RNC-NIC Neonatal Assessment 4

Question 1

A neonate at 32 weeks gestation is on CPAP. The nurse notes nasal flaring, subcostal retractions, and an oxygen requirement of 35%. The Silverman-Anderson score is being used. Which component is NOT part of this scoring system?

Accepted Answer

Skin color/acrocyanosis

Answer

The Silverman-Anderson Retraction Score assesses upper chest movement, lower chest retractions, xiphoid retractions, nasal dilation, and expiratory grunt — skin color is not included.

Question 2

A nurse assesses a neonate and observes rhythmic, repetitive limb movements that cease when the extremity is held. This is most consistent with:

Accepted Answer

Jitteriness

Answer

Jitteriness is characterized by rhythmic, equal-amplitude tremors that are stimulus-sensitive and stop with passive restraint, distinguishing it from seizures which cannot be stopped by holding.

Question 3

In assessing a neonate for respiratory distress, grunting is heard. The physiological purpose of neonatal grunting is to:

Accepted Answer

Maintain positive end-expiratory pressure to prevent alveolar collapse

Answer

Grunting is produced by partial closure of the glottis during expiration, creating auto-PEEP to prevent alveolar collapse in neonates with reduced functional residual capacity.

Question 4

A 2-day-old term neonate is assessed and found to have a capillary refill time of 4 seconds in the central chest area. This finding indicates:

Accepted Answer

Possibly impaired perfusion requiring further cardiovascular assessment

Answer

Central capillary refill time greater than 3 seconds suggests impaired perfusion and warrants further cardiovascular assessment including blood pressure, heart rate, and perfusion status.

Question 5

During a neonatal neurological assessment, the nurse strokes the lateral sole of the foot from heel to toe. The great toe dorsiflexes and the other toes fan out. This response is:

Accepted Answer

Normal Babinski response in neonates due to immature corticospinal tracts

Answer

The Babinski response (great toe extension and toe fanning) is normal in neonates because the corticospinal tracts are not yet myelinated, and typically disappears by 12-24 months.

(RNC-NIC) Registered Nurse Certified in Neonatal Intensive Care Practice Test

(RNC-NIC) Registered Nurse Certified in Neonatal Intensive Care Practice Test

RNC-NIC Neonatal Assessment 4