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Quiz Session - Attempts With Random Questions

AACN CCRN (Neonatal) Exam Questions

Page 3 of 25

41.

Phenytoin (Dilantin) is often used to control neonatal seizures that are not controlled by phenobarbital alone. What is the loading dose for phenytoin in these cases?

  • 15-20 mg/kg intravenous infusion over at least 30 minutes

  • 0.05-0.1 mg/kg intravenous slow push over 10 minutes

  • 3-4 mg/kg/24 hours in two divided doses

  • 20 mg/kg intravenous push given slowly over 10 to 15 minutes

Correct answer: 15-20 mg/kg intravenous infusion over at least 30 minutes 

The loading dose of phenytoin for infants is 15-20 mg/kg IV over at least 30 minutes (no more rapidly than 0.5 mg/kg/min). Flush with normal saline before and after giving the treatment. 

The dose for lorazepam is 0.05-0.1 mg/kg IV slow push over 10 minutes, not phenytoin. The loading dose for phenobarbital is 20 mg/kg IV push given slowly over 10 to 15 minutes, and the maintenance dose of phenobarbital is 3-4 mg/kg/24 hours divided into two doses.

42.

In an infant with congestive heart failure (CHF), medical management often includes digoxin (Lanoxin) therapy. A nurse should expect which of the following effects as a result of this medication?

  • Increased cardiac output

  • Increased renal perfusion

  • Increased heart rate

  • Increased blood pressure

Correct answer: Increased cardiac output 

Medical management of CHF helps the heart to compensate with increased cardiac output. Maintaining the balance of pulmonary and systemic blood flow is the primary treatment approach to CHF in infants. Digoxin acts primarily as a positive inotropic agent, improving contractility and cardiac output and lowering the heart rate in infants with tachycardia. 

Renal perfusion may improve as blood flow improves with increased cardiac output, but this is not the primary treatment goal.

43.

The mother of an infant expresses anxiety regarding values on the infant's monitor and asks the NICU nurse for clarification. What is the MOST appropriate response?

  • “Which numbers on the monitor concern you?”

  • "The numbers tell us when the infant is experiencing problems."

  • "What don't you understand about the monitor?"

  • "The numbers help us determine the best treatment for your baby."

Correct answer: “Which numbers on the monitor concern you?” 

The most important element in communicating with families is listening to them and not making assumptions. Parents are often confused by the amount of information given by multiple subspecialists caring for their infant, and they cannot make sense of it all. Often, in their urgency to communicate information, healthcare providers forget to listen to the grief, fears, and concerns of parents.

In this scenario, the mother is asking about what numbers on the monitor mean. The nurse should ask which specific values are concerning to get a better idea of what exactly she wants to know and how to best formulate an answer.

44.

When an infant is suspected of being exposed to drugs in utero, the FIRST neonatal abstinence syndrome (NAS) score should be performed how soon after birth?

  • 2 to 4 hours

  • 1 to 2 hours

  • 60 minutes

  • 30 minutes

Correct answer: 2 to 4 hours

To determine whether an infant will need pharmacologic treatment for withdrawal, thorough assessments of symptoms are vital. The Finnegan abstinence scoring sheet assesses the onset, progression, and resolution of NAS. The score is also used to monitor the infant's clinical response to pharmacotherapy for the control of NAS symptoms. The 21-item Finnegan neonatal abstinence score includes the following:

  • score of 1 for tremors
  • score of 1 for the Moro reflex
  • score of 1 for stooling
  • score of 1 for crying
  • score of 1 for regurgitation/projectile vomiting

The first score should be recorded approximately 2 to 4 hours after the neonate's admission (birth), and infants are assessed every four hours afterward. Infants born to mothers requiring or taking an opiate with a short half-life (hydrocodone) may be discharged after 72 hours if they have no signs of withdrawal. Infants exposed to maternal opiates with a long half-life (methadone, buprenorphine) should be monitored (inpatient) for 5 to 7 days. 

45.

Which of the following infants is MOST at risk of abuse and neglect following hospital discharge? 

  • An infant requiring inpatient pharmacologic treatment of neonatal abstinence syndrome (NAS) from drug exposure in utero

  • A very-low-birth-weight (VLBW) preterm infant requiring extensive medical treatment at home 

  • An infant with sensorineural hearing loss who is difficult to console 

  • An infant with a mother experiencing postpartum blues and post-traumatic stress related to a difficult delivery 

Correct answer: An infant requiring inpatient pharmacologic treatment of neonatal abstinence syndrome (NAS) from drug exposure in utero

An infant who requires inpatient intervention and treatment for withdrawal from exposure to one or more drugs in utero is at the highest risk for abuse and/or neglect at home. The possibility of long-term neurobehavioral effects in this infant can lead to difficulty consoling, and an infant who cannot be consoled (or who caregivers struggle to console) is at an increased risk of abuse and/or neglect. 

Some symptoms of drug withdrawal may persist for 2 to 6 months, and health care professionals should discuss this possibility with the family caregivers well before discharge so they can begin building the skills they will need with supportive staff before the infant is discharged. Prolonged follow-up care is important to detect short- and long-term problems. The focus should be on neurodevelopmental, nutritional, psychobehavioral, and social adjustments. Family support should be continually assessed. 

46.

When an infant is receiving end-of-life care, all the following interventions are discontinued, EXCEPT: 

  • Intravenous access

  • Measurement of vital signs

  • Artificial feedings

  • Monitors and machines

Correct answer: Intravenous access 

When the decision is made to end or not begin aggressive medical intervention, an infant receives end-of-life care, which is also referred to as palliative or comfort care. During this time, all invasive procedures—including measurement of vital signs, monitors, machines, and artificial feeding—are discontinued. The infant, who has been cleaned and wrapped in a warm blanket, is held by their family. 

Intravenous access may remain in place for the administration of pain medications or sedatives. Medications are given in doses sufficient to provide comfort, relieve pain, and ensure that the infant does not suffer at the end of life.

47.

In most cases of respiratory distress syndrome (RDS), which of the following factors is present?

  • Prematurity

  • Pulmonary hyperperfusion

  • Increased lung compliance

  • Persistent pulmonary hypertension of the newborn

Correct answer: Prematurity

Infants born with immature lungs are at risk of respiratory distress. Prematurity is the most common factor in the occurrence of RDS. Its incidence is inversely proportional to gestational age and occurs most frequently in infants weighing below 1200 g and born before 30 weeks of gestation. RDS affects male infants twice as frequently as female infants, with the primary cause being a deficiency in surfactant.

Pulmonary hypoperfusion and low lung compliance (i.e., little change in volume is achieved with a relatively great application of pressure, thereby contributing to increased work of breathing), are present in infants with RDS. Pulmonary hypertension complicates approximately 25% of these cases (not a majority).

48.

A nurse is educating an infant's family about the significant complications of a ventriculoperitoneal (VP) shunt. All the following manifestations would be important for the family to report immediately to the nursing staff, EXCEPT: 

  • An increase in temperature to 99 degrees F (37.2 degrees C)

  • Swelling, redness, or drainage along the pathway of the shunt tube

  • Lethargy or irritability

  • Bulging soft spot when the baby is sitting quietly

Correct answer: An increase in temperature to 99 degrees F (37.2 degrees C)

A temperature of 101 degrees F (38.3 degrees C) or higher should be immediately reported to nursing staff. In addition, parents should be educated that swelling, redness, or drainage along the shunt tubing pathway, lethargy or irritability, and bulging soft spot when the baby is quietly sitting are also reportable symptoms that could indicate an infection or a shunt malfunction.

49.

Informed consent encompasses four elements. Which of the following is NOT an element of informed consent?

  • Autonomy

  • Disclosure

  • Comprehension

  • Competence

Correct answer: Autonomy

Informed consent encompasses the following elements: 

  • disclosure
  • comprehension
  • voluntariness
  • competence

The issue of valid informed consent is continually raised in the NICU environment. All relevant information must be disclosed. Voluntary consent—which is free of coercion, by competent persons—must be obtained. 

Information given to parents may be poorly understood for a multitude of reasons, including the emotional state of the parent or the complexity of the medical information given. Information must be provided in a way that promotes the parent's or surrogate decision maker's understanding of the infant's current medical status, the proposed interventions, all possible risks and benefits, and the reasonable alternatives to the proposed treatment. 

The intent of the informed consent process is based on the principle of autonomy, as it provides an individual with the necessary information to compare options and make a reasoned choice. Autonomy is not an element but rather a principle upon which informed consent is based.

50.

All the following are summarized clinical point-of-care resources, EXCEPT: 

  • Evidence Updates from the British Medical Journal (BMJ)

  • FirstConsult

  • DynaMed

  • UpToDate

Correct answer: Evidence Updates from the British Medical Journal (BMJ)

Clinicians must keep up with current literature to maintain clinical competence and solve specific clinical problems. Clinicians seek information "just in time" (for seeing specific patients), and "just in case" (to keep up with information pertinent to a particular specialty, also called surveillance of the literature). The latter form of learning is best achieved by using technology tools to survey current original literature such as Evidence Updates from the BMJ, auto-alerts, and RSS feeds in PubMed or online databases and journals. 

UpToDate, DynaMed, and FirstConsult are summary-based clinical point-of-care resources that assist clinicians.

51.

In a newborn, all the following values suggest prerenal failure, EXCEPT: 

  • Urine sodium (UNa) greater than 30 to 40 mEq/L

  • Urine osmolality (UOsm) greater than 350 mOsm/L

  • Urine sodium (UNa) less than 20 to 30 mEq/L

  • Fractional excretion of sodium (FENa) of less than 3%

Correct answer: Urine sodium (UNa) greater than 30 to 40 mEq/L

Urine osmolality (UOsm), urine sodium concentration (UNa), and fractional excretion of sodium (FENa) have been proposed tools to help differentiate between prerenal failure and acute tubular necrosis (ATN). 

Values suggestive of prerenal failure include:

  • UOsm > 350 mOsm/L
  • UNa < 20 to 30 mEq/L
  • FENa < 3%

Alternatively, values suggestive of ATN are: 

  • UOsm < 350 mOsm/L
  • UNa > 30 to 40 mEq/L
  • FENa > 4% to 5%

52.

A preterm infant is receiving caffeine for apnea. The nurse notes a heart rate of 195 beats/minute just prior to administering the morning dose of medication. The infant is resting quietly in the incubator. 

What should the nurse do?

  • Withhold the dose and notify the physician

  • Wait 20-30 minutes before administering the dose

  • Administer the dose

  • Recheck the infant's heart rate and administer the dose if it is below 180 beats/minute

Correct answer: Withhold the dose and notify the physician

Caffeine citrate is considered the drug of choice for apnea of prematurity. However, tachycardia is a side effect of this medication. The dose should be withheld if the infant's heart rate is >180 beats/minute, and the physician should be notified immediately of the finding. The infant should have a serum blood level drawn and evaluated for caffeine toxicity. 

The nurse should monitor the infant closely for other signs of adverse effects of the medication, including dysrhythmias, diuresis, jitteriness, seizure activity, and vomiting.

53.

Type I pneumocytes within the lungs are responsible for which process?

  • Providing gas exchange in the alveoli

  • Producing surfactant

  • Producing macrocytes

  • Producing phagocytes

Correct answer: Gas exchange in the alveoli

In the healing and repair process, type II alveolar cells (which are responsible for producing surfactant) multiply and differentiate into type I pneumocytes, which provide alveolar epithelium and are responsible for the gas (oxygen and carbon dioxide) exchange that takes place in the alveoli. 

Type I pneumocytes cannot replicate when an insult occurs; therefore, type II pneumocytes will replicate to replace damaged type 1 pneumocytes.

54.

Which of the following is NOT an advantage of peritoneal dialysis (PD) for neonates? 

  • Solute and fluid abnormalities can be rapidly corrected 

  • It is relatively easy to perform

  • It does not require anticoagulation 

  • It is well tolerated by hemodynamically unstable neonates

Correct answer: Solute and fluid abnormalities can be rapidly corrected 

In hemodialysis (HD), blood is removed from a neonate via a central hemodialysis catheter and flows across an appropriately sized artificial filter (dialyzer) while dialysate of the preferred composition travels countercurrent across the filter. The advantage of hemodialysis (not PD) is that solute and fluid abnormalities can be rapidly corrected. 

The other choices are advantages of PD; however, in this procedure, the correction of solute and fluid abnormalities occurs at a slower rate than by HD or CRRT (continuous renal replacement therapy), and fluid removal cannot be precisely controlled due to variation in individual peritoneal membrane-transport characteristics. 

55.

Which of the following statements about meconium aspiration syndrome (MAS) in neonates is ACCURATE?

  • Meconium promotes an inflammatory response known as chemical pneumonitis.

  • Meconium aspiration will always require mechanical ventilation.

  • Only term or post-term infants are affected by MAS.

  • Routine intrapartum tracheal suctioning will prevent MAS.

Correct answer: Meconium promotes an inflammatory response known as chemical pneumonitis.

For meconium to enter the amniotic fluid, a hypoxic event must occur in utero, stimulating fetal intestinal peristalsis and relaxation of the anal sphincter. This results in the expelling of meconium into the amniotic fluid and, in severe cases, gasping in utero that leads to meconium aspiration. This condition occurs more frequently in term or post-term infants following a hypoxic event in utero, although it can affect infants of any gestational age. Respirations after birth draw meconium into the airway, causing obstruction, atelectasis, air trapping, and pneumothorax. Meconium can also cause chemical pneumonitis and the inactivation of surfactant, further impairing gas exchange. MAS is a common reason for lung disease in newborns.

Mechanical ventilation is not always warranted; some infants respond to suctioning and CPAP alone, but others require full ventilator support. Recent studies have shown no significant difference in the incidence of MAS with routine intrapartum tracheal suctioning vs. no suctioning. Routine tracheal suctioning is no longer recommended for nonvigorous or depressed infants (e.g., nonvigorous infants with depressed tone and respirations and/or a heart rate below 100 beats/min). While this condition occurs more often in term or post-term infants when a hypoxic episode is experienced in utero, it affects approximately 8% to 29% of all newborns delivered. 

56.

Initially, erythropoietin is produced in the fetal liver. By the last trimester, its production relocates to which organ?

  • Kidneys

  • Brain

  • Spleen

  • Small intestines

Correct answer: Kidneys

Erythropoietin is initially produced in the fetal liver, By the last trimester, as well as after birth, the kidneys produce the majority of erythropoietin.

57.

Which of the following causes of blood loss in a neonate can relate directly to hemorrhage before birth?

  • Twin-to-twin transfusion

  • Placental hematoma or malformation

  • Rupture of a normal umbilical cord

  • Iatrogenic hemorrhage from blood sampling

Correct answer: Twin-to-twin transfusion 

Twin-to-twin transfusion is a cause of occult blood loss during pregnancy (before birth) and affects 15% to 30% of all monochorionic twins with abnormalities of placental blood vessels.

Placental hematoma or malformation, as well as umbilical cord rupture, can often cause neonatal hemorrhage during birth. 

Iatrogenic hemorrhage from blood sampling is a cause of external neonatal hemorrhage after delivery.

58.

A neonate born prematurely via cesarean section at 28 weeks of gestation and weighing just over 1,000 g develops respiratory distress syndrome (RDS) soon after birth. The infant exhibits increasing respiratory difficulty related to progressive atelectasis in the first 6 hours after birth, leading to hypoxia and hypoventilation, and requires respiratory support and surfactant replacement therapy. 

In this scenario, what is generally the FIRST sign of respiratory distress? 

  • Tachypnea 

  • Cyanosis

  • Subcostal retractions 

  • Audible expiratory grunting 

Correct answer: Tachypnea

Tachypnea (>60 breaths per minute) is usually the first sign of respiratory distress. The patient's color is initially maintained; as the disease progresses, cyanosis will become evident due to increasing hypoxemia. Audible expiratory grunting follows during the first several hours after birth. It is caused by the forcing of air past a partially closed glottis and is used by the infant to maintain positive end-expiratory pressure (PEEP) at the alveolar level in an attempt to prevent alveolar collapse. It is more pronounced in patients with severe disease. 

The infant's chest wall is highly compliant and with RDS, it produces greater negative pressure by caving inward with a moderate decrease in pleural pressure. This results in retractions. Retractions are seen at the sternum and subcostal and intercostal spaces of the infant's chest. Nasal flaring is also present, and paradoxical seesaw respirations can occur.

59.

Of the following factors, which is LEAST LIKELY to influence the development of trust versus mistrust for an infant?

  • The nature of the kinesthetic interactions between infant and caregiver.

  • An infant's ability to communicate needs to the environment.

  • The reliability of the responding environment.

  • The contingency of the responding environment.

Correct answer: The nature of the kinesthetic interactions between infant and caregiver.

It is during infancy that trust versus mistrust in self and the environment is solidified. Three major factors influence the development of trust versus mistrust:

  1. the infant's ability to communicate needs to their environment,
  2. the reliability of the responding environment, and
  3. the contingency of the responding environment.

When an infant cries to communicate a need, the caregiver either responds to the infant and meets the need or ignores (or delays) meeting the need. The caregiver's response determines the infant's ability to develop a trusting relationship with the caregiver or fosters suspicion and mistrust, which can lead to emotionally insecure, helpless, and isolated children and, ultimately, adults.

The amount and type of kinesthetic interaction between infants and caregivers influences how infants develop and mature; stimulus deprivation results in impairment of, or deviancy in, skill development for productive living.

60.

An infant born to a diabetic mother (IDM) is exhibiting signs of hypoglycemia secondary to hyperinsulinemia despite feeding. A nurse is initiating treatment with an infusion of IV dextrose. 

What is an appropriate INITIAL rate for this dextrose infusion? 

  • 4 to 6 mg/kg/min 

  • 1 to 3 mg/kg/min

  • 8 to 10 mg/kg/min

  • 12 to 14 mg/kg/min 

Correct answer: 4 to 6 mg/kg/min 

The most common clinical cause of hyperinsulinemia in infants is being born to a diabetic mother (IDM). Most cases of neonatal hypoglycemia can be managed with early and frequent feedings (by breastfeeding or with expressed milk, donor milk when appropriate, or formula).

If hypoglycemia persists despite feeding, or if the infant is symptomatic, correction with an IV glucose (or dextrose [D10W]) infusion is necessary. A minibolus (2 mL/kg of D10W), followed by a continuous dextrose infusion at an initial rate of 4 to 6 mg/kg/min, is indicated. 

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