AACN CCRN (Neonatal) Exam Questions

Correct answer: Regulation of oxidative metabolism 

Thyroid hormone contributes to fetal growth by regulation of oxidative metabolism, a chemical process in which oxygen is used to create energy from carbohydrates.

Cortisol plays a key regulatory role in inflammatory responses. Glucagon, insulin, and cortisol are major components of glucose homeostasis. Gastrointestinal hormones (e.g., enteroglucagon, gastrin, motilin, and neurotensin) have a critical role in mediating gut development in the neonate.

Correct answer: Omphalocele

Omphalocele, an abdominal wall defect, is characterized by the persistent herniation of the abdominal viscera through the umbilical ring, and the herniated contents are covered by the normal components of the umbilical cord (the peritoneum, Wharton's jelly, and amnion). Its development is thought to be the result of failed embryonic enfolding as early as weeks 4-7 of gestation or from failed closure of the exocoelomic space, which is usually completed by week 12 of gestation. Fifty percent of infants presenting with omphalocele will have an underlying chromosomal abnormality, most often trisomies 12 and 18 as well as trisomy 21. 

Gastroschisis is typically not associated with major congenital anomalies, although 5% to 10% of affected infants have concomitant intestinal atresia. Malrotation and midgut volvulus can occur concurrently.

Correct answer: Side-lying

Positioning an infant with gastroschisis on their side prevents "kinking" of the mesentery at the fascial level and prevents intestinal ischemia or cyanotic bowel. 

Supine, prone, or elevated head of bed positions do not aid in bowel perfusion and are not recommended for this diagnosis.

Correct answer: Intermittent mandatory ventilation (IMV)

With IMV, "breaths" are delivered at a predetermined rate, regardless of where the patient is in the respiratory cycle. The ventilator continues to deliver fresh gas, which allows spontaneous respiration as well (at the infant's tidal volume in between the breaths delivered by the ventilator at a set tidal volume). It is possible to stack a ventilator breath on top of a spontaneous breath during either inspiration or expiration. This may lead to air trapping, air leaks, CNS dysfunction, and irregularity of blood pressure and cerebral blood flow. 

Assist/control (A/C) and control ventilation (CV) are both volume control modes. A/C allows the infant to trigger the ventilator, but the ventilator will deliver the set tidal volume. CV does not allow the infant to trigger the ventilator; it delivers a set rate and volume only.  

Correct answer: Carcinoma

The two most frequently encountered neonatal tumors are teratoma (particularly sacrococcygeal but also cervical) and neuroblastoma. Soft tissue sarcomas, infantile myofibromatosis, renal tumors, hepatoblastoma, and central nervous system tumors follow in frequency. 

Malignant tumors (carcinomas) rarely arise in newborns. Carcinomas, which typically appear in adulthood, are virtually nonexistent in neonates.

Correct answer: Morphine

Intravenous (IV) opioids remain the most common class of analgesics administered in the NICU; morphine is the most commonly used opioid in neonatal settings but may cause hypotension in dehydrated patients or when used at higher doses. It provides more sedation than fentanyl. Morphine should be used with caution in preterm infants between 23 and 26 weeks of gestation and those with preexisting hypotension.

Fentanyl is the preferred drug in many NICUs because of its cardiovascular stability and ability to decrease pulmonary vascular resistance. It can, however, lead to chest wall rigidity and decreased lung compliance if administered too quickly. And, because it is 80 to 100 times more potent than morphine, it must be administered with extreme caution. 

Sufentanil is 10 times more potent than fentanyl and significantly more expensive. It is shorter acting and can have even greater effects on lung and chest wall compliance. 

Meperidine is not recommended for preterm or term neonates. Its active metabolite (normeperidine) accumulates in tissues and causes CNS stimulation, in addition to lowering the seizure threshold level. 

Correct answer: Persistent pulmonary hypertension of the newborn (PPHN)

PPHN manifests as severe pulmonary hypertension with pulmonary artery pressure elevation to levels equal to systemic pressure or higher and large right-to-left shunts through the foramen ovale and ductus arteriosus. This condition manifests early in life, with a majority (77%) of cases being diagnosed in the first 24 hours after birth. 

Initial clinical presentation is usually a late-preterm, term, or post-term infant with worsening cyanosis within the first 24 hours. Tachypnea is common and, when accompanied by retractions, is indicative of decreased pulmonary compliance.

Pneumonia results from bacterial, viral, mycoplasmal, or fungal infections acquired perinatally or postnatally and is due to immaturity of the immune system, colonization of the mother's genital and vaginal tracts with pathogens, amnionitis, prolonged rupture of membranes, and nosocomial infections acquired in the NICU. TTN generally occurs in term or late-preterm infants with a history of cesarean section or precipitous delivery. Lack of compression of the fetal chest during delivery results in retained fetal interstitial lung fluid.

Correct answer: Placing an infant on a scale that is not prewarmed

Placing an infant on a scale that is not prewarmed is an example of conductive heat loss, which is the transfer of body heat to a cooler solid object on contact.

The other choices are all examples of heat loss through convection, which is the loss of heat to surrounding air at the skin surface. Convection depends on the air's velocity and temperature. Convective heat loss can be minimized by warming the delivery and infant care rooms (75 degrees to 79 degrees F), placing the isolette and resuscitation tables away from doors or drafts, and covering each infant's head with a knitted cap.

Correct answer: Total serum bilirubin (TSB) level

TSB remains the recommended method on which to make clinical decisions. TcB measurements have been shown to be valid; however, regular monitoring for quality assurance by comparison with TSB measurements is necessary.

Fractionated bilirubin should be obtained if an infant's jaundice is severe, prolonged, or associated with light-colored stools. Serum albumin levels may be helpful at higher bilirubin concentrations, and the bilirubin/albumin ratio is considered as an additional factor in deciding when to start phototherapy or perform an exchange transfusion.

Correct answer: 5

The NSCS scoring system has been extensively used for both premature and full-term infants, with established validity and reliability. It can be integrated into skincare protocols to identify infants with excessive dryness, erythema, or skin breakdown. The categories are as follows:

• dryness: 1 = normal with no sign of dry skin, 2 = dry skin with visible scaling, 3 = very dry skin with cracking/fissures
• erythema: 1 = no evidence of erythema, 2 = visible erythema on <50% body surface, 3 = visible erythema on >50% body surface
• breakdown: 1 = none evident, 2 = small localized areas, 3 = extensive 

A perfect score is 3; the worst score is 9. In this scenario, the infant would have a score of 5.

Correct answer: Empathetic communication

Although all these choices are important in creating an ethical environment in the NICU, empathetic communication is the most critical; clinicians should be compassionate not only in their listening but also in their communication with parents. 

Caregivers must be given information in a way that they can understand, interpret, and absorb, and imparting this information must be done so in a caring and compassionate manner.

Correct answer: Fetal hemoglobin

Oxygen binding with hemoglobin increases as the partial pressure of oxygen increases. The oxygen-dissociation curve is a measure of the affinity that hemoglobin has for oxygen. Fetal hemoglobin increases the affinity of hemoglobin for oxygen, shifting the curve to the left; the affinity of fetal hemoglobin for oxygen is higher than adult hemoglobin. Approximately 70% of hemoglobin in term infants, and more in preterm infants, consists of fetal hemoglobin. 

Fevers, acidemia, and hypercapnia decrease the affinity of hemoglobin for oxygen, thus shifting the curve to the right. 

Correct answer: Closely monitor for any increase in intensity or quality

Heart murmurs are a common finding in neonates and can be normal (affecting up to 10% of the population). When the patent ductus arteriosus (PDA) closes, it causes a murmur; therefore, all newborns who go through the normal cardiac transition will have a transient murmur as the ductus arteriosus closes, generally within the first 48 hours following delivery. Although cardiac murmurs in the neonatal period do not necessarily indicate heart disease, they must be carefully monitored. The intensity (loudness), quality (harsh, vibratory), location, and radiation of the murmur can all help determine a diagnosis and should be closely monitored. Also, the absence of a murmur does not indicate the absence of significant cardiac disease. 

Physician notification would not be necessary at this point, as this finding is integral to the normal transitional process. If the murmur worsens or persists, or the neonate develops symptoms, the physician should be notified. The presence of a congenital heart defect would likely be accompanied by other clinical signs and symptoms. A nurse should never order any diagnostic testing without approval by a physician.

Correct answer: Gastroesophageal reflux (GER)

GER is considered a common physiologic condition that affects most people. In preterm infants, it is more frequent because of lower esophageal sphincter relaxation. This condition may spontaneously resolve within 12-18 months. It becomes problematic if an infant develops failure to thrive, apnea, aspiration, or stridor. 

Treatment involves using a thickening agent with feedings, feeding smaller amounts more frequently, increasing the head of the crib by 45% to 60% after feedings, and keeping the infant still during feedings.

Correct answer: The infant is preterm

The scarf sign on a physical exam is a part of the Ballard system, which incorporates physical maturity and neuromuscular maturity on an equal basis and includes assessments for extremely premature infants. The Ballard is performed shortly after birth to help determine developmental age and muscle tone in neonates. 

When the arm is pulled laterally across the chest, the elbow will cross midline without resistance for a hypotonic infant, indicating prematurity. In a full-term infant with normal tone, the elbow will not reach the midline. 

Correct answer: Incomplete closure of the eye on the involved side 

Facial palsy is a condition in which the muscles on one side of the face become weak or paralyzed, causing it to droop or become stiff on the affected side. It is caused by trauma to the seventh cranial nerve, also called the “facial nerve.” Facial palsy may be part of intrinsic brainstem disease, prenatal compression, trauma, malformation of the nerve, or other conditions such as myotonic dystrophy. It appears on the left side in 75% of cases. 

Features include a widened palpebral fissure, a flat nasolabial fold, and decreased facial expression. When crying, the infant's mouth is drawn to the unaffected side, not the affected side, due to the weakened or paralyzed nerve's inability to move. The paralysis may affect oral sucking strength, and parents should be taught to expect some drooling of milk from the corner of the mouth during breast or bottle feedings. Often, infants require the use of artificial tears due to their inability to close the eye completely on the involved side. 

A majority of infants completely recover within three weeks, but some infants continue to have deficits months later.

Correct answer: Anticipatory guidance for parents

The NBAS, also known as the Brazelton Neonatal Assessment Scale (BNAS), is an assessment tool used by healthcare providers to observe and score the interactive behavior of newborns. With this tool, providers can assess an infant's individual abilities for social relationships based on their best performance. Six categories are utilized in evaluating an infant's performance: habituation, orientation to auditory and visual stimuli, motor maturity, state changes, self-quieting ability, and social behaviors.

Clinical application of the NBAS includes an evaluation of infant capabilities after illness, prematurity, or maternal medication. The most important application is in anticipatory guidance for parents. Demonstrating the exam for the parents helps them to become familiar with their infant's individual patterns of behavior, temperament, and states, thereby greatly influencing bonding and attachment.

Correct answer: Hyperoxia-hyperventilation test 

The hyperoxia-hyperventilation test is the most definitive diagnostic assessment for PPHN. If PO₂ is below 50 mm Hg pre-hyperventilation and rises above 100 mm Hg, the diagnosis is PPHN. 

The other tests will help give a clearer clinical picture but are not diagnostic of PPHN. 

Correct answer: High fibrinogen level

Variable diagnostic studies are performed for delineation of the underlying disease process:

• The platelet count is low.
• PT and PTT are prolonged in 50% to 60% of patients.
• A peripheral blood smear identifies microangiopathic hemolytic anemia, abnormalities of RBC shape, cell fragmentation, and decreased number of platelets.
• The fibrinogen level is low.
• Fibrinogen degradation products are significantly increased but are not specific markers for DIC.
• D-dimer is a sensitive marker for endogenous thrombin/plasmin production and can detect much milder forms of DIC.
• Additional factors and levels may be evaluated (factors VIII and II are decreased, as well as protein C, protein S, and antithrombin III).

Correct answer: Seizures 

Neonatal seizures should be viewed not as a specific disease entity but as a symptom of neurologic dysfunction. They are among the most frequent clinical signs (and occasionally the only sign) of CNS dysfunction, and they occur more frequently during the neonatal period than at any other time of life. The occurrence of neonatal seizures should prompt an immediate search for the underlying etiology, as well as an overall assessment of associated medical disorders.