RNC-NIC Neonatal Intensive Care Nursing Certification Exam — Questions and Answers

Question 1: Which finding on a chest X-ray is most consistent with meconium aspiration syndrome?

Cardiomegaly with pleural effusions
Bilateral white-out appearance
Diffuse ground-glass opacities
Hyperinflation with patchy infiltrates (Correct answer)

Correct answer: Hyperinflation with patchy infiltrates

MAS typically shows hyperinflation with coarse, asymmetric patchy infiltrates due to air trapping and atelectasis.

Question 2: Which of the following gives the recommended daily calorie intake for the infant?

Post-surgical 2800 g infant receiving 60cc half-strength formula by bottle every 3 hours
None of the above
Healthy 2500 g infant receiving 55 cc expressed human milk by gavage every 3 hours (Correct answer)
Healthy 3400 g infant receiving 3.5 oz fortified preterm formula by bottle every 4 hours

Correct answer: Healthy 2500 g infant receiving 55 cc expressed human milk by gavage every 3 hours

For enteral feedings, a typical, developing preterm infant's total daily calorie need is between 105-120 kcal/kg/day. Human milk and normal formula have a calorie content of 20 kcal/oz. Preterm formulations fortified with 22-24 kcal/oz. Human milk or formula at half strength contains 10 kcal/oz. Parenteral dietary needs are approximately 20% lower, ranging from 85-100 kcal/kg/day. Many aspects are considered while establishing an infant's proper calorie intake, including activity, body temperature, and stress level. Infants who are under stress (such as those who have just had surgery) will require extra calories per day.

Question 3: Which electrolyte imbalance is most common in preterm neonates in the first week of life due to immature renal tubular function?

Hyponatremia (Correct answer)
Hypercalcemia
Hypermagnesemia
Hyperphosphatemia

Correct answer: Hyponatremia

Preterm neonates lose excess sodium in urine due to immature renal tubular sodium reabsorption, causing late hyponatremia.

Question 4: Developmentally supportive care in the NICU includes which practice?

Maximizing environmental stimulation at all times
Discouraging parental presence during cares
Clustering care activities to allow extended periods of undisturbed sleep (Correct answer)
Performing all assessments on a strict hourly schedule

Correct answer: Clustering care activities to allow extended periods of undisturbed sleep

Clustering cares reduces the number of infant disturbances, protecting sleep cycles and supporting neurodevelopmental outcomes.

Question 5: A neonate with persistent pulmonary hypertension (PPHN) does not improve with 100% oxygen. Which inhaled medication is the first-line treatment?

Inhaled albuterol
Inhaled surfactant
Inhaled prostacyclin (epoprostenol)
Inhaled nitric oxide (iNO) (Correct answer)

Correct answer: Inhaled nitric oxide (iNO)

Inhaled nitric oxide selectively dilates pulmonary vasculature without systemic hypotension and is the first-line therapy for PPHN.

Question 6: Which finding is the earliest sign of respiratory distress syndrome (RDS) in a newborn?

Bradycardia
Decreased tone
Grunting on expiration (Correct answer)
Central cyanosis

Correct answer: Grunting on expiration

Expiratory grunting is an early compensatory mechanism to maintain functional residual capacity in RDS.

Question 7: A nurse notes a neonate's skin color is blue centrally including the lips and mucous membranes. This is classified as:

Acrocyanosis, a normal newborn variant
Physiologic jaundice
Cutis marmorata from cold exposure
Central cyanosis, indicating low arterial oxygen saturation (Correct answer)

Correct answer: Central cyanosis, indicating low arterial oxygen saturation

Central cyanosis involving mucous membranes indicates systemic hypoxemia and requires immediate assessment and intervention.

Question 8: A neonate receives phenobarbital for seizures. Which side effect requires close monitoring?

Hyperglycemia
Thrombocytopenia
Respiratory depression and sedation (Correct answer)
Hypertension

Correct answer: Respiratory depression and sedation

Phenobarbital causes CNS and respiratory depression, requiring continuous monitoring of respiratory rate and oxygen saturation.

Question 9: Vitamin K is administered to all newborns at birth to prevent:

Hemorrhagic disease of the newborn (Correct answer)
Group B Streptococcus infection
Transient tachypnea
Neonatal jaundice

Correct answer: Hemorrhagic disease of the newborn

Neonates have low vitamin K stores and immature gut flora, placing them at risk for vitamin K deficiency bleeding (VKDB).

Question 10: Indomethacin is used in the NICU to treat which condition?

Patent ductus arteriosus (Correct answer)
Hyperglycemia
Hyperbilirubinemia
Neonatal seizures

Correct answer: Patent ductus arteriosus

Indomethacin is a COX inhibitor that promotes ductal closure by blocking prostaglandin synthesis, which keeps the PDA open.

Question 11: Hypoxic-ischemic encephalopathy (HIE) is graded using the Sarnat classification. Grade II (moderate) HIE is characterized by:

Coma, flaccidity, and absent primitive reflexes
Mild irritability with normal feeding
Lethargy, hypotonia, absent Moro reflex, and possible seizures (Correct answer)
Hyperalertness and normal tone

Correct answer: Lethargy, hypotonia, absent Moro reflex, and possible seizures

Sarnat Grade II HIE presents with lethargy, hypotonia, suppressed primitive reflexes, and seizures occurring within 24 hours of birth.

Question 12: The primary method for assessing fetal health at the moment is the biophysical profile (BPP), which examines a variety of functions that the central nervous system regulates and that are oxygenation-sensitive. The BPP includes the following five variables:

Fetal heart rate, fetal movement, nonstress test, amniotic fluid volume, and fetal tone
Fetal tone, fetal position, amniotic fluid volume, fetal heart rate, and fetal activity
Fetal tone, fetal breathing, fetal movement, non-stress test, and amniotic fluid volume (Correct answer)
Fetal movement, fetal tone, non-stress test, and amniotic fluid index, and fetal position

Correct answer: Fetal tone, fetal breathing, fetal movement, non-stress test, and amniotic fluid volume

According to the biophysical profile (BPP), more variables are a stronger predictor of outcome than fewer ones. Each indication receives a value of 0 if it is missing or 2 points if it is present, and management is based on the overall score. A score of 10 suggests that fetal hypoxia is quite improbable. For the remaining components, the BPP consists of a nonstress test employing an electronic fetal monitor and real time restricted ultrasonography to watch the fetus. Fetal tone, fetal movement, fetal breathing, the nonstress test, and the amniotic fluid index are among the components. The BPP does not account for fetal posture or heart rate.

Question 13: A neonate develops a sudden deterioration in oxygen saturation, decreased breath sounds on the left, and shift of heart sounds to the right. What is the most likely diagnosis?

Right-sided pneumothorax
Left-sided pneumothorax (Correct answer)
Pulmonary hemorrhage
Pleural effusion

Correct answer: Left-sided pneumothorax

Decreased left breath sounds with rightward mediastinal shift indicates a left-sided pneumothorax causing tension physiology.

Question 14: Neonatal seizures most commonly manifest as:

Subtle seizures (eye deviation, lip smacking, cycling limb movements) (Correct answer)
Absence episodes
Myoclonic jerks only
Grand mal tonic-clonic convulsions

Correct answer: Subtle seizures (eye deviation, lip smacking, cycling limb movements)

Due to immature cortical organization, neonatal seizures most often present as subtle signs rather than classic tonic-clonic activity.

Question 15: Necrotizing enterocolitis (NEC) is most commonly seen in:

Infants exclusively receiving breast milk
Preterm infants under 32 weeks gestation (Correct answer)
Post-term infants over 42 weeks
Term infants only

Correct answer: Preterm infants under 32 weeks gestation

NEC primarily affects preterm infants whose immature gut mucosa is susceptible to ischemia and bacterial overgrowth.

Question 16: A neonate is prescribed erythromycin ophthalmic ointment at birth. This is given to prevent:

Retinopathy of prematurity
Cytomegalovirus retinitis
Ophthalmia neonatorum (gonorrheal conjunctivitis) (Correct answer)
Congenital cataracts

Correct answer: Ophthalmia neonatorum (gonorrheal conjunctivitis)

Erythromycin ophthalmic prophylaxis is required by law in most US states to prevent gonococcal and chlamydial ophthalmia neonatorum.

Question 17: Intraventricular hemorrhage (IVH) in preterm infants is most commonly associated with:

Hyperthermia in the first hour
Hyperoxia during delivery
Term birth complicated by prolonged labor
Gestational age under 32 weeks and respiratory distress (Correct answer)

Correct answer: Gestational age under 32 weeks and respiratory distress

IVH risk is highest in the most immature neonates; fragile germinal matrix capillaries rupture under hemodynamic and hypoxic stress.

Question 18: Which infants are at highest risk for hypoglycemia in the first hours of life?

Term AGA infants born at 39–40 weeks
Infants born by elective cesarean section
Infants of diabetic mothers, SGA, LGA, and late preterm infants (Correct answer)
Neonates with O-positive blood type

Correct answer: Infants of diabetic mothers, SGA, LGA, and late preterm infants

IDM, SGA, LGA, and late preterm infants have impaired glucose homeostasis due to hyperinsulinism, poor stores, or metabolic immaturity.

Question 19: Which sign differentiates transient tachypnea of the newborn (TTN) from RDS?

TTN presents with ground-glass changes on chest X-ray
TTN typically resolves within 24–72 hours and occurs in term or near-term infants (Correct answer)
TTN only occurs in preterm infants under 32 weeks
TTN requires surfactant replacement therapy

Correct answer: TTN typically resolves within 24–72 hours and occurs in term or near-term infants

TTN is a self-limited condition in term or near-term infants caused by retained fetal lung fluid that resolves within 72 hours.

Question 20: A NICU nurse is performing developmental positioning for a 28-week preterm neonate. Which position best supports flexion and midline orientation?

Side-lying with knees and elbows flexed toward midline (Correct answer)
Supine with arms extended at sides
Supine with neck hyperextended
Prone with head turned to side and limbs extended

Correct answer: Side-lying with knees and elbows flexed toward midline

Side-lying with flexed extremities brought toward midline mimics the fetal position and promotes neuromotor development.

Question 21: The normal urine output for a neonate after the first 24 hours of life is:

1–3 mL/kg/hour (Correct answer)
0.5 mL/kg/day
0.1–0.5 mL/kg/hour
5–8 mL/kg/hour

Correct answer: 1–3 mL/kg/hour

Normal neonatal urine output of 1–3 mL/kg/hour reflects adequate hydration and renal perfusion after initial physiologic oliguria.

Question 22: A preterm neonate at 28 weeks gestation is placed in a radiant warmer. Which intervention best prevents transepidermal water loss?

Place the infant in a prone position
Administer IV fluids at 100 mL/kg/day
Increase warmer temperature
Apply a polyethylene plastic wrap (Correct answer)

Correct answer: Apply a polyethylene plastic wrap

Polyethylene plastic wraps significantly reduce transepidermal water loss in extremely preterm infants.

Question 23: Which sign indicates hypothermia in a neonate?

Bradypnea with flushed appearance
Hyperthermia with bulging fontanelle
Peripheral vasoconstriction, lethargy, poor feeding, and acrocyanosis (Correct answer)
Fever, tachycardia, and diaphoresis

Correct answer: Peripheral vasoconstriction, lethargy, poor feeding, and acrocyanosis

Cold stress causes peripheral vasoconstriction to conserve heat; neonates respond with lethargy, poor feeding, and acrocyanosis.

Question 24: Periventricular leukomalacia (PVL) in preterm infants results from:

Hemorrhage into the germinal matrix
Bacterial meningitis always
Elevated bilirubin levels
Ischemia to the periventricular white matter causing cystic necrosis (Correct answer)

Correct answer: Ischemia to the periventricular white matter causing cystic necrosis

PVL is caused by hypoxic-ischemic injury to immature oligodendrocyte precursors in periventricular white matter, leading to motor and cognitive deficits.

Question 25: A neonate has a serum sodium of 125 mEq/L. The nurse anticipates which clinical manifestation?

Hypertension and edema
Tachycardia and dry mucous membranes
Seizures, irritability, and poor feeding (Correct answer)
Polydipsia and polyuria

Correct answer: Seizures, irritability, and poor feeding

Severe hyponatremia (Na <130 mEq/L) causes cerebral edema manifesting as irritability, seizures, and neurological deterioration.

Question 26: A neonate has cyanotic legs and toes, but his upper extremities and head are pink. The respiratory rate is 55 beats per minute and the heart rate is 120 beats per minute with a loud murmur. What sort of cyanosis is more likely to be present?

Central pulmonary cyanosis
Differential cyanosis (Correct answer)
None of the above
Central cardiac cyanosis

Correct answer: Differential cyanosis

Central, peripheral, and differential cyanosis are the three basic forms. The infant's lower extremities are frequently cyanotic while the upper extremities and head stay pink in differential cyanosis. The existence of a PDA (patent ductus arteriosus) is the primary cause of differential cyanosis (DC). DC occurs when unoxygenated blood is pushed through the PDA opening in the heart and into the descending aorta, causing cyanosis in just the lower limbs. Large PDAs can generate extremely loud, mechanical-sounding murmurs.

Question 27: Metabolic acidosis in a neonate with normal PaCO2 and low pH is most likely caused by:

Hyperventilation
Respiratory muscle fatigue
Lactic acidosis from poor perfusion or hypoxia (Correct answer)
Excessive CO2 retention

Correct answer: Lactic acidosis from poor perfusion or hypoxia

Metabolic acidosis with normal CO2 indicates a primary metabolic problem, most commonly lactic acidosis from tissue hypoperfusion.

Question 28: Which of the following is required to be an ethical and responsible nurse?

Making decisions independently
Subjective charting
All of the above
Keeping knowledge and skills current (Correct answer)

Correct answer: Keeping knowledge and skills current

It is critical to stay current on one's abilities and knowledge base in an ever-changing area like neonatology, where new technology and treatment methods are always being enhanced. Charting must also be based on objective facts that can be measured and quantified. Feelings are a vital aspect of nursing, but they should not be recorded. Although it is advantageous for a nurse to be able to operate independently without continual monitoring, a nurse should always speak with other colleagues when making decisions.

Question 29: A nurse is caring for a neonate on CPAP. The target SpO2 range for a 26-week gestation infant is:

91–95% (Correct answer)
85–89%
96–100%
80–85%

Correct answer: 91–95%

The recommended SpO2 target for preterm neonates is 91–95% to balance adequate oxygenation with minimizing oxygen toxicity.

Question 30: Persistent pulmonary hypertension of the newborn (PPHN) is characterized by:

Surfactant deficiency as the primary cause
Left-to-right shunting through a PDA only
Elevated pulmonary vascular resistance causing right-to-left shunting (Correct answer)
Low pulmonary arterial pressure

Correct answer: Elevated pulmonary vascular resistance causing right-to-left shunting

PPHN involves failure of normal postnatal pulmonary vascular resistance reduction, causing right-to-left shunting through fetal channels.

Question 31: A 30-week premature neonate is started on caffeine citrate therapy. What is the primary indication for this medication in the NICU?

Treatment of neonatal seizures
Prevention and treatment of apnea of prematurity (Correct answer)
Management of pulmonary hypertension
Promotion of surfactant production

Correct answer: Prevention and treatment of apnea of prematurity

Caffeine citrate is the first-line treatment for apnea of prematurity, stimulating the central respiratory drive.

Question 32: Which arterial blood gas value indicates respiratory acidosis in a neonate?

pH 7.45, PaCO2 35 mmHg
pH 7.38, PaCO2 40 mmHg
pH 7.50, PaCO2 28 mmHg
pH 7.25, PaCO2 58 mmHg (Correct answer)

Correct answer: pH 7.25, PaCO2 58 mmHg

Respiratory acidosis is characterized by a low pH (<7.35) with an elevated PaCO2, indicating inadequate ventilation.

Question 33: Hypocalcemia in a neonate born to a diabetic mother is related to:

Hypomagnesemia impairing PTH secretion (Correct answer)
Maternal calcium supplementation
Excessive calcium excretion
Vitamin D toxicity

Correct answer: Hypomagnesemia impairing PTH secretion

IDM neonates often have hypomagnesemia, which impairs PTH secretion and leads to secondary hypocalcemia.

Question 34: Which congenital heart defect is considered ductal-dependent for systemic circulation, requiring prostaglandin E1 to maintain cardiac output?

Ventricular septal defect (VSD)
Hypoplastic left heart syndrome (HLHS) (Correct answer)
Pulmonary stenosis with intact ventricular septum
Atrial septal defect (ASD)

Correct answer: Hypoplastic left heart syndrome (HLHS)

HLHS has a severely underdeveloped left heart, making systemic perfusion entirely dependent on right-to-left flow through the ductus arteriosus; closing the ductus is fatal.

Question 35: A NICU nurse is assessing a neonate for patent ductus arteriosus. Which clinical finding is most characteristic?

Continuous machine-like murmur at the upper left sternal border (Correct answer)
Systolic murmur at the lower left sternal border
Diastolic murmur at the apex
Fixed split S2

Correct answer: Continuous machine-like murmur at the upper left sternal border

PDA produces a continuous machine-like murmur best heard at the upper left sternal border due to shunting between the aorta and pulmonary artery.

Question 36: Which intervention best prevents heat loss by evaporation immediately after birth for a premature infant?

Bathing immediately after birth
Vigorous drying with warm towels
Immediately wrapping in a polyethylene plastic bag without drying (Correct answer)
Placing under a radiant warmer without any covering

Correct answer: Immediately wrapping in a polyethylene plastic bag without drying

Polyethylene wrapping without drying prevents evaporative heat loss by retaining body moisture against the skin in preterm infants.

Question 37: Gastroesophageal reflux in the NICU is best managed initially by:

Positioning, smaller more frequent feeds, and thickening feeds before pharmacotherapy (Correct answer)
Omeprazole as first-line therapy
Immediate Nissen fundoplication
Stopping all oral feeds indefinitely

Correct answer: Positioning, smaller more frequent feeds, and thickening feeds before pharmacotherapy

Conservative non-pharmacological measures are first-line for neonatal GER; evidence for pharmacotherapy in neonates is limited and carries risks.

Question 38: Furosemide is used in the NICU to manage:

Fluid overload and pulmonary edema (Correct answer)
Hypoglycemia
Neonatal abstinence syndrome
Hyperbilirubinemia

Correct answer: Fluid overload and pulmonary edema

Furosemide is a loop diuretic that promotes sodium and water excretion to manage fluid overload, edema, and chronic lung disease.

Question 39: A neonate on CPAP has a CPAP pressure of 6 cmH2O. The primary purpose of this pressure is to:

Reduce pulmonary blood flow
Maintain functional residual capacity and prevent alveolar collapse (Correct answer)
Deliver supplemental oxygen directly
Prevent gastric reflux

Correct answer: Maintain functional residual capacity and prevent alveolar collapse

CPAP maintains positive end-expiratory pressure to keep alveoli open and preserve functional residual capacity between breaths.

Question 40: Amplitude-integrated EEG (aEEG) in the NICU is used primarily to:

Assess brain stem reflexes
Measure intracranial pressure
Continuously monitor background cerebral activity and detect seizures (Correct answer)
Monitor peripheral nerve function

Correct answer: Continuously monitor background cerebral activity and detect seizures

aEEG provides continuous bedside monitoring of cerebral electrical activity to detect seizures and assess brain function in at-risk neonates.

Question 41: A neonate has a serum sodium of 125 mEq/L and is symptomatic with seizures. What is the most appropriate initial treatment?

Restrict all IV fluids
Increase free water intake
Give oral sodium supplements
Administer hypertonic 3% saline slowly (Correct answer)

Correct answer: Administer hypertonic 3% saline slowly

Symptomatic hyponatremia with seizures requires cautious correction with hypertonic saline to raise sodium rapidly enough to stop seizures.

Question 42: What is the significance of weight loss greater than 10% of birth weight in the first week of life?

Requires immediate blood transfusion
Is a normal physiologic adaptation requiring no action
Indicates the infant has congenital renal disease
Suggests inadequate fluid or nutritional intake requiring assessment (Correct answer)

Correct answer: Suggests inadequate fluid or nutritional intake requiring assessment

Weight loss >10% of birth weight exceeds normal physiologic diuresis and indicates potentially inadequate hydration or nutrition.

Question 43: Which of the following indicates the need for complete parenteral nutrition?

Vomiting
Short-gut syndrome (Correct answer)
Transient diarrhea
All of the above

Correct answer: Short-gut syndrome

Bypassing the GI tract, total parenteral nutrition (TPN) allows doctors to provide patients the vital nutrients they need. Because this frequently necessitates long-term IV access, it is only regarded suitable when full bowel rest is required. This might include neonatal short-gut syndrome, gastroschisis, intestinal blockage, or persistent diarrhea. TPN administration is fraught with danger and should only be utilized when absolutely required.

Question 44: A term neonate has a heart rate of 90 bpm immediately after birth. What is the priority action?

Provide supplemental oxygen via mask
Administer epinephrine
Start chest compressions
Begin positive pressure ventilation (Correct answer)

Correct answer: Begin positive pressure ventilation

A heart rate below 100 bpm after birth requires immediate positive pressure ventilation per NRP guidelines.

Question 45: What is the most common ECMO (extracorporeal membrane oxygenation) complication?

None of the above
Infection
Thrombosis
Bleeding (Correct answer)

Correct answer: Bleeding

The most common complication of ECMO is bleeding, which is likely due to the massive quantities of heparin required to keep the blood from clotting during the mechanical procedure. Bleeding may occur in any internal organ, but it is most dangerous when it happens in the brain. As a result, newborns receiving ECMO are checked for cerebral hemorrhages on a regular basis.

Question 46: Short bowel syndrome following NEC surgery is caused by:

Vitamin deficiency alone
Insufficient intestinal absorptive surface area after resection of necrotic bowel (Correct answer)
Normal variant of intestinal growth
Excessive feeding after surgery

Correct answer: Insufficient intestinal absorptive surface area after resection of necrotic bowel

Extensive bowel resection for NEC leaves insufficient surface area for nutrient and fluid absorption, causing malabsorption and TPN dependence.

Question 47: Which electrolyte abnormality is most commonly associated with early-onset seizures in a term neonate?

Hypercalcemia
Hyperkalemia
Hypoglycemia (Correct answer)
Hyponatremia

Correct answer: Hypoglycemia

Hypoglycemia is a leading cause of early neonatal seizures and must be checked and corrected promptly.

Question 48: Which assessment finding best indicates a neonate requires suctioning of the airway?

Heart rate above 150 bpm
Audible secretions, increased work of breathing, or decreased SpO2 (Correct answer)
Routine time-based schedule regardless of clinical status
Temperature instability alone

Correct answer: Audible secretions, increased work of breathing, or decreased SpO2

Suctioning should be clinically indicated by signs of airway obstruction such as audible secretions, respiratory distress, or desaturation.

Question 49: Which acid-base disturbance is most commonly seen in a neonate with severe respiratory distress syndrome?

Mixed metabolic and respiratory alkalosis
Respiratory acidosis (Correct answer)
Respiratory alkalosis
Metabolic alkalosis

Correct answer: Respiratory acidosis

RDS causes CO2 retention due to alveolar collapse, resulting in respiratory acidosis.

Question 50: Surfactant replacement therapy is MOST indicated for which condition?

Transient tachypnea of the newborn
Meconium aspiration syndrome
Respiratory distress syndrome (Correct answer)
Persistent pulmonary hypertension

Correct answer: Respiratory distress syndrome

Surfactant replacement therapy is the primary treatment for RDS caused by surfactant deficiency in preterm infants.

Question 51: What causes neonatal pneumothorax the most frequently?

Atrial/septal defects
RDS (respiratory distress syndrome) (Correct answer)
None of the above
Shock

Correct answer: RDS (respiratory distress syndrome)

Respiratory distress syndrome, caused by a shortage of pulmonary surfactant required to preserve alveolar integrity, is a significant and rather common condition in premature infants. When RDS is severe, the newborn may require mechanical ventilation, which raises the air pressure in the neonatal lungs dramatically. The damage caused by the increased air pressure on already weakened and noncompliant alveoli might lead them to burst, resulting in neonatal pneumothoraxes.

Question 52: Which developmental care intervention has the strongest evidence for reducing pain during minor procedures in preterm neonates?

Oral sucrose with non-nutritive sucking (Correct answer)
Swaddling alone
Dimming room lights
Playing recorded lullabies

Correct answer: Oral sucrose with non-nutritive sucking

Oral sucrose combined with non-nutritive sucking is the best-evidenced pharmacologic and behavioral pain management strategy for minor neonatal procedures.

Question 53: Which sign is an early indicator of feeding intolerance in a tube-fed neonate?

Increased urine output
Weight gain greater than 30 g/day
Increasing gastric residuals, abdominal distension, or emesis (Correct answer)
Improving SpO2 after feedings

Correct answer: Increasing gastric residuals, abdominal distension, or emesis

Increasing gastric residuals, abdominal distension, and vomiting are early signs of feeding intolerance requiring reassessment of feeding plan.

Question 54: An ideal gestational duration for glucose screening in women at low risk of developing gestational diabetes in pregnancy is:

20-21 weeks' gestation
32-34 weeks' gestation
22-23 weeks' gestation
24-28 week's gestation (Correct answer)

Correct answer: 24-28 week's gestation

Patients are tested between 24-28 weeks' gestation if they meet the low-risk criteria for gestational diabetes (25 years, normal weight, belonging to an ethnic group with a low prevalence of diabetes, no first-degree relatives with diabetes, no history of abnormal glucose tolerance, and no history of poor obstetric outcome). Patients with risk factors (>35 years, BMI >30, history of gestational diabetes, delivery of a large-for-gestational-age infant, polycystic ovarian syndrome, strong family history of diabetes) should have a plasma glucose screening at their first prenatal visit, followed by another at 24-28 weeks.

Question 55: The NICU nurse caring for an infant with HIE on therapeutic hypothermia should position the infant:

Head-down Trendelenburg position
Supine with head midline and slightly elevated to 15–30 degrees (Correct answer)
Left lateral decubitus position
Prone only

Correct answer: Supine with head midline and slightly elevated to 15–30 degrees

Head midline positioning with slight elevation reduces ICP and promotes venous drainage in infants with suspected brain injury.

Question 56: Brown adipose tissue (BAT) in neonates is used for:

Shivering-based heat production
Immune function
Energy storage only
Non-shivering thermogenesis to generate heat (Correct answer)

Correct answer: Non-shivering thermogenesis to generate heat

Neonates cannot shiver effectively; they rely on BAT metabolism (non-shivering thermogenesis) mediated by norepinephrine to generate heat.

Question 57: A neonatal nurse is administering a loading dose of phenobarbital 20 mg/kg IV. The maximum infusion rate should be no faster than:

20 mg/kg/min
1 mg/kg/min (Correct answer)
5 mg/kg/min
10 mg/kg/min

Correct answer: 1 mg/kg/min

Phenobarbital must be infused slowly at no more than 1 mg/kg/min to prevent respiratory depression and cardiovascular collapse.

Question 58: A neonate at 27 weeks gestation is receiving mechanical ventilation. Which ventilator setting primarily controls oxygenation?

FiO2 and PEEP (Correct answer)
Inspiratory time
Peak inspiratory pressure
Respiratory rate

Correct answer: FiO2 and PEEP

Oxygenation is primarily regulated by FiO2 and PEEP, which determine mean airway pressure and alveolar recruitment.

Question 59: Dopamine at low doses (1–5 mcg/kg/min) in neonates primarily causes:

Systemic vasoconstriction
Decreased heart rate
Renal and mesenteric vasodilation (Correct answer)
Bronchodilation

Correct answer: Renal and mesenteric vasodilation

Low-dose dopamine acts on dopaminergic receptors to cause renal and mesenteric vasodilation, increasing organ perfusion.

Question 60: The BEST indication of fetal oxygenation status during labor when electronic fetal monitoring is used is:

Moderate fetal heart rate variability (Correct answer)
Absence of decelerations of the fetal heart rate
Presence of accelerations in the fetal heart rate
Fetal heart rate baseline within the normal range

Correct answer: Moderate fetal heart rate variability

Moderate fetal heart rate (FHR) variability is closely related with an arterial umbilical greater than 7.15. Normal FHR variability gives confidence concerning fetal health and the absence of metabolic acidemia. FHR variability is the most accurate predictor of fetal well-being. Variability is the most significant single FHR attribute. Regardless of gestational age, the FHR baseline is 110 to 160 bpm. Decelerations are caused by head compression, umbilical cord compression, or a temporary disruption in oxygen delivery. The nonstress test is based on accelerations, which are strongly predictive of the absence of fetal metabolic acidemia. They occur in tandem with fetal movement.

Question 61: The fluid of choice for volume resuscitation in a hemodynamically unstable neonate is:

Normal saline (0.9% NaCl) 10 mL/kg IV bolus (Correct answer)
Albumin 5% 20 mL/kg
D10W 20 mL/kg
D5 0.45% NaCl

Correct answer: Normal saline (0.9% NaCl) 10 mL/kg IV bolus

Normal saline 10 mL/kg is the first-line isotonic volume expander for neonatal hypovolemia and poor perfusion.

Question 62: Four-extremity blood pressure measurement in a neonate is performed primarily to screen for which condition?

Pulmonary arterial hypertension
Transposition of the great arteries
Coarctation of the aorta (Correct answer)
Tetralogy of Fallot

Correct answer: Coarctation of the aorta

Coarctation of the aorta creates a pressure gradient between the upper and lower extremities; a difference greater than 10-20 mmHg suggests significant coarctation.

Question 63: A preterm infant at 28 weeks gestation is placed on mechanical ventilation. Which ventilator parameter directly controls oxygenation?

Peak inspiratory pressure only
FiO2 and PEEP (Correct answer)
Tidal volume only
Rate and inspiratory time

Correct answer: FiO2 and PEEP

FiO2 and PEEP are the primary ventilator parameters that control oxygenation in mechanically ventilated neonates.

Question 64: Which of the following is a contraindication to lumbar puncture in a neonate?

Elevated C-reactive protein
Normal CBC results
Gestational age over 35 weeks
Cardiorespiratory instability, thrombocytopenia, or skin infection at the puncture site (Correct answer)

Correct answer: Cardiorespiratory instability, thrombocytopenia, or skin infection at the puncture site

Lumbar puncture is contraindicated when the neonate is hemodynamically unstable, has coagulopathy, or has infection near the puncture site.

Question 65: A nurse is caring for a neonate with suspected hypoxic-ischemic encephalopathy (HIE). Which intervention is the standard of care to improve neurological outcomes?

Aggressive fluid resuscitation
Therapeutic hypothermia (cooling to 33–34°C for 72 hours) (Correct answer)
Immediate hyperventilation to reduce cerebral edema
Prophylactic phenobarbital for all HIE cases

Correct answer: Therapeutic hypothermia (cooling to 33–34°C for 72 hours)

Therapeutic hypothermia (33–34°C for 72 hours) initiated within 6 hours of birth is the standard neuroprotective treatment for moderate-to-severe HIE.

Question 66: Which maternal history finding is an important risk factor for early-onset neonatal sepsis (EOS)?

Maternal hypothyroidism
Group B Streptococcus (GBS) colonization with inadequate intrapartum prophylaxis (Correct answer)
Maternal use of epidural analgesia
Maternal gestational hypertension

Correct answer: Group B Streptococcus (GBS) colonization with inadequate intrapartum prophylaxis

GBS colonization without adequate intrapartum antibiotics is a leading risk factor for early-onset neonatal sepsis.

Question 67: A bulging anterior fontanelle in a febrile neonate is a sign of:

Dehydration
Increased intracranial pressure (e.g., meningitis) (Correct answer)
Normal variant of head shape
Normal hydration status

Correct answer: Increased intracranial pressure (e.g., meningitis)

A tense, bulging fontanelle indicates elevated intracranial pressure, which in a febrile neonate is a warning sign of meningitis.

Question 68: Grade III IVH is distinguished from Grade II by the presence of:

Blood only in the germinal matrix
Blood filling and distending the ventricles (intraventricular clot with ventricular dilation) (Correct answer)
Blood limited to the choroid plexus
Blood in the subdural space

Correct answer: Blood filling and distending the ventricles (intraventricular clot with ventricular dilation)

Grade III IVH involves blood filling and distending the ventricles, increasing risk of post-hemorrhagic hydrocephalus.

Question 69: Which sign indicates that a neonate receiving phototherapy for hyperbilirubinemia should have therapy temporarily stopped?

Temperature instability and bronze skin discoloration (Correct answer)
Mild loose green stools
Increased wakefulness and feeding
Bilirubin level decreasing by 1 mg/dL in 4 hours

Correct answer: Temperature instability and bronze skin discoloration

Temperature instability or bronze baby syndrome (bronze skin, dark urine) are indications to reassess phototherapy and potential complications.

Question 70: Which neonatal condition presents with 'double bubble' sign on abdominal X-ray?

Duodenal atresia (Correct answer)
Pyloric stenosis
Jejunal atresia
Hirschsprung disease

Correct answer: Duodenal atresia

Duodenal atresia produces the classic 'double bubble' sign representing air in the stomach and proximal duodenum with no distal gas.

Question 71: When giving ampicillin and gentamicin together for neonatal sepsis, they should be administered:

Mixed in the same syringe for convenience
At least 1 hour apart through separate IV lines or sites (Correct answer)
Simultaneously through the same IV line
Only via central venous access

Correct answer: At least 1 hour apart through separate IV lines or sites

Ampicillin and gentamicin are chemically incompatible and inactivate each other when mixed, requiring separate administration.

Question 72: What temperature is considered to be over normal for the core body temperature is hyperthermia?

39 ℃
None of the above
38 ℃
37.5 ℃ (Correct answer)

Correct answer: 37.5 ℃

A neonate's normal body temperature range is 36.5-37.5 °C (97.7-99.5 °F). The World Health Organization defines hyperthermia as a core body temperature more than 37.5 °C. The other responses imply a hyperthermic condition, but they are not used to determine hyperthermia.

Question 73: During a ventilator assessment, the NICU nurse notes rising PaCO2 on blood gas. Which intervention addresses hypercapnia?

Increase ventilator rate or tidal volume (Correct answer)
Decrease inspiratory time
Increase FiO2
Increase PEEP

Correct answer: Increase ventilator rate or tidal volume

Hypercapnia (elevated PaCO2) is corrected by increasing minute ventilation through higher rate or tidal volume.

Question 74: During therapeutic hypothermia for HIE, the target core temperature is:

38–40°C to prevent infection
36–37°C continuously
30–32°C for 24 hours
33–34°C for 72 hours (Correct answer)

Correct answer: 33–34°C for 72 hours

Therapeutic hypothermia for HIE uses systemic cooling to 33–34°C for 72 hours to reduce secondary brain injury from excitotoxicity.

Question 75: A premature infant is transitioning from gavage to oral feeding. The nurse should assess feeding readiness by evaluating:

Cue-based signs: rooting, sucking, alertness, and tolerance of handling (Correct answer)
Weight alone
Laboratory values only
Strict chronological age

Correct answer: Cue-based signs: rooting, sucking, alertness, and tolerance of handling

Cue-based feeding readiness assessment uses behavioral cues like rooting, sucking, and alert state rather than a fixed schedule.

Question 76: A neonate receiving TPN develops glucose in the urine (glucosuria). The most likely cause is:

Hyperglycemia exceeding the renal glucose threshold (Correct answer)
Urinary tract infection
Normal variant in neonates
Renal tubular acidosis

Correct answer: Hyperglycemia exceeding the renal glucose threshold

Neonatal glucosuria occurs when blood glucose exceeds the renal tubular threshold (~150–180 mg/dL), causing glucose to spill into urine.

Question 77: A nurse is caring for a neonate suspected of having congenital hypothyroidism. Which finding would be most consistent with this diagnosis?

Jitteriness and tachycardia
Microcephaly and hypertonia
Jaundice, hypotonia, and large fontanelle (Correct answer)
Petechiae and hepatosplenomegaly

Correct answer: Jaundice, hypotonia, and large fontanelle

Congenital hypothyroidism presents with prolonged jaundice, hypotonia, large fontanelle, and coarse features due to thyroid hormone deficiency.

Question 78: A neonate with suspected NEC has abdominal X-ray showing pneumatosis intestinalis. This finding represents:

Normal bowel gas pattern
Perforation only
Meconium plug
Gas within the intestinal wall, a pathognomonic sign of NEC (Correct answer)

Correct answer: Gas within the intestinal wall, a pathognomonic sign of NEC

Pneumatosis intestinalis (intramural gas) is produced by gas-forming bacteria invading damaged intestinal mucosa and is pathognomonic for NEC.

Question 79: Kangaroo mother care (skin-to-skin) has been shown to:

Be contraindicated for infants on respiratory support
Increase risk of hypothermia in preterm infants
Improve breastfeeding rates, stabilize vital signs, and improve neurodevelopmental outcomes (Correct answer)
Reduce breast milk production

Correct answer: Improve breastfeeding rates, stabilize vital signs, and improve neurodevelopmental outcomes

Kangaroo care provides warmth, promotes bonding, increases milk production, and improves cardiovascular stability in NICU infants.

Question 80: Which one of the following does not physically represent cold stress in a newborn?

None of the above
Bradycardia
Hypertonia (Correct answer)
Lethargy

Correct answer: Hypertonia

In a newborn suffering cold stress, hypertonia does not exist. During cold stress, a newborn can become hypotonic with slack muscular tone, especially preterm infants who may already have some degree of hypotonia due to their immaturity. Because hypotonia can be found in hypoxia, it is critical to identify the source and, if feasible, rectify it. If a newborn develops hypertonia symptoms, an examination into the reason and subsequent care is required.

Question 81: Neonatal pain assessment in a non-verbal preterm infant is best performed using:

A validated neonatal pain scale such as NIPS or PIPP (Correct answer)
Clinical judgment without a standardized tool
Blood pressure changes alone
Heart rate alone

Correct answer: A validated neonatal pain scale such as NIPS or PIPP

Validated multidimensional pain scales (NIPS, PIPP) combine behavioral and physiologic indicators to reliably assess neonatal pain.

Question 82: What is the role of pulmonary surfactant in the newborn?

Prevents bronchoconstriction of the smooth bronchial muscles
None of the above
Increases surface tension in lungs to provide more structure
Prevents alveolar collapse (Correct answer)

Correct answer: Prevents alveolar collapse

Proteins and phospholipids combine to form pulmonary surfactant. It is a chemical that the lungs manufacture and release. It decreases surface tension and lubricates the alveolar surfaces. This keeps the alveolar walls from adhering together during exhalation, which avoids alveolar collapse. Because optimal surfactant synthesis develops later in gestation, preterm babies fewer than 32 weeks are more likely to have surfactant deficits. Pulmonary surfactant deficiency is the most common cause of neonatal respiratory distress syndrome.

Question 83: A nurse is preparing to administer surfactant to a 26-week neonate. Which route is used for administration?

Subcutaneous injection
Directly into the endotracheal tube (Correct answer)
Nebulized via face mask
IV bolus over 30 minutes

Correct answer: Directly into the endotracheal tube

Surfactant is instilled directly into the lungs via the endotracheal tube to coat alveolar surfaces and reduce surface tension.

Question 84: Caffeine citrate is used in the NICU primarily for:

Neonatal seizures
Hyperbilirubinemia
Hypoglycemia
Apnea of prematurity (Correct answer)

Correct answer: Apnea of prematurity

Caffeine citrate is the first-line treatment for apnea of prematurity, stimulating the respiratory center to reduce apneic episodes.

Question 85: The preferred enteral nutrition for preterm infants in the NICU is:

Glucose water initially for all preterm infants
Human breast milk (mother's own milk or pasteurized donor milk) (Correct answer)
Soy-based formula
Standard term infant formula

Correct answer: Human breast milk (mother's own milk or pasteurized donor milk)

Human milk reduces NEC risk, improves immune function, and supports neurodevelopment; it is the gold standard for preterm nutrition.

Question 86: Which statement about neonatal drug dosing is correct?

IM absorption is always more reliable than IV in neonates
Neonates metabolize drugs faster than adults
Neonates have reduced protein binding, increasing free drug availability (Correct answer)
Renal clearance is higher in neonates than adults

Correct answer: Neonates have reduced protein binding, increasing free drug availability

Neonates have lower albumin levels and fetal albumin with reduced binding affinity, resulting in more free (active) drug.

Question 87: The anterior fontanelle normally closes at approximately:

2–3 months of age
24–36 months of age
At birth
12–18 months of age (Correct answer)

Correct answer: 12–18 months of age

The anterior fontanelle closes between 12–18 months as the frontal and parietal bones complete ossification.

Question 88: Which of the following patient situations does not require mechanical ventilation?

None of the above
27-week infant weighing 980 g, respiratory rate 80/min, mild retractions
38-week infant weighing 3200 g, respiratory rate 60/min, grunting, marked retractions, in oxy hood at FiO2 45%, SpO2 falling
34-week infant weighing 2400 g, respiratory rate 42/min, in oxy hood at FiO2 30% (Correct answer)

Correct answer: 34-week infant weighing 2400 g, respiratory rate 42/min, in oxy hood at FiO2 30%

A newborn may require mechanical ventilation for a variety of reasons. To establish if mechanical ventilation is required, all elements of respiratory function must be considered. Signs of approaching respiratory failure (respiratory rate more than 60/min, retractions, grunting, nasal flaring), apnea, and the presence of current respiratory failure are general criteria. Other causes that may necessitate artificial ventilation include congenital defects that interfere with breathing, sick newborns, and infants weighing less than 1000 g.

Question 89: The antifungal medication fluconazole is used prophylactically in the NICU for:

All term neonates with fever
Infants receiving phototherapy
Neonates with RDS
Preterm infants under 1000g to prevent invasive candidiasis (Correct answer)

Correct answer: Preterm infants under 1000g to prevent invasive candidiasis

ELBW infants (<1000g) are at highest risk for invasive Candida infections; fluconazole prophylaxis reduces this risk in high-risk NICUs.

Question 90: What disorders are included in the TORCH syndrome?

Toxoplasmosis, Oliier disease, rheumatic fever, chlamydia, hepatitis
Toxoplasmosis, ochronosis, RH disease, cholera, histoplasmosis
None of the above
Toxoplasmosis, other diseases, rubella, cytomegalovirus, herpes simplex (Correct answer)

Correct answer: Toxoplasmosis, other diseases, rubella, cytomegalovirus, herpes simplex

Toxoplasmosis, various illnesses, rubella, cytomegalovirus, and herpes simplex are all included in the TORCH syndrome. In TORCH syndrome, the "other" group of disorders includes syphilis, coxsackievirus, varicellazoster, parvovirus, and HIV. TORCH syndrome can result in a variety of catastrophic complications on the fetus/neonate, including jaundice, microcephaly, intellectual handicap, deafness, eye difficulties, autism, and death. The prognosis varies according to the type of infection and the stage of pregnancy at the time of infection. If the etiology is bacterial and the mother is treated promptly with antibiotics, the infant has a fair prognosis. If the etiology is viral, there is no effective therapy. In the case of the viral TORCH syndrome, maternal immunization is essential for prevention.

Question 91: Neonatal abstinence syndrome (NAS) is most commonly assessed using the:

Apgar score
Ballard Maturity Scale
Finnegan Neonatal Abstinence Scoring Tool (Correct answer)
CRIES pain scale

Correct answer: Finnegan Neonatal Abstinence Scoring Tool

The Finnegan tool scores 21 signs of neonatal withdrawal to guide pharmacological treatment decisions for NAS.

Question 92: The preferred method for monitoring core temperature in a NICU patient is:

Rectal temperature for all neonates
Axillary temperature with a digital thermometer (Correct answer)
Tympanic thermometer
Skin temperature probe on the abdomen

Correct answer: Axillary temperature with a digital thermometer

Axillary temperature is the safest and most clinically used method in neonates; rectal measurement risks perforation in fragile preterm infants.

Question 93: Which clinical finding is most characteristic of a hemodynamically significant patent ductus arteriosus (PDA) in a premature neonate?

Decreased oxygen requirements over time
Hypertension with decreased pulse pressure
Bounding peripheral pulses with a continuous murmur (Correct answer)
Persistent bradycardia and hypotension

Correct answer: Bounding peripheral pulses with a continuous murmur

A hemodynamically significant PDA causes bounding pulses due to wide pulse pressure and a characteristic continuous 'machinery' murmur from left-to-right shunting.

Question 94: The nurse is preparing to administer IV vancomycin to a 28-week neonate. The most important pre-administration assessment is:

Renal function (serum creatinine) and trough level (Correct answer)
Blood pressure
Temperature
Fontanelle assessment

Correct answer: Renal function (serum creatinine) and trough level

Vancomycin is renally cleared and nephrotoxic; trough levels guide dosing intervals and prevent toxicity in preterm neonates.

Question 95: What is the recommended SpO2 target range for most very preterm infants (less than 32 weeks) in the NICU to balance risk of retinopathy of prematurity against mortality?

80-85%
96-99%
91-95% (Correct answer)
85-89%

Correct answer: 91-95%

Current guidelines recommend SpO2 targets of 91-95% for very preterm infants, as targets below 90% increase mortality risk while targets above 95% increase risk of retinopathy of prematurity.

Question 96: A nurse is preparing to discharge a NICU infant whose mother plans to breastfeed. Which instruction regarding breast milk storage is correct?

Frozen breast milk should be thawed in a microwave for even heating
Refrigerated breast milk is safe for up to 4 days (Correct answer)
Refrigerated breast milk is safe for up to 8 days
Fresh breast milk is safe at room temperature for up to 12 hours

Correct answer: Refrigerated breast milk is safe for up to 4 days

Refrigerated breast milk is safe for up to 4 days (96 hours) at or below 4°C per CDC guidelines for healthy infants.

Question 97: A neonate born to a mother with poorly controlled diabetes has a blood glucose of 28 mg/dL at 1 hour of life and is asymptomatic. What is the best initial management?

Start TPN
Administer IV dextrose 10% bolus immediately
Observe and recheck in 2 hours
Feed the infant breast milk or formula (Correct answer)

Correct answer: Feed the infant breast milk or formula

Asymptomatic hypoglycemia in a neonate able to feed is initially treated with a feeding of breast milk or formula before resorting to IV glucose.

Question 98: The Dubowitz/Ballard examination is used to assess:

Nutritional status
Gestational age based on neuromuscular and physical maturity (Correct answer)
Cardiac function
Pain levels in neonates

Correct answer: Gestational age based on neuromuscular and physical maturity

The Ballard score uses neuromuscular maturity signs (posture, tone) and physical features (skin, ear, genitalia) to estimate gestational age.

Question 99: Which of the following indicators show lower levels in cord blood when women give birth sitting upright?

PCO2 (Correct answer)
pH
PO2
Base Excess

Correct answer: PCO2

When women give birth upright, their PCo2 levels are lower than when they give birth supine. A supine position during labor should be avoided to minimize maternal hypotension and to increase uteroplacental blood flow to keep the fetus pH within normal ranges. Women who give birth in an upright position have higher pH and PO2 values. A normal pH, PO2, and PCo2 should suggest a normal base excess.

Question 100: Which blood glucose level requires immediate intervention in a symptomatic term neonate?

Less than 40 mg/dL (Correct answer)
Less than 60 mg/dL
Less than 50 mg/dL
Less than 70 mg/dL

Correct answer: Less than 40 mg/dL

A blood glucose below 40 mg/dL in a symptomatic term neonate requires immediate IV dextrose treatment per AAP guidelines.

Question 101: Dextrose 10% (D10W) is the standard IV fluid for neonates because:

It contains electrolytes needed for neonatal homeostasis
It is isotonic and safe for peripheral veins
It is the only fluid approved for umbilical lines
It provides glucose to meet high neonatal metabolic demands and prevent hypoglycemia (Correct answer)

Correct answer: It provides glucose to meet high neonatal metabolic demands and prevent hypoglycemia

Neonates have limited glycogen stores and high glucose requirements, making D10W the standard maintenance fluid to prevent hypoglycemia.

Question 102: A nurse preparing to administer surfactant via ET tube should position the infant:

Head elevated at 30 degrees
Prone position
Right lateral decubitus only
Supine with head midline (Correct answer)

Correct answer: Supine with head midline

Supine with the head midline ensures the ET tube is centered and surfactant is distributed evenly to both lungs.

Question 103: A neonate has a pre-ductal SpO2 of 98% and a post-ductal SpO2 of 88%. What does a difference greater than 3-5% most likely indicate?

Respiratory distress syndrome only
Normal physiologic variation between sites
Persistent pulmonary hypertension or a ductal-dependent cardiac lesion (Correct answer)
Peripheral vasoconstriction from cold stress

Correct answer: Persistent pulmonary hypertension or a ductal-dependent cardiac lesion

A pre-to-post-ductal SpO2 difference greater than 3-5% indicates right-to-left shunting through the ductus arteriosus, suggesting PPHN or a duct-dependent cardiac defect.

Question 104: Total parenteral nutrition (TPN) in neonates should be infused through:

Intraosseous access
Any peripheral IV access
Umbilical artery catheter
A central venous catheter when concentrations exceed 12.5% dextrose (Correct answer)

Correct answer: A central venous catheter when concentrations exceed 12.5% dextrose

Hyperosmolar TPN solutions exceeding 12.5% dextrose require central venous access to prevent peripheral vein damage and infiltration.

Question 105: Post-hemorrhagic hydrocephalus after IVH is identified by:

Declining blood pressure
Progressive head circumference increase, bulging fontanelle, and cranial ultrasound findings (Correct answer)
Hyperglycemia
Fever and irritability alone

Correct answer: Progressive head circumference increase, bulging fontanelle, and cranial ultrasound findings

Hydrocephalus after IVH causes CSF accumulation, progressive ventricular dilation seen on cranial ultrasound, and increasing head circumference.

Question 106: Neonatal meningitis most commonly presents with:

Fever or hypothermia, poor feeding, irritability, seizures, and a bulging fontanelle (Correct answer)
Respiratory distress only
A rash with fever
Localized neck stiffness identical to adult meningitis

Correct answer: Fever or hypothermia, poor feeding, irritability, seizures, and a bulging fontanelle

Neonatal meningitis presents with nonspecific signs including temperature instability, poor feeding, and neurological signs like seizures and bulging fontanelle.

Question 107: Cranial ultrasound screening for IVH should be performed in all infants born at:

Only symptomatic neonates
Less than 30 weeks gestation (Correct answer)
All term neonates after birth
Infants over 35 weeks gestation

Correct answer: Less than 30 weeks gestation

AAP guidelines recommend routine cranial ultrasound screening for all infants born before 30 weeks due to high IVH risk.

Question 108: Which medication is used as an antidote for neonatal opioid toxicity?

Atropine
Epinephrine
Naloxone (Correct answer)
Flumazenil

Correct answer: Naloxone

Naloxone is a pure opioid receptor antagonist used to reverse respiratory depression caused by maternal or neonatal opioid exposure.

Question 109: Which of the following symptoms characterizes maternal HELLP syndrome?

Hypertension, electrolyte loss, loss protein
None of the above
Hemolysis, elevated liver enzymes, low platelet count (Correct answer)
Hemorrhage, episodic liver lesions, pulmonary insufficiency

Correct answer: Hemolysis, elevated liver enzymes, low platelet count

Hemolysis, increased liver enzymes, and low platelet count make up the HELLP syndrome, a trio of unique maternal hematologic abnormalities. HELLP syndrome is thought to occur in roughly 1 in every 1500 normal pregnancies and in up to 20% of women with preeclampsia or eclampsia. The causes of the illness is unknown, and it is frequently misidentified as other illnesses or health issues. Because the only effective therapy for HELLP syndrome is infant delivery, the risk of preterm birth is significant.

Question 110: Which route of administration is preferred for emergency medications in neonates when IV access is unavailable?

Subcutaneous
Oral
Intraosseous (IO) (Correct answer)
Intramuscular

Correct answer: Intraosseous (IO)

Intraosseous access provides rapid vascular access for emergency drug administration when IV access cannot be quickly established.

Question 111: High-frequency oscillatory ventilation (HFOV) is distinguished from conventional ventilation by:

Not requiring PEEP
Requiring higher FiO2 settings
Using very small tidal volumes at high frequencies (Correct answer)
Delivering larger breaths less frequently

Correct answer: Using very small tidal volumes at high frequencies

HFOV delivers very small tidal volumes (often less than dead space) at frequencies of 3–15 Hz to minimize lung injury.

Question 112: Which vitamin deficiency is a NICU nurse most concerned about in infants receiving exclusive breast milk without supplementation?

Vitamin E deficiency
Vitamin C deficiency
Vitamin B12 deficiency
Vitamin D deficiency (Correct answer)

Correct answer: Vitamin D deficiency

Breast milk contains insufficient vitamin D; all breastfed infants (including NICU graduates) require 400 IU/day supplementation to prevent rickets.

Question 113: Human milk fortifier (HMF) is added to breast milk for preterm infants because:

HMF reduces NEC risk by adding probiotics
Breast milk alone does not meet the elevated protein, calcium, and phosphorus needs of preterm infants (Correct answer)
Breast milk contains too many calories for preterm infants
Formula is not available in most NICUs

Correct answer: Breast milk alone does not meet the elevated protein, calcium, and phosphorus needs of preterm infants

Preterm infants have higher nutrient requirements for growth; HMF supplements protein, minerals, and vitamins to optimize preterm bone and growth outcomes.

Question 114: At 32 weeks' gestation, a lady arrives at the triage unit concerned because she has been "leaking fluid" from her vagina for the previous hour. She claims she hasn't felt any contractions and that fetal activity is typical. AmniSure, a bedside immunoassay, is used. The test detects a glycoprotein that is prevalent in amniotic fluid. This glycoprotein is known as:

Fetal fibronectin
Alpha-fetoprotein
Placental alpha-microglobulin-1 (Correct answer)
Prolactin

Correct answer: Placental alpha-microglobulin-1

Premature membrane rupture is one of the most prevalent pregnancy problems that results in an infant being admitted to the NICU. AmniSure ROM is a bedside immunoassay test that is straightforward, easy to conduct, quick (5-10 minutes), and less invasive. This test detects a placental glycoprotein that is rich in amniotic fluid but low in maternal blood and cervicovaginal secretions. Prolactin is in charge of priming the breast tissue in preparation for lactation, whereas Alpha-fetoprotein is used to detect neural tube abnormalities (high) and Down Syndrome (low). Fetal fibronectin is an extracellular glycoprotein that acts as an adhesive between the fetal membranes and the uterine wall and is used to predict premature delivery.

Question 115: The caloric goal for adequate growth in a preterm NICU infant is approximately:

110–130 kcal/kg/day (Correct answer)
50–60 kcal/kg/day
80 kcal/kg/day
150–200 kcal/kg/day

Correct answer: 110–130 kcal/kg/day

Preterm infants require 110–130 kcal/kg/day enterally to achieve weight gain of approximately 15–20 g/kg/day comparable to intrauterine growth.

Question 116: Which assessment tool is most commonly used to evaluate pain in nonverbal neonates in the NICU?

Visual Analog Scale
Numeric Rating Scale
Wong-Baker FACES Scale
CRIES or N-PASS Scale (Correct answer)

Correct answer: CRIES or N-PASS Scale

Validated neonatal pain tools like CRIES and N-PASS use behavioral and physiologic indicators since neonates cannot self-report pain.

Question 117: A cyanotic neonate fails to improve despite administration of 100% supplemental oxygen (hyperoxia test). What is the most likely underlying cause?

Respiratory distress syndrome
Meconium aspiration syndrome
Transient tachypnea of the newborn
Cyanotic congenital heart disease (Correct answer)

Correct answer: Cyanotic congenital heart disease

Failure to improve SpO2 above 95% with 100% oxygen (hyperoxia test) strongly suggests cyanotic congenital heart disease with intracardiac right-to-left shunting that bypasses the lungs.

Question 118: Bell's staging criteria classifies NEC into stages I, IIA/B, and IIIA/B. Stage III requires:

Monitoring alone
Medical management only with antibiotics
Phototherapy
Surgical intervention due to intestinal perforation or severe deterioration (Correct answer)

Correct answer: Surgical intervention due to intestinal perforation or severe deterioration

Bell Stage III NEC involves intestinal perforation or clinical deterioration with peritonitis, requiring surgical management including exploratory laparotomy.

Question 119: Which measurement is used to confirm ET tube placement after intubation in a neonate?

Heart rate response only
Pulse oximetry alone
Abdominal girth
Colorimetric CO2 detector plus bilateral chest rise (Correct answer)

Correct answer: Colorimetric CO2 detector plus bilateral chest rise

Colorimetric CO2 detection combined with bilateral chest rise assessment is the recommended confirmation method for neonatal ETT placement.

Question 120: Hypoglycemia in a neonate is defined as a blood glucose level below:

80 mg/dL at all neonatal ages
40–45 mg/dL (2.2–2.5 mmol/L) in the first 48 hours, with treatment thresholds varying by age (Correct answer)
60 mg/dL at all ages
100 mg/dL

Correct answer: 40–45 mg/dL (2.2–2.5 mmol/L) in the first 48 hours, with treatment thresholds varying by age

Neonatal hypoglycemia thresholds vary by postnatal age and risk factors; <40–45 mg/dL in the first 48 hours typically requires intervention.

Question 121: A preterm infant in an open radiant warmer has excessive insensible water losses primarily due to:

Thin, immature skin with high transepidermal water loss (Correct answer)
Excessive respiratory water loss only
High metabolic rate causing sweating
Increased urine output

Correct answer: Thin, immature skin with high transepidermal water loss

Preterm infants have thin, poorly keratinized skin with minimal subcutaneous fat, causing dramatically elevated transepidermal water loss.

Question 122: A nurse notices that a 34-week neonate receiving nasal CPAP has a distended abdomen. What is the most likely explanation?

Air swallowing causing gastric distension (Correct answer)
Hepatosplenomegaly from infection
Ascites from hydrops fetalis
Bowel obstruction from NEC

Correct answer: Air swallowing causing gastric distension

CPAP can cause air swallowing leading to gastric distension; an orogastric tube is often placed to vent the stomach.

Question 123: A 30-week infant's chest X-ray shows a ground-glass appearance with air bronchograms. This is consistent with:

Meconium aspiration syndrome
Congenital pneumonia
Respiratory distress syndrome (Correct answer)
Transient tachypnea of the newborn

Correct answer: Respiratory distress syndrome

Ground-glass opacity with air bronchograms is the classic radiographic finding of RDS due to diffuse alveolar atelectasis.

Question 124: A G2P2 patient at 32 weeks' gestation enters at the triage unit complaining of frequent uterine contractions. Her pregnancy history involves a 34-week premature birth. The nurse does electronic fetal monitoring and takes a detailed history before evaluating her. The patient reports no bleeding or membrane rupture. She hasn't had a vaginal examination or sexual activity in over 24 hours. In this case, the biochemical marker effective for predicting premature delivery is:

Corticotropin-releasing hormone
Placental alpha-microglobulin-1
Fetal fibronectin (Correct answer)
Cervical ferritin

Correct answer: Fetal fibronectin

In the late second and early third trimesters, fetal fibronectin (fFN) is rare in cervicovaginal secretions. fFN is an extracellular glycoprotein that acts as an adhesive between the fetal membrane and the uterine wall and is damaged by inflammation. After a positive test result, a premature delivery within two weeks is likely. Cervical ferritin is an inflammatory marker, not a biomarker, and its presence supports the hypothesis that infection is a mediator of premature delivery. In both term and preterm pregnancies, maternal plasma corticotropin-releasing hormone concentrations are high. It appears to be a part of the same labor route regardless of gestation. Placental alpha-microglobulin-1 is a protein discovered to be a biomarker for membrane rupture.

Question 125: Which primitive reflex is normally absent at birth and indicates neurological damage if present?

Babinski reflex
Asymmetric tonic neck reflex beyond 6 months (Correct answer)
No primitive reflexes are normally absent at birth; all should be present
Moro reflex

Correct answer: Asymmetric tonic neck reflex beyond 6 months

The asymmetric tonic neck reflex (ATNR) is normal in newborns but persistent beyond 6 months suggests upper motor neuron pathology.

Question 126: Which test is most accurate in determining prenatal lung maturity in a diabetic mother's infant?

Lemellar body count
Phosphatidylglycerol level (Correct answer)
Lecithin/sphyngomyelin ratio
Fetal lung maturity test

Correct answer: Phosphatidylglycerol level

Blood glucose management is the most important factor impacting pulmonary maturity in diabetes moms' babies. Fetal lung development is not delayed in women who have adequate control. Phosphatidylglycerol (PG) promotes phospholipid distribution on alveoli and its presence signals advanced fetal lung development and function. The fetal lung maturity test measures surfactant levels in milligrams per gram of albumin. The test utilized is the AminoSTAT, which utilizes 55mg of surfactant/gram albumin as "mature." Lamellar bodies are lamellated phospholipids that constitute a surfactant storage form. Because lamellar bodies are comparable in size to platelets, a lamellar body count may be acquired quickly using a hematology analyzer's platelet channel. It is proposed that the fetal lung maturity cut off be 50,000 microliters. When combined with the PG test, the lecithin/sphingomyelin ratio is optimal. The PG represents the advanced stage of progressive lung development.

Question 127: The NICU nurse notes a 30-week infant's feeding tube aspirate is bright green/bile-stained. The immediate action is:

Hold the feeding, notify the provider, and assess for signs of obstruction or NEC (Correct answer)
Administer an antacid
Increase the feeding rate
Continue feeding as bile-stained aspirates are normal

Correct answer: Hold the feeding, notify the provider, and assess for signs of obstruction or NEC

Bilious gastric aspirates suggest bowel obstruction, malrotation, or NEC and require immediate medical evaluation before continuing feeds.

Question 128: The thermoneutral zone for a neonate is defined as:

The environmental temperature range in which metabolic rate is minimal and body temperature is normal (Correct answer)
The incubator temperature for all neonates
The temperature at which neonates begin shivering
The core temperature range considered safe for neonates

Correct answer: The environmental temperature range in which metabolic rate is minimal and body temperature is normal

The thermoneutral zone minimizes metabolic oxygen consumption while maintaining normal body temperature through minimal thermogenesis.

Question 129: Hyperkalemia in the first 72 hours of life in an extremely preterm infant is most likely caused by:

Renal failure with oliguria
Excessive potassium supplementation
Adrenal insufficiency
Non-oliguric hyperkalemia from immature Na/K-ATPase pump activity (Correct answer)

Correct answer: Non-oliguric hyperkalemia from immature Na/K-ATPase pump activity

ELBW infants frequently develop non-oliguric hyperkalemia due to immature Na/K-ATPase function causing potassium to shift from cells.

Question 130: Bronchopulmonary dysplasia (BPD) is defined as a need for supplemental oxygen at:

36 weeks postmenstrual age (Correct answer)
Discharge from the NICU
28 days of life in all infants
Term corrected age only

Correct answer: 36 weeks postmenstrual age

BPD is defined as supplemental oxygen requirement or respiratory support at 36 weeks postmenstrual age in preterm infants.

Question 131: The sucking-swallowing-breathing coordination necessary for safe oral feeding typically matures at approximately:

Term (40 weeks) and not before
24–28 weeks gestational age
6 weeks postnatal age regardless of gestation
33–35 weeks postmenstrual age (Correct answer)

Correct answer: 33–35 weeks postmenstrual age

Coordinated sucking, swallowing, and breathing for safe oral feeding develops between 33–35 weeks PMA in most preterm infants.

Question 132: Minimal enteral feeding (trophic feeding) in preterm infants is initiated to:

Prevent hypoglycemia by providing glucose calories
Replace TPN entirely from day one
Achieve full caloric nutrition immediately
Stimulate gut development, improve intestinal maturity, and prime the GI tract (Correct answer)

Correct answer: Stimulate gut development, improve intestinal maturity, and prime the GI tract

Trophic feeds of 10–20 mL/kg/day stimulate gut hormones, villous development, and enzyme maturation without significant caloric contribution.

Question 133: When administering gentamicin to a neonate, the nurse should monitor which laboratory value most closely?

Serum glucose
Bilirubin level
Platelet count
Serum creatinine and BUN (Correct answer)

Correct answer: Serum creatinine and BUN

Gentamicin is nephrotoxic and ototoxic; serum creatinine and BUN must be monitored to detect aminoglycoside-induced renal injury.

Question 134: Which complication is the NICU nurse most concerned about when a preterm infant receives a rapid IV fluid bolus?

Intraventricular hemorrhage (Correct answer)
Meconium aspiration
Hypercalcemia
Hyperglycemia

Correct answer: Intraventricular hemorrhage

Rapid fluid boluses can cause sudden fluctuations in cerebral blood flow, increasing the risk of intraventricular hemorrhage in preterm neonates.

Question 135: A neonate is receiving a prostaglandin E1 (PGE1) infusion. The nurse should monitor for which adverse effect?

Hypoglycemia
Bradycardia
Hypertension
Apnea (Correct answer)

Correct answer: Apnea

PGE1 commonly causes apnea in neonates, requiring respiratory support and monitoring for all infants receiving this medication.

Question 136: At 30 weeks' gestation, a baby was delivered. She'll be flying home on room air. She tolerates bottle feedings well and has breastfed successfully twice in the NICU. The mother want to continue nursing at home. Which of the following things should be addressed in discharge planning/teaching at this time?

Special equipment needs
Physical therapy
Lactation consult (Correct answer)
All of the above

Correct answer: Lactation consult

It is always a good idea to organize a lactation consult when releasing any newborn whose mother intends to nurse at home. By offering a professional/competent source of evaluation, encouragement, training, and troubleshooting, this will guarantee the best possibility for successful home nursing. It is not essential to arrange for physical/occupational treatment or any durable medical equipment at this time because this child is not going home with any special equipment and is not demonstrating any physical difficulties that require therapy. However, it is critical to educate parents/caregivers on the potential developmental problems associated with preterm. Encourage the parents to contact their doctor if they have any questions or concerns.

Question 137: A neonate born at 34 weeks has decreased tone, minimal response to stimulation, and poor suck. These findings are MOST consistent with:

Normal development for 34 weeks gestation
Hypotonia from prematurity, birth asphyxia, or CNS depression (Correct answer)
Hyperkalemia
Hyperthyroidism

Correct answer: Hypotonia from prematurity, birth asphyxia, or CNS depression

Hypotonia, poor responsiveness, and weak suck in a preterm infant suggest CNS depression from asphyxia, metabolic causes, or prematurity.

Question 138: Which of the following situations, in terms of oxygen supply, would be a proper justification for utilizing a nasal cannula in a baby?

A 33-week-old infant who requires FIO2 of 0.5 (50%) to maintain SpO2 greater than 90%
A 34-week-old infant who is bottle-feeding and requires 0.5 1pm O2 to maintain a SpO2 greater than 90% (Correct answer)
None of the above
A 32-week-old, gavage-fed infant who requires 2 lpm O2 to maintain a SpO2 greater than 90%

Correct answer: A 34-week-old infant who is bottle-feeding and requires 0.5 1pm O2 to maintain a SpO2 greater than 90%

Nasal cannulas are ideal for newborns who require less than 1 lpm (liter per minute) of O2. Cannulas will also enable continuous bottle feeding. Infant nasal cannulas can only deliver less than 1 lpm of oxygen. Infants requiring higher flow rates or FiO2 concentrations greater than 0.4 (40%) will require other administration strategies.

Question 139: A neonate on total parenteral nutrition (TPN) develops signs of cholestasis. Which component of TPN is most associated with this complication?

Excessive amino acid load
High glucose concentration
Supplemental electrolytes
Intravenous lipid emulsions (Correct answer)

Correct answer: Intravenous lipid emulsions

Prolonged intravenous lipid emulsions are strongly associated with TPN-associated cholestasis in neonates.

Question 140: A neonate born at 35 weeks receives phototherapy for jaundice. The nurse notes a bronze discoloration of the skin and dark urine. This finding indicates:

Biliary atresia
Bronze baby syndrome from phototherapy (Correct answer)
Severe hemolytic disease
Physiologic jaundice resolving normally

Correct answer: Bronze baby syndrome from phototherapy

Bronze baby syndrome is a rare complication of phototherapy occurring primarily in neonates with conjugated hyperbilirubinemia.

Question 141: What is the correct sequence for the initial steps of neonatal resuscitation after birth?

Warm, stimulate, clear airway, assess (Correct answer)
Clear airway, warm, stimulate, give oxygen
Assess, clear airway, warm, stimulate
Stimulate, warm, assess, clear airway

Correct answer: Warm, stimulate, clear airway, assess

NRP guidelines specify: Warm, Dry/Stimulate, Clear airway if needed, then assess heart rate, respirations, and tone.

Question 142: Daily weights in the NICU are most important for monitoring:

Head circumference growth only
Fluid balance, nutritional adequacy, and edema (Correct answer)
Gestational age correction
Medication dosing accuracy alone

Correct answer: Fluid balance, nutritional adequacy, and edema

Daily weights guide fluid management, detect fluid overload or dehydration, and assess nutritional support adequacy in NICU patients.

Question 143: Humidity in the incubator for a 24-week gestation neonate should initially be set to approximately:

40–50%
60–65%
80–90% (Correct answer)
100%

Correct answer: 80–90%

High humidity (80–90%) in incubators for extremely preterm infants dramatically reduces transepidermal water loss and prevents dehydration.

Question 144: What is the normal resting heart rate range for a term neonate?

80-100 bpm
60-80 bpm
160-200 bpm
100-160 bpm (Correct answer)

Correct answer: 100-160 bpm

Term neonates have a normal resting heart rate of 100-160 bpm, which is higher than adult norms due to their elevated metabolic demands.

Question 145: A neonate with necrotizing enterocolitis (NEC) shows sudden abdominal distension, bloody stools, and a fixed dilated loop of bowel on X-ray. What is the priority intervention?

Administer probiotics
Perform a barium enema
Prepare the infant for surgical consultation (Correct answer)
Increase enteral feeds slowly

Correct answer: Prepare the infant for surgical consultation

A fixed dilated loop of bowel suggests intestinal perforation or necrosis, necessitating urgent surgical evaluation.

Question 146: Inhaled nitric oxide (iNO) is used in the NICU primarily to treat:

Bronchopulmonary dysplasia
Respiratory distress syndrome
Apnea of prematurity
Persistent pulmonary hypertension (Correct answer)

Correct answer: Persistent pulmonary hypertension

iNO selectively dilates pulmonary vasculature, reducing pulmonary vascular resistance and improving oxygenation in PPHN.

RNC-NIC Neonatal Intensive Care Nursing Certification Exam

The RNC-NIC (Registered Nurse Certified – Neonatal Intensive Care) Certification Exam by the National Certification Corporation (NCC) assesses clinical competency in neonatal respiratory management, neonatal pharmacology, thermoregulation and fluid balance, neurological assessment and care, and neonatal nutrition and feeding.

175

Questions

180 min

Time Limit

65%

To Pass

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These practice questions were written with AI tools. They are not real exam questions. Exam facts are checked against the official sources listed below. Not reviewed by a subject-matter expert. Editorial policy

Sources & references

Exam facts on this page (fees, format, dates, passing scores) are checked against these official sources; the date is our last check. Editorial policy

test-takers.psiexams.com — Score release · verified Nov 2026
nccwebsite.org — Fees, exam format, passing score, retake policy, time limit, score validity, renewal, test delivery, eligibility, registration deadline · verified Oct 2026