Answer Key

Section I: General Assessment and Management

Chapter 1: Assessment of Fetal Well-Being

1. (B) Fetal fibronectin (fFN) is uncommonly present in cervicovaginal secretions in the late second and early third trimesters. fFN is an extracellular glycoprotein that is thought to act as an adhesive between the fetal membrane and uterine wall and can be disrupted by inflammation. A preterm birth within 2 weeks is probable after a positive test result. Cervical ferritin is not a biomarker but an inflammatory marker whose presence provides support for the theory that infection is a mediator of preterm birth. Maternal plasma concentrations of corticotropin-releasing hormone are elevated in both term and preterm pregnancies. It appears to be a component of the common pathway of labor regardless of gestation. Placental α-microglobulin-1 is a protein found in amniotic fluid that is a biomarker for rupture of membranes.

References: Ramsey, P., Tsunenobu, T., Goldenberg, R., et al.: The preterm prediction study: Elevated cervical ferritin levels at 22 to 24 weeks of gestation are associated with spontaneous preterm delivery in asymptomatic women. American Journal of Obstetrics and Gynecology, 186(3):458-463, 2002.

Spong, C.Y.: Prediction and prevention of recurrent spontaneous preterm birth. Obstetrics and Gynecology, 110(2, part 1):405-415, 2007.

Weintraub, A., Sheiner, E., Mazor, M., et al.: Maternal serum ferritin concentration in patients with preterm labor and intact membranes. Journal of Maternal Fetal Neonatal Medicine, 18(3):163-166, 2005.

2. (D) Premature rupture of membranes is one of the most common complications of pregnancy resulting in a newborn’s admission to the NICU. A bedside immunoassay test, AmniSure ROM, is simple, easy to perform, rapid (5-10 minutes), and minimally invasive. This test identifies a placental glycoprotein that is abundant in amniotic fluid but present in lower concentrations in maternal blood and cervicovaginal secretions. Prolactin is responsible for priming the breast tissue in preparation for lactation. α-Fetoprotein is assessed to identify neural tube defects (high) and Down syndrome (low). Fetal fibronectin is an extracellular glycoprotein that is thought to act as an adhesive between the fetal membranes and uterine wall and is a biomarker for predicting preterm birth.

Reference: Caughey, A., Robinson, J., Norwitz, E.: Contemporary diagnosis and management of preterm premature rupture of membranes. Reviews in Obstetrics and Gynecology, 1(1):11-22, 2008.

3. (B) Moderate fetal heart rate (FHR) variability is strongly associated with an arterial umbilical cord pH higher than 7.15. Normal FHR variability provides reassurance about fetal status and the absence of metabolic acidemia. FHR variability is the sign most predictive of fetal well-being. The most important single FHR characteristic is variability. FHR baseline is 110 to 160 beats/minute regardless of gestational age. Decelerations are a reflection of head compression, umbilical cord compression, or a transient interruption in oxygen transfer. Accelerations are highly predictive of the absence of fetal metabolic acidemia and form the basis of the nonstress test. They occur in association with fetal movement.

References: American College of Obstetricians and Gynecologists: Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles, No. 106. Washington, D.C., American College of Obstetrics and Gynecologists, July 2009.

Freeman, R.K., Garite, T.J., Nageotte, M.P.: Fetal Heart Rate Monitoring, 3rd ed. Philadelphia, Lippincott Williams & Wilkins, 2003, pp. 63-89.

Tucker, S., Miller, D., Miller, L.: Fetal Monitoring: A Multidisciplinary Approach, 6th ed. St. Louis, Mosby, 2009, pp. 95-138.

4. (A) The biophysical profile (BPP) presumes that multiple indicators are better predictors of outcome than one indicator. The score for each indicator is either 0 if that component is absent or 2 points if it is present, and management depends on the total score. A score of 10 out of 10 indicates that fetal asphyxia is extremely unlikely. The BPP consists of a nonstress test using an electronic fetal monitor and real-time limited ultrasonography to observe the fetus for the other components. The components include fetal tone, fetal movement, fetal breathing, the nonstress test, and amniotic fluid index. Fetal position and fetal heart rate are not included in the BPP.

References: Freeman, R.K., Garite, T.J., Nageotte, M.P.: Antepartum fetal monitoring. In Fetal Heart Rate Monitoring, ed 3, Philadelphia, Lippincott Williams & Wilkins, 2003, pp. 181-202.

Richardson, B., Gagon, R.: Behavioral state activity and fetal health and development. In Creasy, R., Resnik, R. (Eds.): Creasy and Resnik’s Maternal-Fetal Medicine Principles and Practices, 6th ed. Philadelphia, Saunders, 2009, pp. 171-181.

5. (C) Patients who are at low risk for developing gestational diabetes (<25 years, normal weight, member of an ethnic group with low prevalence of diabetes, no diabetes in a first-degree relative, no history of abnormal glucose tolerance, and no history of poor obstetric outcome) are tested between 24 and 28 weeks’ gestation. Patients with risk factors (>35 years, body mass index >30, history of gestational diabetes, delivery of a large-for-gestational-age infant, polycystic ovarian syndrome, strong family history of diabetes) should receive a plasma glucose screening at their first prenatal visit followed by one at 24 to 28 weeks.

Reference: Bowers, N., Curran, C., Freda, M.C., et al.: High risk pregnancy. In Simpson, K., Creehan, P. (Eds.): Perinatal Nursing, 3rd ed. Philadelphia, Lippincott Williams & Wilkins, 2008, pp. 189-207.

6. (B) Values of Pco₂ are lower when women give birth in an upright position than when they give birth in the supine position. A supine position during labor should be avoided to prevent maternal hypotension and to enhance uteroplacental blood flow to keep the fetal pH within normal limits. Values of pH and Po₂ are higher in women who give birth in the upright position. A normal pH, Po₂, and Pco₂ should reflect a normal base excess.

References: Simpson, K., James, D.: Efficacy of intrauterine resuscitation techniques in improving fetal oxygen status during labor. Obstetrics and Gynecology, 105:1362-1368, 2005.

Zwelling, E.: Overcoming the challenges: Maternal movement and positioning to facilitate labor progress. MCN American Journal of Maternal Child Nursing, 35(2):72-80, 2010.

7. (B) The major factor influencing pulmonary maturity in the infants of diabetic mothers is blood glucose control. In mothers with good control, fetal lung maturation is not delayed. Phosphatidylglycerol (PG) enhances the spread of phospholipids on alveoli and its presence indicates an advanced state of fetal lung development and function. The fetal lung maturity test reports in milligrams of surfactant per gram of albumin. The AmnioSTAT is the test that is used and uses 55 mg of surfactant/gram albumin as “mature.” Lamellar bodies are lamellated phospholipids that represent a storage form of surfactant. The size of lamellar bodies is similar to that of platelets, so a lamellar body count can be obtained rapidly with the use of a platelet channel of a hematology analyzer. The fetal lung maturity cutoff is suggested to be 50,000 µL. The lecithin/sphingomyelin ratio is best used in combination with the PG test. It is the PG that indicates the advanced state of lung development.

References: Fischer, A., Dodia, C., Ruckert, P., et al.: The pathway to lamellar bodies for surface protein A. American Journal of Physiology—Lung Cell Molecular Physiology, 299(1):L51-58, 2010.

Mercer, B.: Assessment and induction of fetal pulmonary maturity. In Creasy, R., Resnik, R. (Eds.): Creasy and Resnik’s Maternal-Fetal Medicine Principles and Practices, 6th ed. Philadelphia, Saunders, 2009, pp. 419-432.

Szallasi, A., Gronowski, A.M, Eby, C.S.: Lamellar body count in amniotic fluid: A comparative study of four different hematology analyzers. Clinical Chemistry, 49:994-997, 2003.

8. (D) A late deceleration of the fetal heart rate reflects a transient interruption of oxygen transfer from the environment to the fetus resulting in transient fetal hypoxemia. It can be corrected by changing the environment. Fetal distress is an imprecise term, and the National Institute of Child Health and Human Development Task Force has recommended that this term be abandoned. Acceleration reflects a sympathetic nervous system response and results in an increase in the fetal heart rate. Rapid descent through the pelvis may cause a parasympathetic response that results in prolonged deceleration or fetal bradycardia, but not in late deceleration.

Reference: Tucker, S., Miller, D., Miller, L.: Fetal Monitoring: A Multidisciplinary Approach, 6th ed. Philadelphia, Mosby, 2009, pp. 95-138.

9. (C) Amnioinfusion has been used to attempt to resolve variable fetal heart rate decelerations by correcting umbilical cord compression as a result of oligohydramnios. During amnioinfusion, normal saline or lactated Ringer solution is infused into the uterus either by gravity flow or through an infusion pump. Amnioinfusion may assist with oligohydramnios (amniotic fluid index <5 cm) to provide additional fluid to cushion the umbilical cord and prevent variable decelerations from occurring. Careful monitoring and documentation of fluid infused is important to avoid iatrogenic polyhydramnios. Amnioinfusion has been shown to significantly improve fetal heart rate patterns characterized by variable decelerations but does not affect late decelerations or patterns with minimal to absent variability. Amnioinfusion does not affect decreased fetal heart variability.

References: Regi, A., Alexander, N. Jose, R., et al.: Amnioinfusion for the relief of recurrent severe and moderate variable decelerations in labor. Journal of Reproductive Medicine, 54(5):295-302, 2009.

Simpson, K.R.: Intrauterine resuscitation during labor: review of the current methods and supportive evidence. Journal of Midwifery and Women’s Health, 52(3):229-237, 2007.

10. (D) Nifedipine (Procardia) works by inhibiting voltage-dependent channels of calcium entry into smooth muscle cells, acting to decrease intracellular calcium and decrease the release of stored calcium. It is rapidly absorbed after oral administration, which makes it convenient to use. It should not be used in combination with either magnesium sulfate or β-sympathomimetics (terbutaline). Magnesium sulfate is an anticonvulsant and acts to relax the smooth muscle of the uterus by substituting itself in place of calcium. Ketorolac (Toradol) is an antiinflammatory and an antiprostaglandin generally used for pain management. Its use can cause oligohydramnios and premature closure of the ductus arterious. Terbutaline is a β-sympathomimetic that supplements or mimics the effects of norepinephrine and epinephrine.

Reference: Iams, J.D., Romero, R., Creasy, R.K.: Preterm labor and birth. In Creasy, R., Resnik, R. (Eds.): Creasy and Resnik’s Maternal-Fetal Medicine: Principles and Practice, 6th ed. Philadelphia, Saunders, 2009, pp. 545-582.

Chapter 2: Adaptation to Extrauterine Life

1. (C) Systemic vascular resistance in the aorta normally increases postnatally with the removal of the placenta. Pulmonary vascular resistance normally decreases postnatally with the onset of ventilation and the dilation of the pulmonary vasculature, which increases pulmonary blood flow to the lungs. An increase in pulmonary vascular resistance after birth would further decrease blood flow to the lungs. Increased pulmonary vascular resistance can develop from cardiac defects (e.g., ventricular septal defect, single ventricle) or in infants with persistent pulmonary hypertension.

References: Kenny, P.A., Hoover, D., Williams, L.C., et al.: Cardiovascular diseases and surgical interventions. In Gardner, S.L., Carter, B.S., Enzman-Hines, M., et al. (Eds.): Merenstein and Gardner’s Handbook of Neonatal Intensive Care, 7th ed. St. Louis, Mosby, 2011, pp. 678-716.

Verklan, M.T.: Adaptation to extrauterine life. In Verklan, M., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 72-90.

2. (C) During fetal life, the ductus arteriosus is responsible for shunting blood away from the lungs to the aorta. This shunt functionally closes during the transition period following delivery. The foramen ovale is an opening between the left and right atria. Following delivery, as pressures increase on the left side of the heart and decrease on the right side of the heart, this connection functionally closes. Changes in an infant’s condition can open this connection and allow blood to shunt in either direction. The ductus venosus is responsible for shunting blood from the umbilical vein to the inferior vena cava so that blood bypasses the liver. A Blalock-Taussig shunt is a surgical procedure performed to connect the subclavian artery to the pulmonary artery.

Verklan, M.T.: Adaptation to extrauterine life. In Verklan, M., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 72-90.

3. (B) A scaphoid abdomen is the classic appearance of an infant with a diaphragmatic hernia. The majority of diaphragmatic hernias generally occur on the left side, resulting in breath sounds greater on the right side. The degree of respiratory distress varies depending on the size of the herniation. Respiratory distress can increase when the infant is bag-and-mask ventilated, because some air enters the stomach and passes to the intestine. Bowel sounds can sometimes be audible in the chest on the affected side. Bag-and-mask ventilation should be stopped and the infant intubated if assisted ventilation is required. Respiratory distress generally accompanies a pneumothorax. Breath sounds are diminished or absent on the affected side and the abdomen appears normal. The presence of a scaphoid abdomen is a hallmark pointing to a different diagnosis. Although respiratory distress can occur in an infant with a tracheoesophageal fistula, the presence of excessive oral secretions is usually the primary presenting symptom. Abdominal distention, rather than a scaphoid abdomen, would be expected in an infant with a gastrointestinal obstruction. When the abdomen is palpated, the infant can experience pain and may show some guarding.

References: Bradshaw, W.T.: Gastrointestinal disorders. In Verklan, M., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 589-637.

Lovvorn, H.N. III, Glenn, J.B., Pacetti, A.S., et al.: Neonatal surgery. In Gardner, S.L., Carter, B.S., Enzman-Hines, M., et al. (Eds.): Merenstein and Gardner’s Handbook of Neonatal Intensive Care, 7th ed. St. Louis, Mosby, 2011, pp. 812-847.

Verklan, M.T.: Adaptation to extrauterine life. In Verklan, M., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 72-90.

4. (B) Vacuum-assisted delivery places the infant at a higher risk for developing a subgaleal hemorrhage. A subgaleal hemorrhage can result in massive blood loss, leading to shock and death. Any changes in vital signs, level of consciousness, or swelling that is extending to the eyes and neck requires the caregiver to transfer the infant into an intensive care environment so that the delivery of blood products and hemodynamic stabilization are not delayed. Preparation may also be needed to transfer this infant to a higher level of care. A cephalohematoma can be unilateral or bilateral but does not cross the suture line; it will usually resolve within weeks after birth. A cephalohematoma generally does not require the infant to be cared for in an NICU unless there is significant blood loss or a fractured skull is suspected and the baby needs further evaluation. Otherwise, these infants can stay with their mothers in the labor and delivery department. However, they must be assessed for hyperbilirubinemia, for which they are at a higher risk. Caput succedaneum is caused by contact of the presenting part (scalp) with the cervix. The swelling is fluid in the subcutaneous tissues of the scalp. The swelling usually resolves within 1 to 2 days after birth. These infants can stay with their mothers in the labor and delivery department.

References: Karlsen, K.: The S.T.A.B.L.E. Program, 5th ed. Park City, Utah, American Academy of Pediatrics, 2006, pp. 147-148.

Verklan, M.T., Lopez, S.M.: Neurological disorders. In Gardner, S.L., Carter, B.S., Enzman-Hines, M., et al. (Eds.): Merenstein and Gardner’s Handbook of Neonatal Intensive Care, 7th ed. St. Louis, Mosby, 2011, pp. 748-786.

5. (D) The Centers for Disease Control and Prevention (CDC) currently recommends that infants born to mothers whose hepatitis B surface antigen (HBsAg) status is unknown receive hepatitis B vaccine within 12 hours of birth. The mother should have blood drawn to determine her HBsAg status. If the mother is HBsAg positive, the infant should receive hepatitis B immune globulin (HBIG) as soon as possible and no later than 1 week of age. The administration of monovalent hepatitis B vaccine (single-antigen formulation that does not contain the preservative thimerosal) to all infants before discharge is the CDC recommendation. However, the mother’s HBsAg status must be obtained to determine when hepatitis B immunization should be performed and whether or not HBIG should also be given. The mother’s hepatitis status is usually assessed in the prenatal period. Hepatitis B is a serious illness if the infant contracts it from the mother.

Reference: Centers for Disease Control and Prevention: Recommended childhood and adolescent immunization schedule—United States, 2010. MMWR Morbidity and Mortality Weekly Report, 58:1-4, 2010.

6. (C) These assessment findings are normal during the transition period (first 4-6 hours) following birth. The petechiae on the face are the result of the precipitous delivery. Because the lungs are attempting to clear the fluid, infants can often have moist-sounding breath sounds, intermittently elevated respiratory rates, and occasional grunting. Transfer to the special care nursery/neonatal intensive care unit should be considered if the infant has a sudden deterioration in respiratory status, difficulty maintaining temperature, or changes in neurologic status. The pediatric provider should be contacted if the respiratory status changes with sustained grunting, increased work of breathing, and/or central color change. The peripheral cyanosis is normal during the transition period after birth due to vasomotor instability. The risk of aspiration occurring is very rare in this circumstance. Feeding should be delayed if the elevated respiratory rate is sustained.

References: Sielski, L.A., McKee-Garrett, T.M.: Nursery care of the well newborn. In Cloherty, J., Eichenwald, E., Stark, A. (Eds.): Manual of Neonatal Care, 2nd ed. Boston, Little, Brown, 2007, pp. 72-77.

Verklan, M.T.: Adaptation to extrauterine life. In Verklan, M., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 72-90.

7. (B) Coarctation of the aorta has the classic finding of decreased perfusion and pulses in the lower extremities. These infants can develop temperature instability and poor feeding. Congenital heart disease should be suspected when infants present with an increase in respiratory rate in the absence of any other respiratory signs of distress and cyanosis. The physician should be notified immediately and the infant transferred to the nursery for further evaluation and stabilization. Infants with sepsis usually present with signs and symptoms of infection within 12 hours of birth. Clinical findings can include hypoglycemia, poor feeding, lethargy, temperature instability, respiratory distress, weak pulses in all extremities, and cyanosis. Normal transition occurs in the first 4 to 6 hours after birth, so this baby has completed transition. The infant’s poor perfusion in the lower extremities and tachypnea suggest a pathologic process for which the infant should be assessed. Severe meconium aspiration that leads to persistent pulmonary hypertension usually presents itself in the delivery room. Respiratory distress presents with tachypnea and an increase work of breathing that can include grunting, flaring, and retractions.

References: Sadowski, S.L.: Cardiovascular disorders. In Verklan, M., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 534-588.

Verklan, M.T.: Adaptation to extrauterine life. In Verklan, M., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 72-90.

8. (D) Norepinephrine is a stress hormone that is activated in response to cold stress. The release of norepinephrine sends a signal to the nerve endings in the brown fat causing it to be metabolized. Brown fat is located in the axillary area, mediastinum, kidneys, adrenals, and nape of the neck. This metabolic process is referred to as nonshivering thermogenesis. The energy that is produced from this metabolic process heats the blood as it circulates past the areas where the brown fat is stored. Insulin regulates glucose. Infants who are cold stressed are also at risk for developing hypoglycemia and should be monitored closely. Vasopressin is created by the hypothalamus and prompts the pituitary gland to release a hormone that helps maintain blood pressure and water and electrolyte balance. It does not play a role in thermoregulation. Epinephrine is produced within the adrenal glands and works with norepinephrine to produce the “fight or flight” response by increasing the supply of oxygen to the brain and muscles. It does not play a role in thermoregulation.

References: Brand, M.C., Boyd, H.A.: Thermoregulation. In Verklan, M., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 110-119.

Brown, V.D., Landers, S.: Heat balance. In Gardner, S.L., Carter, B.S., Enzman-Hines, M., et al. (Eds.): Merenstein and Gardner’s Handbook of Neonatal Intensive Care, 7th ed. St. Louis, Mosby, 2011, pp. 113-133.

Karlsen, K.: The S.T.A.B.L.E. Program, 5th ed. Park City, Utah, American Academy of Pediatrics, 2006, pp. 46-47.

Soll, R.: Heat loss prevention in neonates. Journal of Perinatology, 28:S57-S59, 2008.

9. (D) Surfactant is produced by type II alveolar pneumocytes and coats the inner lining of the alveoli. Surfactant decreases surface tension and allows alveoli to remain open at the end of expiration, which prevents alveolar collapse. Surfactant increases lung compliance. The increase in catecholamines at birth is responsible for decreasing the secretions and improving absorption through the lymphatic system.

References: Gardner, S.L., Enzman-Hines, M., Dickey, L.A.: Respiratory diseases. In Gardner, S.L., Carter, B.S., Enzman-Hines, M., et al. (Eds.): Merenstein and Gardner’s Handbook of Neonatal Intensive Care, 7th ed. St. Louis, Mosby, 2011, pp. 581-677.

Verklan, M.T.: Adaptation to extrauterine life. In Verklan, M., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 72-90.

10. (D) Provided the baby remains asymptomatic, breast-feeding should be attempted immediately. Glucose level should be assessed approximately 30 minutes to 1 hour after the feed. A glucose level of 33 mg/dl is low, and treatment with an early feeding should not be delayed. Glucose water is no longer recommended as a treatment for hypoglycemia because it can cause rebound hypoglycemia. If the infant becomes symptomatic and is unable to feed, an infusion of dextrose 10% in water at 80 ml/kg/day is appropriate. This infusion would provide glucose at 5.5 mg/kg/minute.

References: Armentrout, D.: Glucose management. In Verklan, M., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 172-181.

McGowan, J.E., Rozance, P.J., Price-Douglas, W., et al.: Glucose homeostasis. In Gardner, S.L., Carter, B.S., Enzman-Hines, M., et al. (Eds.): Merenstein and Gardner’s Handbook of Neonatal Intensive Care, 7th ed. St. Louis, Mosby, 2011, pp. 353-377.

Karlsen, K.: The S.T.A.B.L.E. Program, 5th ed. Park City, Utah, American Academy of Pediatrics, 2006, pp. 12-20.

Verklan, M.T.: Adaptation to extrauterine life. In Verklan, M., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 72-90.

11. (D) The right hand is always preductal, because the right subclavian artery is the first branch off the aorta that originates from the left ventricle carrying oxygenated blood. The ductus arteriosus usually inserts into the aorta distal to the right subclavian artery. Preductal and postductal saturations are used to assess for the presence of right-to-left shunting associated with certain congenital cardiac defects or pulmonary hypertension. In the presence of a right-to-left shunt across the ductus arteriosus, blood distal to the ductus is a mixture of oxygenated and deoxygenated blood. Both the left and right feet are always postductal, because they are perfused by the descending aorta. Although the ductus arteriosus usually inserts into the aorta distal to the right subclavian artery, it may be inserted across from or near the left subclavian artery. The left hand may or may not be preductal, because this depends on where the ductus arteriosus inserts into the aorta in relation to the left subclavian branch off the aortic arch.

Reference: Karlsen, K.: The S.T.A.B.L.E. Program, 5th ed. Park City, Utah, American Academy of Pediatrics, 2006, pp. 79-80.

Chapter 3: Neonatal Resuscitation

1. (D) Along with infant condition, interventions and gestational age significantly impact what the Apgar score will be. Interventions such as positive pressure ventilation will change the Apgar score. Differences in gestational age will affect the infant’s tone, reflexes, and respirations. The Apgar scoring tool is a numerical objective scoring tool with specific operational definitions. Although the Apgar score is not assessed until 1 minute of age, it could be a guide to further resuscitation if it were not influenced by interventions, gestational age, and infant condition. Ethnicity is not one of the indicators tallied in the Apgar score.

Reference: Pappas, B.E., Walker, B.: Neonatal delivery room resuscitation. In Verklan, M., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 95-97.

2. (C) Because the infant is vigorous, intubation is not necessary. The initial steps of resuscitation are required. The infant’s airway should be suctioned with a bulb syringe or large-bore catheter and the infant closely observed. Suctioning of the trachea is not indicated. Because the amniotic fluid is meconium stained, positive pressure ventilation is indicated only if the condition of the infant requires it.

References: Kattwinkel, J., Bloom, R.S., American Heart Association, American Academy of Pediatrics: (2006). Textbook of Neonatal Resuscitation, 5th ed. Dallas, American Heart Association, 2006, pp. 2-7.

Pappas, B.E., Walker, B.: Neonatal delivery room resuscitation. In Verklan, M., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, p. 98.

3. (D) The most common presenting signs of a congenital diaphragmatic hernia are barrel chest, scaphoid abdomen, diminished breath sounds, and bowel sounds in the chest cavity. Signs of a left pneumothorax include diminished or absent breath sounds on the left side. Bowel sounds heard in the chest are not characteristic of a pneumothorax. Presenting symptoms of a tracheoesophageal fistula are respiratory distress and excessive salivation. Although meconium aspiration syndrome can present with respiratory distress and a barrel chest, bowel sounds would not be able to be heard in the chest cavity.

4. (C) The most effective way to address severe respiratory distress related to a diaphragmatic hernia is to intubate the patient and provide direct ventilation to the lungs through the endotracheal tube. Providing oxygen via high-flow nasal cannula, bag-and-mask ventilation, or continuous positive airway pressure to a patient with diaphragmatic hernia will result in gastric dilation and increased difficulty in lung expansion.

5. (D) Epinephrine is a cardiac stimulant that increases the heart rate and the strength of contractions, causes peripheral vasoconstriction, and increases blood flow through the coronary arteries and the brain.

6. (C) Pallor despite good oxygenation, a low-normal blood pressure, and diminished tone are all signs of shock. According to the Neonatal Resuscitation Program, the first treatment of shock is to give a 10-ml/kg bolus of a volume expander—generally normal saline. If the infant shows signs of acute blood loss, administration of O-negative blood may be appropriate. Because normal saline is readily available, it is the preferred volume expander for a newly born infant in shock. While starting a maintenance intravenous infusion of 80 ml/kg/day would be standard treatment for an infant admitted to the NICU, treatment of shock would be a higher priority. Because the blood glucose level is 50 mg/dl, the infant is not hypoglycemic. A push of dextrose 10% in water is not necessary.

7. (C) High-resolution ultrasonography will reveal the presence of pleural effusion and ascites. These findings can significantly impact the respiratory status of the newborn. Amniocentesis allows the chromosomes to be analyzed for fetal defects but will not significantly impact care at the delivery. The Kleihauer-Betke test is sometimes useful to rule out fetomaternal hemorrhage. It would give an idea of a potential cause for the hydrops but is not useful at delivery. The glycosylated hemoglobin test provides an indication of the mother’s glucose control during the pregnancy.

Reference: Bradshaw, W.: Gastrointestinal disorders. In Verklan, M., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, p. 634.

8. (B) Because of the generalized edema and respiratory distress experienced by most hydropic babies, provision of respiratory support would be the most immediate need. Pericardiocentesis may be necessary if the infant has a pericardial effusion, but this would come after respiratory support. Placement of an umbilical arterial line can occur in the NICU. A bilateral tube thoracotomy may be necessary for pleural effusion, but this would come after respiratory support.

Reference: Bradshaw, W.: Gastrointestinal disorders. In Verklan, M., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, p. 635.

9. (A) Choanal atresia commonly presents with cyanosis upon delivery that resolves with crying due to the blockage of one or both nares. Although infants with Pierre Robin syndrome present with cyanosis, they also have stridor and apnea. The jaw is characteristically small and pushed back, which results in obstruction of the airway by the tongue. Infants with congenital cardiac disease would become more cyanotic with crying. Respiratory distress syndrome (RDS) is most frequently seen in premature infants. In addition to cyanosis, infants with RDS normally have other signs of respiratory distress such as retractions and flaring.

10. (B) Because there is no chest rise, breath sounds are heard over the stomach, and the infant has never responded to the positive pressure ventilation via the endotracheal tube, one must assume that the endotracheal is in the wrong position—most likely in the esophagus. If the tube were on the carina, there might be no appreciable sign of this. The infant would likely become pink, chest rise would be visible, and breath sounds would be audible. In many situations, the only way this would be noticed would be through indications on the confirmatory radiograph and the finding of a higher tip-to-lip measurement than expected. If the tube were in the correct position, the infant would have a positive response to the positive pressure ventilation. The color would improve and chest rise would be visible. Generally air would not be heard over the stomach. In addition, if a CO₂ detector were used, it would show color change. If the tube were in the right mainstem bronchus, the infant’s color would show no improvement. Breath sounds would be diminished or absent over the left side of the chest and not audible over the stomach.

Reference: Kattwinkel, J., Bloom, R.S., American Heart Association, American Academy of Pediatrics: Textbook of Neonatal Resuscitation, 5th ed. Dallas, American Heart Association, 2006, pp. 5-24.

Chapter 4: Physical Assessment

1. (A) Checking the infant’s hips is most likely to elicit crying and should be left until the last step of the examination. Reflexes are tested as the examiner moves through the head-to-toe examination. Pulses are difficult to palpate if the infant is crying and therefore should not be left until last. The spinal examination is less likely to elicit crying and therefore can be performed before checking the hips.

Reference: Honeyfield, M.A.: Principles of physical assessment. In Tappero, E.P., Honeyfield, M.A. (Eds.): Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination, 4th ed. Santa Rosa, Calif., NICU Ink, 2009, pp. 1-8.

2. (D) Magnesium sulfate crosses the placenta and may cause hypermagnesemia. Signs of elevated serum magnesium include respiratory depression, hypotonia, poor suck, weakness, and lethargy. Magnesium does not interfere with red cell production and does not cause red blood cell hemolysis. Magnesium depresses rather than exaggerates deep tendon reflexes. Diminished deep tendon reflexes would be an expected finding in a newborn whose mother received magnesium sulfate. Hypernatremia in newborns usually results from inadequate fluid intake leading to decreased plasma fluid volume. Sodium and fluid volume are not affected by hypermagnesemia. Magnesium does not alter blood glucose levels.

Reference: Broussard, A.B., Hurst, H.M.: Antepartum-intrapartum complications. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 20-40.

3. (D) Subgaleal hemorrhage occurs when blood vessels below the aponeurotic membrane tear, which allows a large amount of blood to collect in the connective tissue at the back of the head and in the neck. Subgaleal hemorrhages occur most commonly after vacuum- or forceps-assisted deliveries. Symptoms include a fluctuant mass at the back of the head that increases in size after delivery. There are two types of skull fractures in newborns: linear and depressed. Linear skull fractures are usually asymptomatic, whereas depressed skull fractures present as an indentation that does not cross the suture line. A cephalohematoma results from bleeding under the periosteal lining of the skull. It increases in size after birth but is bounded by suture lines and feels firm to the touch. Subdural hematoma is an intracranial bleed that presents with neurologic signs such as seizures, decreased level of consciousness, and asymmetry of motor function.

Reference: Lynam, L., Verklan, M.T.: Neurologic disorders. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 749-781.

4. (B) The infant’s size in comparison to gestational age indicates that the infant is small for gestational age (SGA). The incidence of hypoglycemia in SGA infants is approximately 15%. This occurs because SGA infants lack the glycogen stores necessary for maintaining blood glucose levels after birth. Some SGA babies may be polycythemic because of chronic intrauterine hypoxia. Anemia is not a risk factor. Prematurity and lung disease requiring mechanical ventilation and supplemental oxygen are risk factors for chronic lung disease. Because growth restriction enhances fetal lung maturity, the risk of chronic lung disease is reduced. Intrauterine growth restriction has been shown to enhance fetal lung maturity. The risk of respiratory distress syndrome is lower in an SGA infant than in an appropriately sized infant of the same gestational age.

Reference: Trotter, C.W.: Gestational age assessment. In Tappero, E.P., Honeyfield, M.A. (Eds.): Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination, 4th ed. Santa Rosa, Calif., NICU Ink, 2009, pp. 21-39.

5. (C) Intrauterine growth restriction (IUGR) has traditionally been described as symmetric (non–head sparing) and asymmetric (head sparing), with asymmetric the most common. In symmetric IUGR, the head and length are at the same or similar percentile as the weight on the growth curve. At 34 weeks, an infant exceeding the 90th percentile, the definition of large for gestational age, would weigh more than 2800 g. The 10th percentile for 34 weeks’ gestation is 1600 g; therefore, an infant of 1500 g would not be appropriately grown. With asymmetric growth restriction, brain growth is preserved, which results in a head circumference in the normal range and a weight that falls below the third percentile for gestational age.

6. (A) Meconium aspiration is more common in postterm infants. Low Apgar scores reflect intrauterine hypoxia, which is associated with meconium aspiration. Radiographic findings in meconium aspiration include hyperinflation and patchy infiltrates. Infants with respiratory distress syndrome present at birth or within hours with clinical signs of respiratory distress that include tachypnea, grunting, retractions, and cyanosis accompanied by increasing oxygen requirements. The chest radiograph is characterized by atelectasis, air bronchograms, and diffuse granular infiltrates that often progresses to severe bilateral opacity. Infants with congenital heart disease do not usually initially demonstrate respiratory distress. Transient tachypnea is more common in late preterm infants and term infants born by cesarean section. Infants with transient tachypnea of the newborn often have chest radiographic findings that include overexpansion, haziness, increased vascular markings, and fluid in the fissure.

Reference: Askin, D.F.: Respiratory distress. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 453-483.

7. (B) Down syndrome, or trisomy 21, is the most common chromosomal aberration recognized at birth. Among the features associated with Down syndrome are Brushfield spots, small ears, simian creases, excess skin at the nape of the neck, upslanting palpebral fissures, hypotonia, large protruding tongue, and cardiac anomalies. Features of trisomy 18 include a prominent occiput, low-set malformed ears, small eyes and jaw, clenched hands with overlapping fingers, and rocker-bottom feet. Infants with Turner syndrome, which occurs in phenotypic females, are usually small for gestational age with a broad chest, widely spaced nipples, edema of the extremities, and a short neck. Klinefelter syndrome occurs in males and results in long limbs, elbow dysplasia, and clinodactyly involving the fifth finger. Hypospadias, hypogonadism, and cryptorchidism are usually present.

Reference: Sterk, L.: Congenital anomalies. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 782-812.

8. (B) Infants with congenital diaphragmatic hernia typically present with dramatic cyanosis and severe respiratory distress secondary to pulmonary hypoplasia. Because the abdominal viscera are dislocated through a defect into the chest, the abdominal contour can appear scaphoid. Breath sounds are diminished or absent, and because the mediastinal structures have been displaced, the heart sounds are heard in the right chest. Congenital diaphragmatic hernia occurs more frequently on the left side, causing a displacement of structures to the right side of the chest. A large or tension pneumothorax can cause a shift in heart sounds away from the affected side as well as unilaterally decreased breath sounds. The shape of the abdomen is unaffected. Depending on the amount of oxygenated blood moving into the aorta, cyanotic heart disease may result in significant cyanosis. Breath sounds are unaffected, as is the shape of the abdomen. Severe respiratory distress syndrome is uncommon in term infants and is not associated with alterations in the shape of the abdomen.

References: Askin, D.F.: Respiratory distress. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 453-483.

Bradshaw, W.T.: Gastrointestinal disorders. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 589-637.

9. (C) The infant’s signs and symptoms are consistent with hydrops. Immune hydrops results from the destruction of fetal red blood cells by maternal antibodies (usually Rhesus or Rh) that cross the placenta. Parvovirus infection results in nonimmune hydrops because it also causes hemolysis of fetal red cells leading to the development of capillary leak and edema. Maternal alcohol ingestion during pregnancy results in growth and central nervous system abnormalities but has not been reported to cause hydrops. HELLP syndrome refers to a maternal condition causing low platelets and elevated liver enzyme levels. It does not result in fetal hydrops. In the newborn, infection with group B streptococcus can cause respiratory distress, shock, or meningitis. Pleural effusions may be seen in group B streptococcus disease, but ascites and generalized edema are not reported.

Reference: Bradshaw, W.T.: Gastrointestinal disorders. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 589-637.

10. (D) Transposition of the great vessels occurs when septation and migration of the truncus arteriosus is interrupted during development. As a result, the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle. Marked cyanosis is a presenting feature of transposition, because the aorta carries deoxygenated blood from the right ventricle to the systemic circulation. Atrial septal defects (ASDs) account for 5% to 10% of all congenital heart defects and are usually asymptomatic at birth. A soft systolic ejection murmur may be audible, but cyanosis does not occur with an ASD. Patent ductus arteriosus is an acyanotic heart defect resulting from a failure of the ductus arteriosus to close after birth. Simple ventricular septal defect (VSD) is the single most common congenital heart malformation, accounting for about 20% to 25% of all cases of congenital cardiac anomalies. Small VSDs are usually asymptomatic at birth, whereas with moderate to larger defects, left-to-right shunting eventually leads to congestive heart failure. Cyanosis is not present in the newborn period.

Reference: Wright Lott, J.W.: Cardiovascular system. In Kenner, C.A., Wright Lott, J.W. (Eds.): Comprehensive Neonatal Care: An Interdisciplinary Approach. St. Louis, Saunders, 2007, pp. 32-64.

11. (A) Weak pulses signal conditions of vascular collapse, such as sepsis, hypovolemic shock, or congestive heart failure. Decreased pulses in the lower extremities with normal pulses in the upper extremities result from obstruction to aortic flow. The differential diagnosis starts with coarctation of the aorta and includes aortic or femoral thrombosis or spasm. Although a small patent ductus arteriosus may be symptomatic, larger defects allow shunting of blood from the aorta into the pulmonary system, which causes symptoms of pulmonary edema and congestive heart failure. Following birth, right ventricular pressures are higher than those on the left side of the heart. In the presence of a ventricular septal defect, blood is initially shunted from right to left. As the pulmonary pressures drop after birth, the flow of blood is reversed, which leads to symptoms of congestive heart failure. Decreased femoral pulses are not part of the initial presentation. Persistent pulmonary hypertension occurs when the pressure in the pulmonary vasculature fails to drop after birth. This allows the foramen ovale and ductus arteriosus to remain patent, which results in the shunting of blood away from the lungs. Hypoxia and respiratory distress result. Although systemic perfusion is affected, femoral pulses do not differ significantly from brachial pulses.

Reference: Wright Lott, J.W.: Cardiovascular system. In Kenner, C.A., Wright Lott, J.W. (Eds.): Comprehensive Neonatal Care: An Interdisciplinary Approach. St. Louis, Saunders, 2007, pp. 32-64.

12. (B) Candida albicans infection, a common fungal skin disorder, is usually found in the groin area. A moist rash with satellite pustules and areas of skin breakdown are common presenting signs. Herpes simplex infections in the newborn present in one of three patterns: skin and eye findings, central nervous system disease, and systemic infection. A herpes skin rash presents as a cluster of vesicles or pustules on an erythematous base. Ulcerated and crusting lesions are also common. Scalded skin syndrome, caused by a staphylococcal infection, appears as a generalized area of erythema followed by peeling of the epidermis. Erythema toxicum is a benign rash found in up to 70% of newborns. It presents as small white or yellow papules on a reddened base. The rash often fades and reappears on a different part of the body.

Reference: Witt, C.L.: Skin assessment. In Tappero, E.P., Honeyfield, M.A. (Eds.): Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination, 4th ed. Santa Rosa, Calif., NICU Ink, 2009, pp. 41-55.

13. (B) Dermal sinuses, markers for spina bifida, can occur anywhere along the spine but are most common in the lumbar region of the spine. The sacral region of the spine is a common location for dimples but a less common location for dermal sinuses. Dermal sinuses are not commonly found over the cervical or thoracic spine.

Reference: Heaberlin, P.D.: Neurologic assessment. In Tappero, E.P., Honeyfield, M.A. (Eds.): Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination, 4th ed. Santa Rosa, Calif., NICU Ink, 2009, p. 177.

14. (B) A cephalohematoma is a collection of blood under the periosteum. Most commonly found over the parietal or occipital bones, a cephalohematoma is bounded by suture lines. It is usually present at birth but increases in size over the first few hours following delivery. Resolution is usually complete but may take weeks to months. An increased risk of jaundice is the only clinical consideration. Skull fractures are rare in newborns. When present, they may be linear or depressed. Linear fractures are often asymptomatic, whereas with depressed fractures, an indentation over the affected bone may be palpated. Caput succedaneum is commonly seen after vaginal delivery, causes scalp edema, crosses cranial suture lines, and gives the head an elongated shape. It usually resolves during the first few days of life. A subdural hematoma is a collection of blood in the subdural space within the cranium. Presentation is one of altered tone, altered alertness, or seizures.

Reference: Johnson, P.: Head, ears, mouth and neck. In Tappero, E.P., Honeyfield, M.A. (Eds.): Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination, 4th ed. Santa Rosa, Calif., NICU Ink, 2009, pp. 57-74.

15. (D) The harlequin color change or harlequin sign is thought to result from an imbalance in the autonomic nervous system that disrupts blood flow to the cutaneous vasculature. It occurs on the dependent side of the body and is rarely seen after 10 days of life. It is a benign finding that lasts from a few seconds to 30 minutes and usually reverses when the infant’s position is changed. Cold stress or hypothermia results in pallor in the extremities or a mottled appearance of the skin. Hypovolemia results in generalized pallor that is not isolated to one side of the body. Overstimulation may cause the infant to have generalized pallor.

Reference: Blackburn, S.T.: Maternal, Fetal, and Neonatal Physiology: A Clinical Perspective. St. Louis, Saunders, 2007, p. 531.

16. (C) The landmarks for the tricuspid valve are the fourth intercostal space and the left sternal angle. The pulmonic valve is best heard at the second intercostal space, left sternal angle. The aortic valve is best heard at the second intercostal space, right sternal angle. The mitral area is found at the fifth intercostal space, midclavicular line.

Reference: Vargo, L.: Cardiovascular assessment. In Tappero, E.P., Honeyfield, M.A. (Eds.): Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination, 4th ed. Santa Rosa, Calif., NICU Ink, 2009, pp. 87-103.

17. (A) Risk factors for late-onset sepsis in premature infants include the presence of a central line or other invasive devices, and the use of total parenteral nutrition. Clinical signs of infection include temperature instability, lethargy, poor tone, respiratory distress, and glucose instability. A pneumothorax or air leakage into the pleural cavity from a ruptured alveolus results in increased respiratory distress, cyanosis, decreased oxygen saturation, tachycardia, and diminished breath sounds on the affected side. If large, it may also shift the apex of the heart away from the affected side. Systemic signs such as temperature instability are not found with a pneumothorax. Failure of the ductus arteriosus to close is common in low birth weight infants. As the initial period of respiratory distress resolves and pulmonary artery pressures decrease, blood is allowed to flow from the aorta across the ductus to the pulmonary arteries and into the lungs. This increased blood flow results in tachypnea, respiratory distress, and signs of congestive heart failure. Poor tone, hyperglycemia, and temperature instability are not common findings in infants with a patient ductus arteriosus. Clinical manifestations of acute severe intraventricular hemorrhage can include seizures, metabolic acidosis, bulging fontanelle, temperature instability, lethargy, coma, and hypotension. Often there is an unexpectedly low hematocrit or a hematocrit that does not rise as expected after transfusion, and an abnormally “tight” popliteal angle.

Reference: Lott, J.W.: Immunology and infectious disease. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 694-723.

18. (B) Fracture of the clavicles is the most common fracture associated with delivery. An infant with shoulder dystocia is at increased risk of fracturing the clavicle. Bell palsy results from damage to the facial nerve caused by pressing against the maternal pelvis. Phrenic nerve paralysis may be unilateral or bilateral. Unilateral damage, usually on the right side, is more common. Symptoms include respiratory distress. Fracture of the cervical vertebrae would affect movement in all limbs and may also impact breathing.

Reference: Askin, D.F.: Chest assessment. Tappero, E.P., Honeyfield, M.A. (Eds.): Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination, 4th ed. Santa Rosa, Calif., NICU Ink, 2009, p. 84.

19. (A) First published in 1979 and modified in 1991, the Ballard assessment uses six physiologic and six neuromuscular criteria to estimate gestational age. The Finnegan score and the Neonatal Abstinence Scoring System are two tools used to quantify the behaviors associated with neonatal narcotic withdrawal. Several tools have been developed to assess the behavioral characteristics of the preterm infant, including the Newborn Behavioral Assessment Scale and the Assessment of Preterm Infant Behavior. In 1967, Battaglia and Lubchenko used length, weight, and head circumference percentiles to construct intrauterine growth charts. These charts defined criteria for identifying large-for-gestational-age, appropriate-for-gestational-age, and small-for-gestational-age infants.

20. (C) Café au lait spots, more common in black infants, are flat macules that are tan or light brown. They are usually less than 3 cm in diameter. When six or more lesions of larger than 0.5 cm are present, there is an increased risk of neurofibromatosis. Salmon patches, a type of hemangioma, are usually found at the back of the neck, over the eyelids, or on the glabella. Mongolian spots are gray-blue in appearance and are usually found over the buttocks and lower back. These lesions are more common in black, Asian, and Native American infants. Congenital melanocytic nevi are brown to black pigmented lesions that may be macular or plaquelike in appearance.

Reference: Blackburn, S.T.: Maternal, Fetal, and Neonatal Physiology: A Clinical Perspective. St. Louis, Saunders, 2007, p. 532.

21. (B) As a result of central nervous system immaturity, seizures in neonates are more subtle than those seen in children and adults. Neonatal seizures are more likely to arise from areas of the brain that are more mature (temporal lobe, limbic area). These areas initiate behaviors such as chewing, sucking, and ocular movements, behaviors common in subtle seizures. Jerky movements of the limbs are frequently seen in normal newborns, but when they occur in a repetitive and rhythmic pattern, are more likely to represent a clonic seizure. Jitteriness or tremulous movements that cease with flexion are common in infants and can be confused with seizure activity. Normal newborns, especially premature infants, startle easily and respond with disorganized or jerky movements.

Reference: Blackburn, S.T.: Maternal, Fetal, and Neonatal Physiology: A Clinical Perspective. St. Louis, Saunders, 2007, p. 587.

22. (B) Hypoxic injury (hypoxic-ischemic encephalopathy, or HIE) is the most common cause of neonatal seizures. Risk factors for HIE include birth after due date, low Apgar scores, and abnormal fetal heart rate patterns. The majority of seizures secondary to hypoxic injury begin within 6 to 12 hours after delivery. Although a serum sodium level of 133 mEq/L is low, this level is unlikely to precipitate a seizure. Risk factors for subdural hemorrhage include large fetal head, vaginal breech delivery, malpresentation, and forceps or vacuum extraction. Subdural hematomas are usually asymptomatic in the first 24 hours. Intraventricular hemorrhages (IVH) are uncommon in postmature infants. Seizures are a late sign of an IVH.

Reference: Lynam, L., Verklan, T.: Neurologic disorders. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 748-781.

23. (D) The optimal test for postural tone is the pull-to-sit maneuver. In a normal response, the newborn contracts the shoulder and arm muscles and flexes the neck. Turning the head from side to side is useful in assessing range of motion in the neck but does not address postural tone. Stimulating a newborn’s palm should elicit the grasp reflex. An intact grasp reflex is one indication of a healthy brachial plexus. Touching the newborn’s feet to a firm surface should result in the infant’s taking a step. The stepping reflex is most active after 72 hours of age.

24. (A) Signs of a tension pneumothorax include decreased breath sounds on the affected side, a shift in the heart sounds, increasing respiratory distress, and hypoxia. Severe respiratory distress is consistent with pulmonary hypoplasia but is more likely to be present at birth. A pneumothorax may occur as a result of pulmonary hypoplasia. When inserted too deeply, the endotracheal tube is most likely to pass into the right mainstem bronchus, which results in louder breath sounds on the right and diminished sounds on the left. Congenital cystic adenomatoid malformation (CCAM) may be asymptomatic at birth or cause some degree of respiratory distress. Acute deterioration in respiratory status is not an expected finding in CCAM.

Reference: Askin, D.F.: Respiratory distress. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 453-483.

25. (D) The incidence of tracheoesophageal fistulas is estimated to be 1 in 1000 to 2500 live births. Of the five types of esophageal malformations, esophageal atresia with a tracheal fistula connecting to the lower esophagus is most common. A history of polyhydramnios, drooling, excessive oral secretions, and choking with feeding is common. Pyloric stenosis presents with projectile vomiting after feeding. An olive-sized mass may be palpated in the epigastric region. Symptoms usually begin after 3 weeks of age. Regurgitation after feeds is common in newborn infants. Pathologic reflex resulting in respiratory distress or esophagitis is more likely in premature infants. Polyhydramnios and excessive oral secretions are not findings in reflux. Duodenal atresia occurs in 1 per 7000 live births, and a history of polyhydramnios is present. Presentation at birth is more likely to include abdominal distention and bilious vomiting.

Reference: Bradshaw, W.T.: Gastrointestinal disorders. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 589-637.

26. (D) During pregnancy, antilupus antibodies cross the placenta resulting in neonatal lupus erythematous (NLE), which is characterized by congenital heart block, a cutaneous lupus rash, and pancytopenia. These antibodies persist in the neonatal circulation for several weeks after delivery, followed by resolution of the NLE. Maternal diabetes predisposes the fetus and newborn to cardiomyopathy. Sustained bradycardia is not a feature of cardiomyopathy. Preeclampsia is sometimes treated with magnesium sulfate, which can cause respiratory depression in the newborn. Chorioamnionitis usually presents with an increased heart rate and decreased heart rate variability.

Reference: Blackburn, S.T.: Maternal, Fetal, and Neonatal Physiology: A Clinical Perspective. St. Louis, Saunders, 2007, p. 489.

27. (D) Talipes equinovarus is a developmental deformity of the hindfoot. Commonly known as clubfoot, talipes equinovarus is bilateral in 50% of cases, with males being affected twice as often as females. The sole of the foot is turned medially and inverted, with varus deformity of the hindfoot and equinus of the ankle. The deformity can be positional or structural, and radiographs are helpful in identifying a bony defect. Genu recurvatum, or congenital hyperextension of the knee, may result from frank breech positioning. Webbing of the fingers or toes is referred to as syndactyly. External rotation, or knock-knee, usually presents in older children.

Reference: Tappero, E.: Musculoskeletal assessment. In Tappero, E.P., Honeyfield, M.A. (Eds.): Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination, 4th ed. Santa Rosa, Calif., NICU Ink, 2009, pp. 133-157.

28. (A) The presence of peritoneal fluid in the scrotum results in the formation of a hydrocele. The scrotum is nontender but swollen and appears translucent when transilluminated. The testes can be felt in the scrotal sac. Inguinal hernias, more common in premature infants, result when one or more loops of intestine herniate through the processus vaginalis. In the presence of a hernia, crepitus may be felt in the scrotal sac, and it is impossible to feel the entire perimeter of the testes. The scrotal sac does not transilluminate. Cryptorchidism results from failure of one or both testes to descend into the scrotum and presents as a hypoplastic or empty scrotal sac. Testicular torsion or twisting of the testes presents as a hard, swollen scrotum that is red or blue in appearance.

Reference: Cavaliere, T.A.: Genitourinary assessment. In Tappero, E.P., Honeyfield, M.A. (Eds.): Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination, 4th ed. Santa Rosa, Calif., NICU Ink, 2009, pp. 115-132.

29. (A) Erb palsy results when the brachial plexus is injured at C5 or C6. Upper-arm paralysis results in the arm being adducted and internally rotated with pronation of the forearm and flexion of the wrist. The Moro reflex is absent on the affected side. Bell palsy results from compression of the facial nerve and presents with facial drooping. Neonatal stroke most commonly presents with seizures and may affect alertness and global tone. Absence of the radius occurs more often in males than in females and may be found in infants with VACTERAL association (vertebral, anal, cardiovascular, tracheal, esophageal, renal, and limb abnormalities). The hand and wrist are deviated 90 degrees or more, and the forearm is shortened and may be bowed.

30. (C) Occurring at a rate of 1 in 800 live births, developmental dysplasia of the hip (DDH) is more common in infants born in frank breech position. DDH occurs more often in females (80% of cases). Oligohydramnios, which limits fetal movement, increases the risk of DDH; polyhydramnios does not limit fetal movement. Genetically the risk of DDH is higher in white than in black newborns.

References: Sterk, L.: Congenital anomalies. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 782-812.

McCarthy, J.J.: Developmental dysplasia of the Hip. Emedicine. 2009. Available from http://emedicine.medscape.com/article/1248135-overview.

31. (D) The anterior fontanelle is normally 0.6 to 3.6 cm across in white infants and 1.4 to 4.7 cm in black newborns. A large fontanelle is a finding in congenital hypothyroidism. Craniosynostosis results from premature fusion of one or more of the sutures in the skull. Depending on which bones are affected, the skull assumes an abnormal shape. Features of Turner syndrome include webbing of the neck and lymphedema of the extremities. A large fontanelle is not a reported association. Maternal diabetes may result in fetal macrosomia and a large head. The head size is usually proportionate to the body size.

Reference: Johnson, C.B.: Head, eyes, ears, nose, mouth, and neck assessment. In Tappero, E.P., Honeyfield, M.A. (Eds.): Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination, 4th ed. Santa Rosa, Calif., NICU Ink, 2009, pp. 57-74.

32. (A) Malrotation, or volvulus, must be urgently ruled out in any infant presenting with bilious emesis. A volvulus results when the bowel is rotated and wrapped around the mesentery, which obstructs the flow of blood to the bowel. Pyloric stenosis presents with an olive-shaped mass in the epigastric region of the abdomen. Projectile nonbilious vomiting and visible peristaltic waves are also present. Surgical correction is required but not emergent. Duodenal atresia or obstruction of the duodenum presents with abdominal distention and bilious emesis. It is not a surgical emergency. The absence of ganglion cells, usually in the large bowel (Hirschsprung disease), results in diminished peristalsis, abdominal distention, and failure to pass meconium.

Reference: Goodwin, P.: Gastrointestinal assessment. In Tappero, E.P., Honeyfield, M.A. (Eds.): Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination, 4th ed. Santa Rosa, Calif., NICU Ink, 2009, pp. 105-114.

33. (B) Turner syndrome occurs in 1 in 2500 live-born female infants. The absence of the second X chromosome (45, X) results in widely spaced nipples, a short webbed neck, and edema of the hands and feet. Trisomy 13 occurs in 1 in 5000 births. Findings include cleft lip, polydactyly, microphthalmia, and microcephaly. DiGeorge syndrome, a 22q11 chromosomal deletion, includes physical findings of small abnormally shaped ears, dysmorphic facial features, and congenital heart defects. Features of trisomy 21 (Down syndrome) include hypotonia, excessive skin at the back of the neck, upturned palpebral fissures, simian crease, and a wide space between the first and second toes.

Reference: Bennett, M., Meier, S.: Assessment of the dysmorphic Infant. In Tappero, E.P., Honeyfield, M.A. (Eds.): Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination, 4th ed. Santa Rosa, Calif., NICU Ink, 2009, pp. 201-217.

34. (A) Heroin exposure in pregnancy results in typical symptoms of narcotic withdrawal, usually beginning about 48 hours after delivery. Symptoms of neonatal abstinence syndrome include increased tone and reflexes, tremors, tachypnea, yawning, sneezing, nasal stuffiness, poor feeding, and vomiting. In newborns, the onset of alcohol withdrawal is usually seen between birth and 12 hours of age and includes hypertonia, tremors, and a poor feeding pattern. Excessive crying and exaggerated sucking is reported. Restlessness, irritability, and tremors have been described in cocaine-exposed newborns. These effects are thought to be direct effects of the drug rather than signs of withdrawal. After an initial period of hyperalertness, infants often become drowsy or lethargic. Reported effects of selective serotonin reuptake inhibitors on newborns include seizures, respiratory distress, hypoglycemia, and problems with temperature regulation.

Reference: Pitts, K.: Perinatal substance abuse. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 41-71.

35. (D) Low-set ears are found in conjunction with a number of genetic syndromes. If a line drawn toward the ear from the inner canthus through to the outer canthus of the eye falls above the insertion of the ear, the ear is low set. The size and shape of the nose may vary according to the infant’s size and race. It is not used to determine correct ear position. The orientation of the eyebrow is not relevant in determining ear position. A line from the outer eye to the mastoid process normally bisects the lower portion of the ear.

36. (A) A diffuse petechial rash is suggestive of thrombocytopenia. A low platelet count would be an expected finding. If internal bleeding accompanies petechiae, a low hematocrit may result, but it would not cause the petechial rash. When significant blood loss accompanies thrombocytopenia, anemia may result but is not a contributing factor. Low white blood cell counts are found in newborns with infection, but infection is not a common cause of petechiae.

Reference: Furdon, S.A., Benjamin, K.: Physical assessment. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 120-155.

37. (C) The rash seen in skin infections caused by the herpes simplex virus is often vesicular and may occur first over the area of the body presenting at birth. Disruption of skin integrity provides a portal of entry for the virus. Candida skin infection usually occurs in the diaper area and is characterized by white or yellow pustules on an erythematous base. Klebsiella, a water-borne pathogen, usually causes pneumonia and is not implicated in newborn skin infections. Staphylococcus aureus causes omphalitis abscesses, impetigo, and scalded skin infections in the newborn. Presenting signs include erythema, warmth, tenderness, or bullous lesions. When present, blisters usually begin in the groin area.

Reference: Witt, C.L.: Neonatal dermatology. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 813-831.

38. (D) Port-wine stains in infants with Sturge-Weber syndrome are confined to the area of the face innervated by the trigeminal nerve, including the eyes and nose. Vascular lesions on the neck are most commonly nevus simplex, or “stork bites.” These lesions usually fade with time and have no associated pathology. Port-wine stains can occur on any part of the body, but only those on the face are markers for Sturge-Weber syndrome. Vascular birthmarks on the buttocks are usually mongolian spots, bluish purple lesions resembling bruises.

Reference: Witt, C.L.: Neonatal dermatology. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 813-831.

39. (A) Infants with trisomy 18 have a third copy of chromosome 18. The clinical features include syndactyly, rocker-bottom feet, a narrow pelvis, clenched fists with overlapping fingers, and a short sternum. Infants with trisomy 21, or Down syndrome, have a variety of physical findings, including a fat pad at the back of the neck, epicanthal folds, almond-shaped eyes, and a simian crease. DiGeorge syndrome, or velocardiofacial syndrome, results from a 22q11 deletion. These infants usually have microcephaly, cleft palate, a long face with a prominent nose, and hyperextensible fingers. Six types of osteogenesis imperfecta (OI) have been identified, with effects ranging from macrocephaly and altered dentition to severe growth deficiency with kyphoscoliosis and limb deformities. Clenched hands and rocker-bottom feet are not reported in OI.

Reference: Sterk, L.: Congenital anomalies. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 782-812.

40. (C) Although only 5% to 10% of infants with congenital cytomegalovirus (CMV) infection are symptomatic at birth, chorioretinitis is the single most common symptom. Infants with congenital CMV infection are usually small for gestational age rather than macrosomic. Microphthalmia is a characteristic finding in congenital rubella but is not reported in CMV infection. Pleural effusions are a common manifestation of congenital parvovirus infection, which causes anemia that results in the development of nonimmune hydrops.

Reference: Askin, D.F., Diehl-Jones, W.: Ophthalmologic and auditory disorders. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 832-849.

41. (B) Among infants with omphalocele, 45% to 55% have accompanying anomalies. Fifty percent of these anomalies involve the heart and 40% involve the neural tube. Only 10% to 15% of infants with gastroschisis have associated anomalies. These usually involve the gastrointestinal system. The incidence of pyloric stenosis is 3 in 1000 live births, but associated anomalies are rare. Hirschsprung disease may be associated with colonic atresia or imperforate anus, but these conditions are not common.

Reference: Bradshaw, W.T.: Gastrointestinal disorders. In Verklan, M.T., Walden, M. (Eds.): Core Curriculum for Neonatal Intensive Care Nursing, 4th ed. St. Louis, Saunders, 2010, pp. 589-637.

42. (B) Erythema toxicum, a benign transient neonatal skin condition, consists of patches of erythematous skin with a yellow or white central pustule. It appears between 24 and 72 hours after birth and can affect any area of the body except the palms or soles. Milia appear as small yellow-white cysts usually found on the cheeks, forehead, and nose. They occur in clusters. Candidiasis is usually found in the groin area and presents as an area of generalized erythema with pebbly white satellite lesions. Transient neonatal pustular melanosis is usually present at birth. It occurs most commonly on the face, hands, and soles of the feet. It is most frequently seen in black infants.

References: Blackburn, S.T.: Maternal, Fetal, and Neonatal Physiology. A Clinical Perspective. St. Louis, Saunders, 2007, p. 531

Lund, C.H., Kuller, J.M.: Integumentary system. In Kenner, C., Wright Lott, J. (Eds.): Comprehensive Neonatal Care: An Interdisciplinary Approach, 4th ed. St. Louis, Saunders, 2007, p. 71.

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Jul 11, 2016 | Posted by admin in NURSING | Comments Off

Nurse Key

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Section I: General Assessment and Management

Chapter 1: Assessment of Fetal Well-Being

Chapter 2: Adaptation to Extrauterine Life

Chapter 3: Neonatal Resuscitation

Chapter 4: Physical Assessment

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Nurse Key

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Section I: General Assessment and Management

Chapter 1: Assessment of Fetal Well-Being

Chapter 2: Adaptation to Extrauterine Life

Chapter 3: Neonatal Resuscitation

Chapter 4: Physical Assessment

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