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CCRN-NICU Questions & Answers
A patient who is G3P2 at 32 weeks' gestation arrives at the triage unit complaining of regular uterine contractions. Her pregnancy history includes a preterm delivery at 34 weeks. Before examining her, the nurse performs electronic fetal monitoring and obtains a complete history. The patient reports no bleeding and no rupture of membranes. She has no vaginal examinations or sexual activity for more than 24 hours. The biochemical marker useful in this situation for predicting preterm birth is: - ✔Fetal Fibronectin- Fibronectins are a family of proteins found in extracellular matrix. Fetal fibronectins are found in fetal membranes and decidua throughout the pregnancy. As the gestational sac implants and attaches to the interior of the uterus in the first half of pregnancy, fFns are normally found in cervicovaginal fluid. After 22 wks, the presence of fFns normally is no longer detected in vaginal secretions until approximately 2 weeks before the onset of delivery, term or preterm. When electronic fetal monitoring is used, the best indicator of fetal oxygenation status during labor is - ✔Moderate fetal heart rate variability- variability is the most important fetal HR characteristic. It is the most important indicator of normal fetal pH or acidosis. Moderate FHR variability reliably predicts the absence of fetal metabolic academia The biophysical profile (BPP) is currently the primary method for evaluating fetal well-being through the assessment of various activities that are controlled by the central nervous system and are sensitive to oxygenation. The five variables included in the BPP are: - ✔Feral tone, fetal breathing, fetal movement, nonstress test, and amniotic fluid An appropriate gestational age for glucose screening in women who are at low risk for developing gestational diabetes is - ✔24-28 weeks' gestation. Patients with risk factors (>35 years, body mass index
30, history of gestational diabetes, delivery of a LGA infant, polycystic ovarian syndrome, strong family hx) should receive a plasma glucose screening at their first prenatal visit followed by one at 24-28 weeks When women give birth sitting upright, which of the following indicators show lower values in cord blood? - ✔PCO What is the physiologic cause of late decelerations? - ✔Transient interruption in fetal oxygenation An intrauterine pressure catheter, placed for the monitoring of uterine pressure, amnioinfusion, and fluid sampling, is useful in the treatment of - ✔Variable decelerations- amnioinfusion is used to attempt to resolve variable fetal heart rate decelerations by correcting umbilical cord compression as a result of oligohydramnios. Must be careful to not cause polyhydramnios A patient who is at 42+5 has been pushing for 90 minutes and is near delivery. Her membranes spontaneously ruptured 3 hours ago and meconium was observed. The electronic fetal monitor demonstrates minimal fetal heart rate baseline variability. The most likely potential cause is: - ✔Fetal metabolic acidosis- moderate variability reliably predicts the abscence of fetal metabolic acidemia at the time it is observed. Absent variability --> severe hypoxia. Marked variability--> methamphetamine use and scalp stimulation
When performing a BPP, which of these fetal variables should the nurse recognize as placing the fetus at high risk and in need of either delivery or repeat BPPs no fewer than two times/week? - ✔An amniotic fluid pocket measuring 1.5cm in two planes perpendicular to each other. Oligohydramnios is defined as a single deepest pocket of <2cm, or an amniotic fluid index of <5cm Elevated maternal serum a-fetoprotein is associated with: - ✔neural tube defects- MSAFP is a protein made by the fetal liver. High levels may indicate neural tube defects or ventral abdominal wall defects, esophageal and duodenal atresia, and some renal or urinary tract anomalies. Low levels occur in some case of down syndrome What is triple marker screening? - ✔Combines the chemical markers of MSAFP, hCG, and unconjugated estriol with the mother's age. A low value is associated with trisomy 18 After a vacuum-assisted delivery, the nurse should assess the infant for: - ✔Subgaleal hemorrhage- the hemorrhage causes the veins above the skull and periosteum to rupture and bleeding occurs in the subaponeurotic space, which extends from the orbital ridges to the nape of the neck laterally to the ears. Potentially, the entire neonatal blood volume can hemorrhage into this space. Crosses the suture lines. Nurse should monitor serial head circumferences ad HCT levels and observe for signs of shock What are the fetal complications of forceps delivery? - ✔Transient facial marks, facial palsies, and fracture of facial bones or the skull A patient has chosen to receive a combined spinal-epidural for the mgmt of labor pain. The nurse should instruct the patient that this type of analgesia: - ✔Increases the risk of hypotension- hypotension can be observed in up to 100% of pregnant women after spinal anesthesia due to the production of a sympathetic vasomotor block What shunt is responsible for the mvmt of blood between the R and L atrium, and in what direction does the blood primarily flow during fetal life? - ✔Foramen ovale with R to L shunt - due to the high pulmonary vascular resistance and lower systemic vascular resistance What is the ductus arteriosus responsible for? - ✔Shunting blood from the R to L between the pulmonary artery and the aorta during fetal life What vessel(s) is/ are responsible for transporting oxygenated blood from the placenta to the fetus? - ✔Umbilical vein- oxygenated blood from the placenta is delivered to the fetus from the umbilical vein and carried to the IVC via the ductus venosus. The umbilical arteries transport deoxygenated blood from the aorta to the placenta. During resuscitation of a term newborn in the L&D department, a sat probe is placed on the infant to assess the need for supplemental O2. Which of the following describes the appropriate site for placement and an acceptable saturation during the first 10 min of life? - ✔Right hand- 3 min sat at 74% 1 min- 60-65% 2 min- 65-70% 3 min- 70-75% 4 min- 75-80% 5 min- 80-85%
✔Diaphragmatic hernia Which of the following descriptions defines a cephalohematoma? - ✔Collection of blood between the periosteum and the skull that does not cross the suture line. May enlarge during the 24 hours after birth and may take several months to resolve. After the birth of an infant through pea soup meconium who has poor muscle tone and inadequate breathing, the appropriate first step is to: - ✔Place the infant on the radiant warmer, dry, stimulate, and clear the airway A newborn is cyanotic, is grunting, and has a barrel chest and scaphoid abdomen, Upon auscultation the nurse hears bowel sounds in the L side of its chest. Breath sounds are diminished. Most likely cause? - ✔Congenital diaphragmatic hernia The most effective intervention to treat respiratory distress in the infant with intestines herniated in the chest cavity is: - ✔Intubation and ET tube ventilation After resuscitation of a term infant delivered after a motor vehicle accident, the infant is noted to be pale with sats of 95%. The BP is 34/22 (28). Tone is diminished and blood glu is 30. First action at this time would be? - ✔Give a 30mL NS When preparing for the delivery of a hydropic infant, the team should be prepared to immediately: - ✔Perform a thoracentesis- remove the fluid so it does not inhibit chest expansion -- ABCs A term infant is born via normal spontaneous vaginal deliver. The infant is noted to be cyanotic when quiet but pinks up when crying. The most likely dx? - ✔Choanal atresia Despite continuous PPV via ETT, a newborn is persistently cyanotic. The HR remains less than 100 bpm. Breath sounds can be heard over both the lung fields and the stomach. The stomach is distended. Most likely, the ETT is: - ✔In the esophagus The use of epi in neonatal resuscitation for bradycardia less than 60 bpm is recommended when? - ✔Following initial steps, 30 seconds of effective ventilations, and 60 seconds of chest compressions After a crash c-section for a cord prolapse, a term newborn's HR is 50 bpm at 12 minutes of life. The newborn remains hypotonic and does not have any spontaneous respirations. This newborn is most at risk for? - ✔HIE (hypoxic ischemic encephalopathy) A 32-week preterm newborn born at a community facility has a HR of 130 bpm. The newborn is breathing spontaneously, although it has moderate retractions. The O sat on RA is 75% at 5 min of life. the next step would be to: - ✔Provide CPAP at 5cm H2O- this noninvasive form of resp support is particularly helpful for premature babies who are breathing spontaneously and have an adequate HR but have increased WOB and a low O2 sat Chest compressions are most effective if: - ✔They are performed at a rate of at least 90/ min 90 compressions/min, 30 breaths/min, compress 1/3rd of the anteroposterior diameter. Performed after 30s of PPV with no results
An infant is born via vacuum-assisted vaginal delivery after a prolonged second stage of labor. In the few minutes after delivery, the resuscitation team needs to observe closely for: - ✔Signs of intracranial bleeding (apnea, tachypnea, hypotension, shock) Exposure to mag sulfate before delivery increases the likelihood that the newborn will develop: - ✔hypotonia and resp depression (signs of hypermagnesia) also poor suck, weakness, lethargy. Depresses deep tendon reflexes A newborn infant born at 37 weeks is in the 5th percentile for weight, length, and HC. The most likely explanation for this finding is: - ✔Intrauterine infection- symmetric IUGR begins early in gestation and is most often caused by intrauterine infection or genetic abnormalities. Chronic fetal distress is implicated as a cause of asymmetric growth restriction, resulting in a larger HC in comparison to length and weight. Maternal HTN can cause asymmetric IUGR A 3.2 kg, 37 week infant is admitted to the NICU because of resp distress. The infant was a c-sec for maternal HTN, APGARS were 6 and 8. On admission, the RR is 80- 90 w/ moderate indrawing and occasional grunting. A chest radiograph shows increased vascular markings with expansion of the chest to the tenth rib. This infant most likely has: - ✔TTN- more common in late preterm and term infants born by c-sec. CXRs w/ over-expansion, haziness, increased vascular markings, and fluid in the fissure X-ray findings for MAS & RDS - ✔1. Hyperinflation, patchy infiltrates
- Atelectasis, air bronchograms, and diffuse granular infiltrates that often progress to severe b//l opacity A term, SGA infant is noted to have several anomalies, including low set ears, a low posterior hairline with webbed neck, a broad chest with widely spaced nipples, and edema of the hands and feet. These findings are most likely r/t: - ✔Turner Syndrome- occurs in phenotypic females These findings including a prominent occiput, low-set malformed ears, small eyes and jaws, clenched hands with overlapping fingers, and rocker bottom feet are signs of: - ✔Trisomy 18 These findings including Brushfield spots, small eats, simian creases, excess skin at the nape of the neck, upslanting palpebral fissures, hypotonia, large protruding tongue, and cardiac anomalies - ✔Trisomy 21 Occurs in males, presents with long limbs, elbow dysplasia, clindodactyly of the 5th finger, hypospadias, hypogonadism, and cryptorchidism - ✔Klinefelter Syndrome A term infant presents with tachypnea and increased WOB. The infant's O2 sat is 78%-80% despite being given 100% O2. Congenital heart disease is suspected. Which of the following defects is most likely to cause these symptoms? - ✔Transposition of the great vessels occurs when the aorta arises from the RV and the pulmonary artery rises from the LV. Marked cyanosis is a presenting feature because the aorta carries deoxygenated blood from the RV to the systemic circulation Aortic stenosis - ✔Usually asymptomatic at birth. When PDA closes, pallor, mottling, and poor perfusion mat develop
An SGA infant is born with several anomalies, including micrognathia, a cleft lip, overlapping digits, rocker bottom feet, and cutis aplasia. Most likely explanation? - ✔Trisomy 13 The presence of central cyanosis is assessed in which part of the body? - ✔Tongue A 41 wk baby is delivered by c sec for failure to progress. The baby is LGA with head, length, and weight all at the 95th percentile. On exam, the baby is centrally pink with no resp distress and has good tone. There is no caput or molding of the head noted. However, on palpation several soft spots that recoil with pressure are noted over the back of the head. Most likely explanation? - ✔Craniotabes- soft spots on the skull that collapse and recoil with pressure. Usually found in parietal or occipital region and though to result from bone reabsorption due to the pressure of the skull against the maternal pelvis An SGA infant is born with hypoplasia of the arm with cicatricial scarring and microphthalmia. The most likely cause of these findings is congenital infection caused by? - ✔Varicella- cicatricial scarring is a classic finding in congenital varicella. Limb hypoplasia and microphthalmia are also described with this condition "Blueberry muffin" rash and hepatosplenomegaly are characteristic of which infection? - ✔Congenital CMV Microphthalmia, cataracts, glaucoma, chorioretinitis, and congenital heart disease are characteristic of which infection? - ✔Congenital Rubella A 10-day old infant born at 34 wks by spontaneous vaginal delivery after 12 hours of ruptured membranes develops a vesicular rash over the occiput. In addition to culturing the lesion, the nurse should anticipate that this infant will require which of the following tests on an urgent basis? - ✔LP- performed in all suspected cases of neonatal herpes simplex virus Which of the following (BP, fundoscopy, percussion, red reflex) is done as part of the routine assessment of the well newborn? - ✔Red reflex exam As part of a developmental assessment, the nurse is assessing the infant's ability to fixate on a picture of a human face. The technique she uses is based on the knowledge that a term newborn can be expected to briefly fixate on objects at a distance of _____ in? - ✔10- Which of these is the most common early sign of neonatal sepsis - ✔Tachypnea-the lungs are the most frequent infection entry portal An infant is born vaginally complicated by mod shoulder dystocia. The infant is noted to have an asymmetric Moro reflex, and his arm is adducted and internally rotated. The wrist is flexed. Most likely cause? - ✔Erb palsy- injury to brachial plexus A 1 month old infant born at 27 weeks gestation has developed two soft, raised, bright red tumors, one on the chest and one on the arm. These lesions have grown in size over the past 10 days when they were first noted. The mom asks the nurse if these lesions will continue to grow. The nurse's response is based off the knowledge that this type of lesion will: - ✔Grow for 6-12 months and then involute- can treat with oral or topical propanolol, however, not necessary for it to go away
A 2 day old full term male w/ a hx of low apgar scores, poor urine output, and hypertonicity was noted to have 2 episodes of apnea accompanied by lip smacking and eye deviations. Episodes are most likely: - ✔Subtle seizures- most common type of seizures in premature infants Benign familiar seizures present similarly but w/o hx of low apgar scores Neonatal myoclonus manifests as episodes of repetitive jerking or jitteriness that does not stop with passive restraint Tonic-clonic include stiffening and repetitive jerking An infant was born at 31 weeks and tx with CPAP for 10 days. At 2 weeks the infant was noted to have difficulty feeding and high-pitched inspiratory stridor. Most likely cause? - ✔Laryngomalacia- most common cause of stridor in infants and typically presents in the first month of life. Risk factors include prematurity and respiratory support Laryngeal atresia is present at birth A newborn presents with FTT, liver failure, coppery brown skin rash, and purulent nasal discharge. The mother should be tested for? - ✔Syphilis Skin lesions or scars, microphthalmia, and microcephaly or hydranencephaly are symptoms of which infection - ✔Congenitally acquired herpes A 2 day old is noted to have significant jaundice. His blood work shows decreased hgb, hyperbili, and a positive direct antigen test. These findings are most likely a result of? - ✔Immune-mediated hemolysis The nurse caring for a 2 day old African American infant notices a scattered rash on the infant's face and trunk. The rash consists of a mix of vesicles, pustules, and brown macules. The infant is afebrile and feeding well. The rash most likely represents: - ✔Transient neonatal pustular melanosis- pustular melanosis is more common in infants with pigmented skin. The benign rash consists of a mixture of vesicles and pustules and pigmented macules. The vesicles and pustules resolve quickly, however the macules may remain for several months. Milia - ✔small white cysts appearing most often over the nose and chin of the newborn Erythema toxicum - ✔A pustular rash on an erythematous base. Tends to fade in one location and reappear in another Cutaneous candida - ✔beefy red rash with satellite lesions. Found in the groin, diaper area, and occasionally in other skin folds such as the axilla A term newborn presents with a large port-wine stain over the forehead and eyelid. this infant is at risk for - ✔Underlying hemangiomas- port wine stains over the trigeminal area may indicate the presence of Sturge-Weber syndrome which includes the development of hemangiomas A newborn infant presents with cyanosis. On exam the nurse hears a murmur at the left upper sternal border, but hears nothing else unusual. What cardiac defect is most likely responsible for these findings? -
At 6 days of life a 24 week neonate is noted to have edema of the eyes with reddened conjunctiva and yellow discharge The most likely cause is: - ✔Chalmydia trachomatis infection- onset of symptoms is between 5-7 days Herpes infection of the eye presents with keratoconjunctivitis, inflammation of the cornea, and conjunctiva, some edema may be present but no purulent discharge During a routine assessment after a spontaneous vaginal birth at term gestation, the neonate is pink when crying but demonstrates central cyanosis when quiet. Breath sounds are equal w/ no tachypnea. Most likely cause? - ✔Bilateral choanal atresia *neonates are obligate nose breathers The mother of a healthy full teem newborn asks about the hymenal tag that she saw when changing her daughter's diaper. The nurse's response is based on the knowledge that: - ✔Tags are benign and resolve spontaneously- usually disappear within a few weeks of delivery After therapeutic cooling for HIE, the nurse notes a 1.5 cm area of induration on the infant's right arm and a second small, firm nodule over the sacrum. Which of the following should be monitored in this infant? - ✔Calcium- these nodules are the result of subcutaneous fat necrosis, a complication of cooling. In the presence of multiple nodules, the risk of hypercalcemia is increased; Mg, Na, & K are not affected by the presence of these nodules In the immediate newborn period, the nurse should assess the PMI by placing the stethoscope over which intercostal space? - ✔5th- because of the dominance of the RV, the PMI best heard over 5th in the immediate newborn period Pulmonic valve- second intercostal Mitral valve- third intercostal Apex- 4th intercostal An infant born at 33 weeks gestation is now 2 weeks old and is noted to have an umbilical mass and persistent fluid drainage in the umbilical area. The infant is otherwise well and there is no erythema or edema around the umbilicus. The most likely explanation for this finding is? - ✔Umbilical granuloma- most common umbilical mass and most frequently identified after cord separation due to persistent drainage from the umbilicus The strength of the lower extremities can be evaluated by eliciting which reflex? - ✔Stepping Low birth weight is classified as birth weight less than: - ✔2500g very low birthweight <1500g extremely low birthweight <1000g Length measurement entails measuring the infant: - ✔crown to heel LGA is birth weight - ✔greater than the 90th percentile SGA is birth weight - ✔less than the 10th percentile Head circumference indicates brain - ✔growth- normal 10th-90th% An infant is born at 36 weeks. This infant is considered to be -
✔late preterm- between 34 and 36+ Term- 38-42+ Postterm- 43 onwards When assessing an infant with IUGR, the nurse can anticipate finding the infant's - ✔Head is disproportionately large for the infant's trunk, little to no vernix on the skin, umbilical cord is thin with decreased wharton jelly, anterior fontanelles large with cranial sutures wide or overlapping A physical assessment performed on a newborn infant notes that the skin of the infant is wrinkling, the areolae are raised with 10-mm buds, and the pinna springs back from being folded. Based on these physical assessment findings, this infant is considered to be - ✔Term- beyond 38 weeks, subcutaneous tissue decreases which causes the skin to wrinkle, breast tissue nodule measures up to 10mm, cartilage in pinna *very postterm and extremely preterm are not gestational categories After the initial assessment of the newborn, the infant's weight, length, and HC are plotted out on a growth chart. The growth chart shows that the infant's weight is at the 15th percentile, length is at the 20th, and HC is at the 30th. These results indicate the infant is - ✔Appropriate for gestational age A 4000-g male infant has just been delivered via c sec due to fetal distress. The infant is born through thick meconium and requires ET suctioning. At the initial assessment, the infant's skin is noted to be leathery, cracked, and wrinkled. The infant's scrotum is noted to be pendulous with the testes descended. The nurse assessing this infant can anticipate that this infant is: - ✔Postterm A gestational age exam has just been performed on a newborn infant. The infant was noted to be in flexed position. The assessment shows that the square window angle is 0 degrees and the popliteal angle is 45 degrees, and the scarf sign eval shows increased resistance to crossing the midline. The infant's skin is noted to be cracking with no veins visible. Creases over the entire sole of the plantar surface are noted. Based on findings what's the gestational age? - ✔40 weeks For a term infant, the square window angle would be 0 degrees, the popliteal would be 90 degrees, and in scarf sign testing, the elbow could not be pulled over the infant's body The correct way to assess the scarf sign in an infant is to: - ✔Position the infant supine, take the infant's hand and pull it across the infant's chest and around the neck as far posterior as possible toward the opposite shoulder, and observe the elbow position in relation to the midline of the infant's body The correct way to perform the square window test is to: - ✔Flexing the infant's hand on the forearm between the examiner's thumb and index ginger, using enough pressure to get full flexion, and visually measuring the angle between the hypothenar eminence and the ventral aspect of the forearm A newborn's mother asks why the nurse is performing a gestational age assessment when she had ultrasonography to determine her due date. The best explanation is: - ✔The newborn's care is based on the gestational age and size-date plotting. *early (second trimester) ultrasonograms provide an accurate estimation of gestational age
Gestational age is defined as: - ✔The time between the last menstrual period and the day of delivery Which of the following statements demonstrates the nurse's understanding of gestational age? - ✔An infant born at 35 weeks' gestation is considered a late-preterm infant and is at risk for higher morbidity and mortality Upon assessment of a neonate, the nurse notes the infant's head to be disproportionately large for the trunk, extremities wasted, facial appearance to look like a "wizened old man," large anterior fontanelles with cranial sutures overlapping, and no vernix caseosa. These findings are consistent with: - ✔IUGR The mother of a newborn born at 24 weeks is worried about her infants eyes being fused. Which statement indicates the nurse's understanding of fused eyes? - ✔Fused eyelids normally open between 26 and 28 weeks' gestation.
