Neonatal and Pediatric Assessment

MULTIPLE CHOICE

     1.   What range of gestational weeks is considered term?

a.
32 to 36
b.
34 to 40
c.
37 to 42
d.
38 to 44

ANS:  C

Term infants are born at between 37 and 42 weeks of gestational age.

REF:   pg. 264           OBJ:   1

     2.   Which of the following conditions is associated with an infant born early in gestation?

a.
Meconium aspiration
b.
Respiratory distress syndrome (RDS)
c.
Persistent pulmonary hypertension
d.
Perinatal asphyxia

ANS:  B

A disease of prematurity is RDS.

REF:   pg. 265           OBJ:   3

     3.   You are looking in the chart of your patient, and in the maternal history, you see the following: G3, P2, Ab0. Which of the following statements is true?

a.
The mother is in her third pregnancy.
b.
The mother is in her second pregnancy.
c.
The mother has delivered three healthy children.
d.
The mother has had one abortion.

ANS:  A

Gravida is a pregnant woman, para is a woman who delivers a live infant, and abortion is the delivering of a dead infant. These terms most likely will be abbreviated and followed by numbers (e.g., G2, P1, Ab0, meaning that this woman is in her second pregnancy, has delivered a living infant, and has not had any abortions).

REF:   pg. 265           OBJ:   1

     4.   Which of the following is part of the biophysical evaluation of a fetus performed by ultrasound?

a.
Reactive heart rate
b.
Fetal brain development
c.
Fetal gastrointestinal function
d.
Body size

ANS:  A

The biophysical profile reflects an ultrasound evaluation of fetal breathing, body movement, tone, reactive heart rate, and amniotic fluid volume.

REF:   pg. 267           OBJ:   3

     5.   What do the L/S ratio and phosphatidylinositol (PI) and phosphatidylglycerol (PG) levels assess?

a.
Cardiovascular maturation
b.
Lung maturation
c.
Renal system maturation
d.
Overall level of fetal maturation

ANS:  B

The L/S ratio is the ratio of two phospholipids: lecithin and sphingomyelin. Increasing levels of lecithin indicate improving maturation of the lung’s surfactant system. Similar to lecithin, PI and PG become present with advancing maturation of the lung. Their presence usually is indicative of lung maturation.

REF:   pg. 267           OBJ:   1

     6.   What Apgar parameter usually deteriorates first in a hypoxic infant?

a.
Respiratory effort
b.
Heart rate
c.
Muscle tone
d.
Skin color

ANS:  D

If an infant is becoming asphyxiated, the signs measured by the Apgar score generally decline in a particular order (color, reflex irritability, muscle tone, respiratory effort, and heart rate).

REF:   pg. 266           OBJ:   2

     7.   Infants who need extensive medical resuscitation at birth will have Apgar scores in the range of:

a.
9 to 10.
b.
6 to 8.
c.
4 to 6.
d.
0 to 3.

ANS:  D

Moderately depressed infants have 1-minute scores of 4 to 6. They need more than routine care and often need an increased FIO2 (fraction of inspired oxygen) with bag-and-mask ventilation. Most infants respond well to this therapy and improve in a few minutes. Infants who have 1-minute scores of 0 to 3 are severely depressed and need extensive medical care such as intubation and mechanical ventilation.

REF:   pg. 266           OBJ:   2

     8.   What does the Ballard examination of a newborn infant assess?

a.
Lung maturation
b.
Transition from fetal to extrauterine circulation
c.
Gestational age
d.
Cerebral function

ANS:  C

If an infant is small or was born prematurely, or if there is uncertainty about gestational age, an assessment to determine gestational age should be performed. Most nurseries currently use a Ballard examination for this assessment.

REF:   pg. 269           OBJ:   1 | 2

     9.   Which of the following is a common cause of hypothermia in an infant?

a.
Infection
b.
Heart failure
c.
Atelectasis
d.
Liver disease

ANS:  A

Hypothermia is a more common and significantly more serious sign of infection in a newborn than in an older child or adult. Hypothermia probably occurs because the infant is unable to maintain normal heat production during an acute infection.

REF:   pg. 270           OBJ:   3

   10.   What is the upper limit of the normal range for the heart rate in the newborn?

a.
120 beats/min
b.
140 beats/min
c.
160 beats/min
d.
180 beats/min

ANS:  C

The normal pulse rate for infants is age and size dependent and usually is between 100 and 160 beats/min; it is a function of the developmental age of the infant.

REF:   pg. 270           OBJ:   1

   11.   Which of the following are typical causes of tachypnea in the newborn?

1. Hypothermia

2. Hypoxemia

3. Respiratory acidosis

4. Pain

a.
2, 3, 4
b.
2, 4
c.
1, 3
d.
1, 2, 3, 4

ANS:  A

In newborns, tachypnea can be caused by hypoxemia, metabolic and respiratory acidosis, congenital heart disease, anxiety, pain, hyperthermia, and crying.

REF:   pg. 271           OBJ:   3

   12.   What is the upper limit for normal systolic blood pressure in the term newborn?

a.
60 mm Hg
b.
70 mm Hg
c.
80 mm Hg
d.
90 mm Hg

ANS:  B

Usually, a term infant’s systolic blood pressure should be no higher than 70 mm Hg, with diastolic pressure no higher than 50 mm Hg.

REF:   pg. 272           OBJ:   3

   13.   What is indicated by the presence of retractions in the newborn?

a.
A compliant chest wall
b.
Stiff lungs
c.
Reduced airway resistance
d.
Heart failure

ANS:  B

Retractions (sinking inward of the skin around the chest wall during inspiration) occur when the lung’s compliance is less than the compliance of the chest wall or when airway obstruction is significant. Thus, retractions are a sign of an increase in the work of breathing.

REF:   pg. 273           OBJ:   4

   14.   What is the significance of “grunting” in an infant?

a.
A low functional residual capacity (FRC)
b.
Increased airway resistance
c.
Significant secretion retention
d.
High compliance

ANS:  A

Infants who have a disease that decreases the FRC attempt to increase their lung volume by holding their tidal volume at end-inspiration. The infant accomplishes this by occluding the airway with glottic closure and actively exhaling against the closed glottis after the end of inspiration. The grunting sound is produced when the infant suddenly opens the glottis and quickly exhales, inhales, and again closes the glottis.

REF:   pg. 274           OBJ:   4

   15.   What is indicated by a capillary refill greater than 3 seconds in the infant?

a.
Normal cardiopulmonary function
b.
Respiratory failure
c.
Circulatory failure
d.
Renal failure

ANS:  C

To check skin perfusion, or capillary refill, the examiner should blanch the infant’s skin with a finger and note how long it takes for the blanched skin to recover its color. Capillary refill is checked on the trunk and extremities. Capillary refill should be less than 3 seconds and will be greater than 3 seconds if the infant has a low cardiac output.

REF:   pg. 274           OBJ:   4

   16.   What effect does abdominal distention have on respiration?

a.
Impedes diaphragm movement
b.
Decreases the work of breathing
c.
Does not have any impact on respiration
d.
Improves expiration and lung stabilization

ANS:  A

An infant’s abdomen and abdominal organs move significantly with respiration because the diaphragm is the major source of power for respiration and the abdominal wall musculature is relatively weak. Anything that impedes the motion of the abdomen or its organs hinders the infant’s respiration.

REF:   pg. 274           OBJ:   3

   17.   An infant’s entire right hemithorax “lights up” during transillumination. What does this signify?

a.
Normal lung tissue
b.
Significant pleural effusion
c.
Significant pneumothorax
d.
Intensity of the light is set too high

ANS:  C

Transillumination is a technique that often is used in examining infants because their chest wall is thin enough to shine a light through. Normally, this produces a lighted halo around the point of contact with the skin. In the presence of a pneumothorax or a pneumomediastinum, the entire hemithorax lights up.

REF:   pg. 275           OBJ:   8

   18.   What is the normal leukocyte count for newborns?

a.
5000 to 15,000/mm3
b.
9000 to 30,000/mm3
c.
15,000 to 40,000/mm3
d.
21,000 to 35,000/mm3

ANS:  B

The white blood cell (WBC) count in infants tends to be higher than in older patients. Normal values vary with the chronologic age of the infant. At birth, this ranges from 9000 to 30,000 mm3.

REF:   pg. 276           OBJ:   9

   19.   What is indicated by leukopenia in an infant?

a.
Overwhelming infection
b.
Chronic infection
c.
Acute infection
d.
Local infection

ANS:  A

Leukopenia, particularly neutropenia (an absolute neutrophil count of less than 2000 neutrophils/mm3), is an ominous sign. Usually, neutropenia indicates an infection and implies that the infant is being overwhelmed.

REF:   pg. 277           OBJ:   9

   20.   Why is it so important to quickly identify a low blood glucose level in a newborn?

a.
Because of worry about impaired pulmonary function
b.
Because it is detrimental to brain development
c.
Because it results in rapid renal deterioration
d.
Because it can result in blindness through retinal detachment

ANS:  B

The blood glucose level probably is the most frequent blood chemistry determination made in newborns. This simple test is of tremendous importance because hypoglycemia, or low serum glucose, is as detrimental to the developing newborn’s brain as hypoxia. Because the exact levels and the length of time necessary to cause damage to the central nervous system have not been determined, most physicians treat an infant with a glucose level of less than 40 mg/dL.

REF:   pg. 278           OBJ:   11

   21.   What clinical problem is associated with low serum levels of calcium and phosphorus?

a.
Acute hypoxia
b.
Liver failure
c.
Poor nutrition
d.
Renal failure

ANS:  C

Calcium and phosphorus levels are of indirect importance in the evaluation of a newborn with chronic lung disease. Infants with bronchopulmonary dysplasia or other chronic lung diseases have increased work of breathing and increased metabolic and nutritional needs. The metabolism of calcium and phosphorus provides a valuable clue to the nutritional status of the chronically ill infant. A chronically ill infant with poor nutrition has low levels of calcium and phosphorus and an increased risk of developing rickets.

REF:   pg. 279           OBJ:   11

   22.   What is the normal range for PaO2 at birth?

a.
40 to 60 mm Hg
b.
50 to 70 mm Hg
c.
60 to 80 mm Hg
d.
70 to 90 mm Hg

ANS:  B

Arterial blood samples are the most reliable source for blood gas analysis in newborns. Normal values in newborns depend on the age of the infant when the blood is drawn. A normal newborn PaO2 is 50 to 70 mm Hg.

REF:   pg. 279           OBJ:   14

   23.   What parameter demonstrates the largest difference when capillary blood is compared with arterial blood?

a.
PO2
b.
PCO2
c.
pH
d.
HCO3–

ANS:  A

When the values of capillary carbon dioxide tension (PcCO2) and pH are compared with those obtained by arterial sample, the carbon dioxide level is 2 to 5 mm Hg higher and the pH is 0.01 to 0.03 unit lower. These small differences are inconsequential in most clinical situations. However, when the values for capillary oxygen tension (PcO2) are compared with those obtained by arterial samples, the differences are not so slight. Unfortunately, there is no fixed ratio for PaO2/PcO2. An infant with a PcO2 of 50 mm Hg may have a PaO2 of 50 to 90 mm Hg or higher. The only statement that can be made about PaO2 when only PcO2 is known is that PaO2 is no lower than PcO2. Bicarbonate is calculated in accordance with the Henderson-Hasselbalch equation.

REF:   pg. 280           OBJ:   14

   24.   Which of the following conditions is most likely to cause a falsely low tcPO2 reading?

a.
Alkalosis
b.
Hypertension
c.
Hypovolemia
d.
Hyperthermia

ANS:  C

Any condition that decreases blood flow under the electrode, such as acidosis, shock, hypovolemia, or hypoglycemia, can cause tcPO2 to be falsely lower than PaO2.

REF:   pg. 281           OBJ:   15

   25.   Which lung volumes can be measured easily in newborns?

1. Thoracic gas volume

2. Residual volume

3. Functional residual capacity

4. Crying vital capacity

a.
1, 3, 4
b.
2, 44
c.
1, 3
d.
1, 2, 3, 4

ANS:  A

Three volumes can be measured easily in newborns independent of their cooperation: the FRC, thoracic gas volume (TGV), and crying vital capacity (CVC).

REF:   pg. 282           OBJ:   17

   26.   Which of the following clinical findings suggests the need for a chest radiograph in the infant?

1. Cyanosis

2. Unexplained tachypnea

3. Abnormal breath sounds

4. Worsening clinical status

a.
1, 3, 4
b.
2, 4
c.
1, 3
d.
1, 2, 3, 4

ANS:  D

Chest radiographs should be done in infants who have unexplained tachypnea, cyanosis, abnormal breath sounds, malformation of the chest or airway, or a sick appearance. In addition, any infant who has a significant worsening of his or her clinical status should have a chest radiograph.

REF:   pg. 284           OBJ:   19

   27.   What differentiates pneumonia from transient tachypnea of the newborn (TTNB) on chest radiograph?

a.
Rapid resolution of TTNB
b.
TTNB will have a ground-glass appearance
c.
Silhouette sign
d.
Diffuse streakiness and fluid in the major and minor fissures

ANS:  A

The characteristic chest radiograph shortly after birth shows diffuse streakiness and fluid in the major and minor fissures. This is impossible to distinguish from the chest radiograph of pneumonia. The characteristic of TTNB results from rapid resolution of the disease. By 24 hours of age, the newborn’s chest radiograph is typically normal.

REF:   pg. 284           OBJ:   19

   28.   A child presents at the emergency department with difficulty breathing and a harsh, barking cough. The history reveals a runny nose over the past few days. What is the most likely diagnosis?

a.
Croup
b.
Epiglottitis
c.
Asthma
d.
Bronchopulmonary dysplasia (BPD)

ANS:  A

Croup usually is a viral disease that affects the trachea and small airways. The child may have cold symptoms such as a stuffy or runny nose for a few days. He or she also may have a fever. These symptoms progress to a loud, seal-like barking cough and rapid and/or difficult respirations.

REF:   pg. 288           OBJ:   20

   29.   A 4-year-old presents to the emergency room with difficulty breathing, a dry cough, and audible inspiratory and expiratory wheezing. The parents report the child was playing outside with siblings prior to the difficulty breathing. The symptoms have been progressively worsening. What is the most likely diagnosis?

a.
Epiglottitis
b.
Asthma
c.
Croup
d.
Pneumonia

ANS:  B

Asthma is a chronic airway disease that is caused by airway inflammation and hyper-responsiveness to irritants. The typical symptoms include intermittent dry cough and expiratory wheezing. Young children may report non-focal chest pain. Older children may report shortness of breath and chest tightness. Severe exacerbations may include airflow obstruction that can be life threatening.

REF:   pg. 289           OBJ:   20

   30.   Which of the following conditions is a result of a bacterial disease?

a.
Asthma
b.
Croup
c.
Epiglottitis
d.
Respiratory Distress Syndrome (RDS)

ANS:  C

Epiglottitis is usually a bacterial disease that causes significant edema and inflammation of the epiglottis.

REF:   pg. 289           OBJ:   20