RNC-INC Practice Test Video Answer

1. B
Surfactant therapy should be administered as soon as possible after delivery to preterm infants with RDS. Surfactant deficiency is the primary cause of RDS in preterm neonates, and early administration (within the first 1-2 hours of life) has been shown to reduce mortality and complications. The surfactant helps reduce surface tension in the alveoli, improving lung compliance and oxygenation.

2. B
A sudden drop in hematocrit combined with a bulging fontanel indicates increased intracranial pressure and acute hemorrhage, which are critical signs of significant IVH. This represents a Grade III or IV hemorrhage requiring immediate intervention. Other symptoms like seizures, apnea, or cardiovascular instability may also accompany severe IVH.

3. C
While mild tachycardia and jitteriness are common side effects of caffeine, cardiac arrhythmias indicate potentially dangerous cardiovascular toxicity requiring immediate intervention, possible dose reduction, or discontinuation. Serious arrhythmias can compromise cardiac output and require immediate medical attention.

4. C
The Premature Infant Pain Profile (PIPP) is specifically designed and validated for assessing pain in preterm infants, incorporating behavioral and physiological indicators along with gestational age. This tool accounts for the developmental differences in pain response in extremely preterm infants and provides more accurate assessment than tools designed for term infants.

5. B
Inhaled nitric oxide is the first-line treatment for PPHN as it causes selective pulmonary vasodilation, reducing pulmonary vascular resistance without affecting systemic blood pressure. It works by increasing cyclic GMP, leading to smooth muscle relaxation in pulmonary vessels. ECMO is reserved for cases that fail to respond to conventional therapy.

6. B
Progressive abdominal distension with visible bowel loops, absent bowel sounds, and signs of peritonitis indicate advancing NEC, possibly with perforation. These findings, along with pneumatosis intestinalis on X-ray, bloody stools, and systemic signs of sepsis, suggest the need for surgical intervention.

7. B
Eye protection prevents retinal damage from phototherapy lights, and temperature monitoring is essential because phototherapy increases insensible water loss and can cause hyperthermia or hypothermia. The infant should be undressed (except for eye shields and diaper) to maximize skin exposure to light. Adequate hydration must be maintained.

8. B
ELBW infants have immature skin with high insensible water losses and immature renal function. Starting with restricted fluids (60-80 ml/kg/day) and carefully monitoring weight, electrolytes, and urine output prevents fluid overload while allowing for appropriate increases as needed. Fluid requirements increase over the first week of life.

9. B
BPD management requires gradual weaning of respiratory support while optimizing nutrition for growth and lung development. Diuretics help manage fluid retention in the lungs. Adequate calories and protein are essential for lung repair and growth. Sudden discontinuation of support can cause respiratory failure.

10. C
Prolonged suctioning causes hypoxia, bradycardia, and increased intracranial pressure. Suctioning should be limited to 5-10 seconds per pass, with pre-oxygenation if indicated. The suction catheter should not be inserted beyond the tip of the endotracheal tube to avoid tracheal trauma.

11. C
Transposition of the great arteries presents with cyanosis that does not improve with supplemental oxygen because deoxygenated blood is pumped to the systemic circulation. This is a ductal-dependent lesion requiring prostaglandin infusion to maintain ductal patency until surgical correction. An echocardiogram confirms the diagnosis.

12. B
Developmental care focuses on creating an environment that minimizes stress and supports normal neurodevelopment through strategies like clustering care, reducing light and noise, supporting sleep-wake cycles, and promoting parent-infant bonding. This approach has been shown to improve long-term neurodevelopmental outcomes.

13. B
Symptomatic or severe hypoglycemia (generally <40-45 mg/dL) requires immediate IV glucose administration. A bolus of 200 mg/kg (2 ml/kg of D10W) followed by continuous infusion at 4-8 mg/kg/min is standard. Oral feeding alone is insufficient for severe hypoglycemia and delays appropriate treatment.

14. A
A continuous “machinery-like” murmur best heard at the left upper sternal border, along with bounding peripheral pulses (due to decreased diastolic pressure and increased pulse pressure), are classic signs of PDA. Other signs include increased oxygen requirement, difficulty weaning from ventilator, and widened pulse pressure.

15. B
Opioids (morphine or methadone) are first-line pharmacological treatment for NAS because they directly address the withdrawal symptoms from maternal opioid use. Treatment is guided by NAS scoring systems (like Finnegan), and non-pharmacological interventions are always implemented first. Phenobarbital may be added for refractory cases.

16. B
The UVC tip should be positioned above the diaphragm in the inferior vena cava near the junction with the right atrium. The insertion distance can be estimated using the formula: UAC length (cm) = [3 × weight (kg)] + 9, or by measuring shoulder-to-umbilicus distance. Proper positioning is confirmed by X-ray.

17. A
Starting with 4-6 mg/kg/min of glucose infusion rate (GIR) and advancing gradually prevents hyperglycemia while meeting metabolic needs. Preterm infants have limited insulin production and glucose utilization. The GIR can be slowly increased to 10-12 mg/kg/min as tolerated, with careful blood glucose monitoring.

18. B
For infants born at less than 27 weeks gestation, the first ROP examination should occur at 31 weeks post-menstrual age. For infants born at 27 weeks or greater, the first exam should be at 4 weeks chronological age. Earlier or more frequent exams may be indicated based on findings.

19. B
Bag-mask ventilation should be avoided in CDH because it forces air into the stomach and intestines, which are in the chest cavity, further compressing the lungs and heart. Immediate endotracheal intubation with gentle ventilation is preferred. A nasogastric tube should be placed to decompress the stomach.

20. C
Surfactant dosing varies by product. Poractant alfa (Curosurf) is typically dosed at 100-200 mg/kg, while beractant (Survanta) is dosed at 100 mg/kg. The medication is administered endotracheally, and doses may be repeated if respiratory distress persists. Proper positioning and administration technique are critical.

21. B
Coagulase-negative Staphylococcus (especially S. epidermidis) is the most common cause of late-onset sepsis in the NICU, particularly associated with central venous catheters. Early-onset sepsis is more commonly caused by Group B Streptococcus and E. coli acquired during delivery.

22. B
Kangaroo care (skin-to-skin contact) and active parental involvement have demonstrated benefits including improved thermoregulation, enhanced bonding, better breastfeeding success, reduced stress for infant and parents, and improved neurodevelopmental outcomes. Family-centered care is now standard of care in modern NICUs.

23. B
Hypoxic-ischemic encephalopathy (HIE) commonly presents with seizures within the first 12-24 hours of life in term infants who experienced perinatal asphyxia. After ruling out metabolic causes (hypoglycemia, hypocalcemia), HIE is the most likely diagnosis. Therapeutic hypothermia should be initiated if indicated.

24. C
Current evidence supports maintaining oxygen saturations between 90-95% for preterm infants to balance the risks of hypoxia against oxygen toxicity and retinopathy of prematurity. This target range has been shown to optimize outcomes. Lower saturations increase mortality risk, while higher saturations increase ROP and chronic lung disease risk.

25. C
The neonatal resuscitation compression-to-ventilation ratio is 3:1, providing 90 compressions and 30 breaths per minute (120 events per minute). This differs from pediatric and adult ratios and allows for adequate ventilation in neonates whose primary problem is often respiratory rather than cardiac.

26. A
UAC tip placement should be either high (T6-T9, above the diaphragm) or low (L3-L4, below the renal and mesenteric arteries) to minimize risk of vascular complications. Mid-position catheters (T10-L2) are associated with increased complications and should be avoided.

27. B
Minimal enteral nutrition (10-20 ml/kg/day) stimulates gut hormone release, promotes intestinal maturation, enhances gut motility, and prevents mucosal atrophy without providing significant nutrition. It primes the gut for eventual full feeding and may reduce time to full feeds and duration of parenteral nutrition.

28. B
Therapeutic hypothermia (cooling to 33.5°C for 72 hours) is indicated for term or near-term infants with moderate to severe HIE. Treatment must be initiated within 6 hours of birth to be effective. It reduces neurological injury and improves neurodevelopmental outcomes by decreasing cerebral metabolic rate and reducing secondary injury.

29. B
Immediate protection of exposed bowel is critical to prevent fluid loss, hypothermia, and infection. The bowel should be covered with warm sterile saline-soaked gauze wrapped in plastic, and the infant should be positioned on their side to prevent kinking of blood vessels. Gastric decompression via NG tube is also important.

30. A
Term newborns typically start with restricted fluids (60-80 ml/kg/day) on day 1-2 of life, accounting for expected physiologic weight loss and transitional diuresis. Fluid requirements increase gradually over the first week to 140-160 ml/kg/day by day 7. Monitoring weight, urine output, and serum sodium guides adjustments.

31. D
In stable preterm infants without bleeding, platelet transfusion is typically considered when platelets fall below 25,000-50,000/mm³. Higher thresholds (50,000-100,000/mm³) are used for unstable infants, those with active bleeding, or those requiring surgery. Each institution may have specific protocols based on current evidence.

32. C
The medial or lateral plantar surface of the heel is the safest location for heel stick, avoiding nerves, arteries, and bone. The posterior curvature and center of the heel should be avoided due to risk of calcaneal injury. Proper technique minimizes pain and complications.

33. B
While blood culture is the gold standard for diagnosis, the CBC with differential (particularly the I/T ratio – immature to total neutrophil ratio) provides the earliest indication of infection. An I/T ratio >0.2 or absolute neutrophil count abnormalities can be present within hours. CRP and procalcitonin rise later (12-24 hours) and are more useful for tracking response to treatment.

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