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Quiz Session - Attempts With Random Questions

AACN CCRN (Neonatal) Exam Questions

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21.

An asphyxiating infant will have three low measurements: serum pH, glucose, and what other value?

  • Bicarbonate  

  • Carbon dioxide

  • Hemoglobin

  • Specific gravity 

Correct answer: Bicarbonate 

Asphyxia often leads to combined respiratory and metabolic acidosis. During and after asphyxia, when tissue oxygen supply is limited, a neonate relies largely on anaerobic metabolism for energy production, which utilizes more glucose than aerobic metabolism. As a result, glucose produced by lipolysis and glycogenolysis is rapidly consumed, leading to hypoglycemia. 

Ventilation will resolve respiratory acidosis. Improved oxygenation delivery and tissue perfusion usually resolve lactic acidosis and return bicarbonate levels to normal. 

22.

An infant is receiving peritoneal dialysis. How much fluid should the nurse expect to recover after each cycle? 

  • At least equal to the amount infused, possibly more 

  • Less than the amount infused 

  • More than the amount infused 

  • Unimportant 

Correct answer: At least the amount infused, possibly more 

Acute peritoneal dialysis (PD) is a major modality of dialysis therapy for acute and chronic kidney failure in neonates, particularly when vascular access is difficult to maintain. 

Dialysis fluid (dialysate) is infused into the peritoneal space, either via a machine or manually, and allowed to "dwell" for a designated time. The initial fill volume is generally 10 to 20 mL/kg, progressing to 40 mL/kg for chronic dialysis; the goal is to remove excess fluid and waste from the body, leaving a negative fluid balance (equal to or larger than the amount infused). 

23.

The lab calls the NICU to report that a blood specimen sample obtained from an infant is "clotted." Which of the following labs is MOST likely falsely elevated? 

  • Potassium

  • Creatinine 

  • AST/ALT

  • Calcium

Correct answer: Potassium 

Potassium is released from clot formation in blood collection tubes and can falsely elevate potassium levels. This is called pseudohyperkalemia. 

The other lab values are not as affected by a "clotted" tube. 

24.

A nurse is assessing a two-hour-old male and notes that his urethral opening is on the ventral surface of the penis. What is this finding called?

  • Hypospadias

  • Epispadias

  • Inguinal hernia

  • Hydrocele

Correct answer: Hypospadias

In hypospadias, the urethral opening is on the ventral surface of the penis. It is one of the most common abnormalities of the penis, occurring in 1 of every 250 to 300 male births. 

Epispadias exists if the opening is on the dorsal surface. Inguinal or scrotal swelling, discoloration, palpable masses, and pain and/or tenderness with palpation can indicate an inguinal hernia, testicular torsion, trauma, a tumor, or hydrocele (a collection of fluid in the scrotal sac).

25.

Which principle is an integral part of the informed consent process that directly affects decision-making?

  • Fidelity

  • Beneficence

  • Nonmaleficence

  • Confidentiality

Correct answer: Fidelity

Fidelity, commonly called truth-telling or promise-keeping, is an integral part of the informed consent process and can be derived from the principle of autonomy (respect for persons). It assumes an implicit contract between parties that the truth will be told. 

At the heart of truth-telling is trust, which gives professional-patient relationships their integrity. Issues of what to tell, how and when to tell, and whom to tell become a daily part of providers' interaction with each other and the families of affected newborns.

26.

When addressing maternal needs in the NICU, a nurse can provide empowering information to the mother in all the following ways, EXCEPT: 

  • Criticizing maternal caregiving at the bedside 

  • Explaining how a preterm baby differs from a term baby

  • Showing how to read and respond to a baby's cues and behaviors

  • Providing opportunities for direct parental care of the infant

Correct answer: Criticizing maternal caregiving at the bedside 

Rather than criticizing a mother, this NICU nurse should understand the parental need for supportive appraisal and should give positive feedback and reinforcement of maternal caregiving (i.e., feeding, bathing, diapering). NICU nurses should model preterm care tasks so that mothers can first observe the tasks before performing them.

Other recommendations for NICU staff include providing information on how a preterm baby differs from a term baby, explaining how to read/respond to the infant's cues and behaviors, and facilitating opportunities for parents to care directly for their infant.

27.

Analyze the following arterial blood gas values of an infant born at 32 weeks on 2L oxygen via nasal cannula:

  • pH: 7.56
  • CO2: 33
  • HCO3: 25

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

  • Uncompensated respiratory alkalosis

  • Normal values

  • Compensated respiratory acidosis

  • Uncompensated (mixed) respiratory/metabolic alkalosis

Correct answer: Uncompensated respiratory alkalosis 

This result is uncompensated respiratory alkalosis because the pH is greater than 7.45 (normal is 7.35 to 7.45), so the value is uncompensated alkalosis. 

To determine whether the alkalosis is respiratory or metabolic, find the value that represents alkalosis. This would be CO2 at 34 mm Hg (normal is 35 to 45). HCO3 is within the normal range in this scenario (22 to 26 mmol/L).

28.

Cafe-au-lait spots that are large in size or more than six in number may be associated with which of the following conditions?

  • Neurofibromatosis

  • Neural tube defects

  • Hydrocephalus

  • Myelomeningocele

Correct answer: Neurofibromatosis 

Irregularly shaped oval lesions, otherwise known as cafe-au-lait spots, that are large in size (>4 x >6 cm) or greater than six in number are associated with neurofibromatosis, a condition in which tumors form on cutaneous nerves and along the thoracic, brachial, and lumbar nerve trunks. Cranial nerves may also be affected. 

Neurofibromatosis is an autosomal-dominant disorder, and these cafe-au-lait macules may be the only finding in the neonatal period. 

29.

Placental pathology would be MOST important in the diagnosis and management of which of the following? 

  • Listeria monocytogenes infection 

  • Syphilis 

  • GBS infection 

  • Preeclampsia 

Correct answer: Listeria monocytogenes infection 

Placental pathology is important because placental microabscesses occur with listeria. To prevent this unpleasant bacterial infection, pregnant women should avoid unpasteurized dairy products. 

If listeria infection is present in a neonate at the time of birth, the recommended therapy is IV ampicillin and IV gentamycin for 14-21 days. 

30.

Surfactant production is accelerated in all of the following scenarios, EXCEPT:

  • Acidemia and hypoxemia

  • Premature rupture of membranes for over 48 hours

  • Infants subjected to maternal infection

  • Infants of heroin-addicted mothers

Correct answer: Acidemia and hypoxemia 

Surfactant provides multiple useful properties in addition to reducing surface tension, thus increasing lung compliance, providing alveolar stability, and decreasing opening pressure. In addition, surfactant enhances alveolar fluid clearance, decreases precapillary tone, and helps protect the epithelial cell surface. Surfactant is constantly being formed, stored, secreted, and recycled.

Surfactant production is accelerated in the following:

  • infants of diabetic mothers (IDMs) of classes D, F, and R
  • infants of heroin-addicted mothers
  • premature rupture of membranes of greater than 48 hours' duration
  • infants of mothers with hypertension
  • infants subjected to maternal infection
  • infants suffering from placental insufficiency
  • infants affected by administration of corticosteroids
  • infants affected by abruption placentae

Conditions that interfere with surfactant metabolism include:

  • acidemia
  • hypoxemia
  • shock
  • overinflation or underinflation
  • pulmonary edema
  • mechanical ventilation
  • hypercapnia

Surfactant production is delayed in infants with the following conditions:

  • IDMs classes A, B, and C
  • erythroblastosis fetalis
  • infants who are the smaller of twins

31.

A large ventricular septal defect (VSD) in a neonate results in which of the following?

  • Left-to-right shunting

  • Right-to-left shunting

  • Decreased pulmonary circulation

  • A harsh diastolic murmur heard over the lower left sternal border

Correct answer: Left-to-right shunting 

VSDs are the most common congenital heart defect. At 2 per 1,000 live births, VSDs are the most common of all CHDs, accounting for 37% of all congenital heart disease. 

A large VSD allows significant left-to-right shunting; pulmonary vascular resistance (PVR) is less than systemic vascular resistance (SVR), causing a left-to-right shunt. Highly oxygenated blood returning from the lungs is shunted across the defect and back to the lungs. This pulmonary overcirculation results in CHF, pulmonary edema, respiratory distress, and failure to thrive. A pansystolic murmur can be heard over the left sternal border.

32.

When is the treatment of a neonatal urinary tract infection (UTI) indicated?

  • When an organism is cultured from the urine

  • When pyuria is present

  • When the infant is symptomatic

  • When a complete blood count (CBC) reveals leukocytosis

Correct answer: When an organism is cultured from the urine 

For a neonate with suspected UTI, treatment is indicated when an organism is cultured from the urine (the diagnosis is based on an organism culture from the urine). The most advantageous method of obtaining urine for culture is suprapubic aspiration of the bladder or catheterization. Treatment involves antibiotic therapy for 10 to 14 days, with a follow-up urine culture three days after therapy is discontinued.

Pyuria, or white blood cells in urine, can be observed in neonates normally. Thus, this finding alone does not warrant treatment for UTI. If an infant is symptomatic, a urine sample, blood cultures, and a CBC should be performed and evaluated prior to the initiation of treatment. A CBC that reveals leukocytosis (increased white blood cells) simply means the infant is likely fighting an infection, not necessarily a UTI, and warrants further testing.

33.

A neonate born at 29 weeks is receiving treatment via oxygen hood with a 50% FiO2. The neonatologist suspects the patient has worsening respiratory distress syndrome (RDS). The following blood gas results were obtained:  

  • PaCO2 = 38 mm Hg
  • pH = 7.36
  • HCO3 = 25 mEq/L
  • PaO2 = 46 
  • Base excess = 0

Based on these results, which of the following interventions is recommended?

  • Initiate a trial of nasal CPAP at 5-8 cm H2O

  • Increase oxygen hood concentration to 100%

  • Intubate and initiate mechanical ventilation with PEEP

  • Obtain a chest x-ray for evidence of air leaks (pneumothorax) 

Correct answer: Initiate a trial of nasal CPAP at 5-8 cm H2O

The pH of 7.36 (7.35-7.45) and PaCO2 of 38 mm Hg (35 to 45 mm Hg) are both within normal ranges. Therefore, in this scenario, an initial trial of nasal CPAP (nCPAP) should be attempted before intubation and mechanical ventilation due to its much less invasive nature. The goal is to try to avoid mechanical intubation if at all possible. 

If the infant does not improve, mechanical ventilation will be necessary. 

34.

Which nerves are affected by Klumpke's palsy, a type of brachial nerve paralysis in newborns that results from a difficult delivery?

  • Cervical nerve VII (C7) to thoracic nerve I (T1)

  • Cervical nerve IV (C4) to cervical nerve VIII (C8)

  • Thoracic nerve II (T2) to thoracic nerve IV (T4)

  • Thoracic nerve I (T1) to thoracic nerve III (T3)

Correct answer: Cervical nerve VII (C7) to thoracic nerve I (T1)

Klumpke's palsy, a type of plexus injury that results from lateral traction on the shoulder (as with vertex deliveries) or the head (as with breech deliveries), is rare for newborns. It involves only the distal upper extremity (lower arm and hand), whereas the muscles in the proximal extremity are normal. 

The lower part of the plexus—C7 to T1—is involved. 

35.

Tachypnea is the earliest sign of respiratory disease in a neonate. It is defined by which of the following rates?

  • 60 breaths/min or greater after the first hour from birth

  • 70 breaths/min or greater after the first hour from birth

  • 50 breaths/min or greater after the first hour from birth

  • 80 breaths/min or greater after the first hour from birth

Correct answer: 60 breaths/min or greater after the first hour from birth

A normal respiratory rate in a neonate is 30 to 60 breaths/minute. Tachypnea is a rate of 60 breaths/min or greater after the first hour post-birth and is the earliest sign of respiratory disease. 

As a compensatory mechanism, tachypnea attempts to maintain alveolar ventilation and gaseous exchange. However, it increases oxygen demand, energy output, and the "work" of breathing.

36.

Neonatal apnea in the presence of cyanosis and/or bradycardia is commonly defined as the cessation of breathing for how long?

  • 15 seconds

  • 20 seconds

  • 10 seconds

  • 30 seconds

Correct answer: 15 seconds

Apnea is the cessation of breathing for 20 seconds or longer or for 15 seconds with cyanosis and/or bradycardia in neonates.

37.

Which of the following items is NOT part of the criteria for systemic inflammatory response syndrome (SIRS) in neonates? 

  • Mean arterial pressure (MAP) of <60 mm Hg

  • Hypothermia (<98.6 °F/36 °C) or hyperthermia (>101.3 °F/38.5 °C)

  • Average heart rate >2 standard deviations above normal for age 

  • Elevated leukocyte count

Correct answer: Mean arterial pressure (MAP) of <60 mm Hg

Neonatal SIRS is considered a state of physiologic dysregulation that is associated with deviations in laboratory values and vital signs, and despite scientific advances, remains poorly understood. SIRS is generally presumed to be caused by infection, though it has many more noninfectious etiologies that produce symptoms mimicking sepsis. Prolonged treatment of presumed occult infection with negative cultures may cloud the timely identification and treatment of the causes of SIRS. 

A neonate must meet two of the following criteria, one of which must be an abnormal temperature or leukocyte count (elevated or depressed). Hypothermia or hyperthermia, tachycardia or bradycardia, tachypnea (increased respiratory rate), and proved or suspected sepsis are all criteria for a diagnosis of SIRS.

Hypotension is not included in the SIRS criteria. 

38.

The predominant manifestation of gonorrhea in newborns is conjunctivitis, which generally manifests within how many days post birth?

  • 2 to 5

  • 1 to 2

  • 5 to 7

  • 7 to 10

Correct answer: 2 to 5

Conjunctivitis in a neonate with gonorrhea usually begins 2 to 5 days after birth. Eye prophylaxis (e.g., erythromycin, silver nitrate, or tetracycline) minimizes but does not guarantee freedom from infection. A gram stain of the purulent drainage from the eye revealing gram-negative intracellular diplococci is diagnostic. 

For penicillin-sensitive N. gonorrhoeae, treatment generally involves IV or IM penicillin G for 10 days. For penicillin-resistant N. gonorrhoeae, give ceftriaxone (25 to 50 mg/kg) IV or IM in a single daily dose, along with azithromycin for 5 days. 

39.

Which of the following congenital chest masses generally presents in infants as hyperinflation of one or more lung lobes?

  • Congenital lobar emphysema

  • Congenital pulmonary airway malformations (CPAMs)

  • Pulmonary sequestrations

  • Bronchogenic cysts

Correct answer: Congenital lobar emphysema 

Congenital lobar emphysema typically manifests in neonates as hyperinflation of one or more lung lobes. This condition is not generally discovered in utero. 

Hyperinflation of a pulmonary lobe develops after birth because inspired air enters the affected lobe but cannot exit; this is because the positive pressure of expiration collapses the malacic airway. 

Congenital lobar emphysema most commonly affects the upper lobes. Infants may present with mild or moderate respiratory distress, and a mediastinal shift may develop with progressive trapped air. Decreased breath sounds are auscultated on the involved side. Causes of this condition include bronchomalacia of cartilaginous rings or external compression of a segmental bronchus by a large pulmonary artery that predisposes to air trapping. Treatment involves surgical resection of the mass.

40.

When an infant has suspected syphilis, which of the following tests is mandatory for diagnosis?

  • VDRL (venereal disease research laboratory) tests on CSF

  • Long bone x-ray examination

  • RPR (rapid plasma reagin) test

  • FTA-ABS (fluorescent treponemal antibody absorption) IgM test

Correct answer: VDRL (venereal disease research laboratory) tests on CSF

VDRL tests on CSF are mandatory for all infants with suspected congenital syphilis. An infant exposed to syphilis may be asymptomatic initially or show involvement in virtually all organ systems. Clinical manifestations include hepatitis, pneumonitis, bone marrow failure, myocarditis, meningitis, nephrotic syndrome, rhinitis, a rash of the palms and soles, and pseudoparalysis of an extremity. 

RPR tests are useful for screening, but not mandatory in diagnosis. Long bone x-ray examination showing metaphysitis or periostitis may help in diagnosis but is not mandatory. An FTA-ABS IgM test is unreliable in diagnosis, as false-positive results may occur.

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