after 20 weeks of pregnancy in women with or without preexisting hypertensive disease. Preeclampsia is often precluded by gestational hypertension, which is defined as hypertension arising during the second half of pregnancy in the absence of proteinuria. Preeclampsia is most common in primigravidae, obese women, and women with multiple gestations and molar pregnancies. It is also commonly seen in women with a family history of preeclampsia and pregestational diabetes mellitus.

Eclampsia is the onset of seizures in a preeclamptic woman and is a rare and serious condition. Chronic hypertension in pregnancy is diagnosed either before pregnancy or before 20 weeks of gestation. Chronic hypertension is associated with IUGR, preterm birth, placental abruption, and stillbirth. 

20.

All the following are "rights" of drug administration in the neonate, EXCEPT: 

  • Right weight

  • Right patient

  • Right route

  • Right response

Correct answer: Right weight 

Many medical errors are medication errors. In a review of medication errors at a large general hospital, pediatric medication errors occurred at a higher rate than in the emergency department and medicine, surgery, and obstetric and gynecology units, with dosage calculation errors being the most common problem. The "six rights" of drug administration include:

  • right drug
  • right patient
  • right route
  • right dose
  • right time
  • right response

The AAP has published further recommendations for reducing medication errors for pediatric patients, including the establishment of a clearly defined system for drug ordering, dispensing, and administration. Confirmation of patient weight, drug dosage, and medication strength are also recommended.

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