Newborn Assessment and Care

Questions

DIRECTIONS (Questions 1 through 43): For each of the multiple choice questions in this section, select the lettered answer that is the one best response in each case.

1. An infant is born and at 5 minutes it has a vigorous cry, a heart rate of 105, movement of all four extremities, grimacing with stimulation, and has bluish hands and feet. What is the Apgar score of this infant?

(A) 10 (B) 9 (C) 8 (D) 7 (E) 6

2. Newborns who are allowed to remain at room temperature immediately after delivery rather than warmed by skin-to-skin contact with mom or placement in a warmer are at risk for the development of which of the following?

(A) metabolic acidosis (B) metabolic alkalosis (C) respiratory acidosis (D) respiratory alkalosis (E) pneumonia

3. Which of the following is the most common cause of failure to establish effective respiratory effort in the newborn?

(A) fetal acidosis (B) fetal immaturity

4. A patient with no prenatal care presents in labor claiming to be at 43 weeks of gestation. Which of the following neonatal findings would support the diagnosis of a postmature infant?

(A) anemia

(B) increased subcutaneous fat (C) long fingernails

(D) vernix

(E) fusion of the fetal eyelids

5. Five infants are admitted to the newborn nursery after uncomplicated vaginal deliveries. Which of the following newborns would be classified as high-risk and merits closer monitoring?

(A) 3,500 g, 39 weeks’ gestation, Apgar score 8/9 (B) 2,650 g, 41 weeks’ gestation, Apgar score 7/8 (C) 3,800 g, 41 weeks’ gestation, Apgar score 7/8 (D) 3,100 g, 38 weeks’ gestation, Apgar score 7/9 (E) 2,650 g, 37 weeks’ gestation, Apgar score 7/9

6. A 2-day-old newborn has a mild degree of hyperbilirubinemia. What is the most appropriate next step in management?

(A) observation only

(B) exposing the infant to light

(E) soy-based formula feeding

7. On the 5th day of life, how would the weight of a term infant that weighed 7 lb, 8 oz at birth be expected to change?

(A) increased 6–8 oz (B) increased 2 oz (C) remained the same (D) decreased 2 oz (E) decreased 5–7 oz

8. The first-time mother of a newborn would like to know about the care of the umbilical cord stump.

When does the umbilical cord stump of a newborn most frequently slough off?

(A) 2nd day after delivery (B) 5th day after delivery (C) 10th day after delivery (D) 15th day after delivery (E) 21st day after delivery

9. A term infant is delivered via cesarean delivery as a double-footling breech. It is noted to have an Apgar score of 3 at 1 minute and later to be irritable and restless. The infant’s muscles are rigid, and the anterior fontanel bulges. The infant develops progressive bradycardia. What is the most likely cause of these findings?

(A) brain stem injury (B) infection

(E) intracranial hemorrhage

10. A heroin-abusing woman presents to labor and delivery and has a precipitous vaginal delivery of a term infant who has poor respiratory effort and Apgar scores 2/4/6. Rather than simply sedation from narcotic abuse, what is the most likely finding in a neonate with intrapartum asphyxia?

(A) alkalemia (B) hypoxia (C) hypocapnia (D) tachycardia

(E) increased anal sphincter tone

11. Continued apnea in the newborn most often results from which of the following?

(A) maternal infection (B) epidural anesthesia

(E) naloxone administration

12. After a delivery complicated by a shoulder dystocia, a newborn is found to have paralysis of one arm with the forearm extended and rotated inward next to the trunk. These findings are most consistent with which of the following?

(A) damage to the C8–T1 nerve roots (B) neonatal asphyxia

(E) comminuted fracture of the humerus

13. Within the first minute after delivery, the baby does not breathe spontaneously. The heart rate is 80 to 90 bpm. There is some movement, with pale and limited irritability. What is the most appropriate next step in management?

(A) dry and warm the newborn

(B) slap the baby’s back gently at first, then vigorously if necessary (C) ventilate the infant by mask

(D) do external cardiac massage

(E) administer intravenous bicarbonate (NaHCOs) via umbilical vein

14. When faced with the delivery of a premature newborn, the normal resuscitation should be altered to routinely include which of the following?

(A) assisted ventilation (B) minimal handling

(E) intravenous bicarbonate (NaHCO3)

15. At a new obstetrics visit, a nulliparous patient shares her fears of having a neonatal death because her mother had a child with a neonatal death. In counseling the patient, you explain that, in the United

States, which of the following is the most common factor associated with neonatal death?

(A) birth injury (B) prematurity

(E) intrauterine growth restriction

16. A premature newborn exhibits rapid grunting respiration, chest retraction, and a diffuse infiltrate in the lung fields demonstrated on chest X-ray. What is the most likely cause for these findings?

(A) pneumococcal pneumonia

(B) neonatal sepsis

(E) hypoglycemia

17. After a normal labor and delivery of monozygotic twins at 35 weeks of gestation, one is found to be polycythemic, and the other small and markedly anemic. What is the most likely etiology of this phenomenon?

(A) acute fetal bleeding (B) fetal cardiac failure

(E) Rh incompatibility

18. Approximately 2 days after delivery, an apparently healthy newborn male infant develops an

intracranial hemorrhage. Vital signs are normal. His hematocrit and white blood cell (WBC) counts are normal, but platelets are slightly decreased. The bleeding time is normal for age, but the prothrombin time is greatly prolonged. Blood type is A, Rh-negative. What is the most likely explanation for these findings?

(A) unrecognized birth trauma (B) sepsis

(E) hemorrhagic disease of the newborn

19. A premature newborn is found to have abdominal distention, ileus, and bloody stools. An abdominal x-ray shows excessive gas in the bowel and free air under the diaphragm. What is the most likely diagnosis?

(A) appendicitis (B) toxic megacolon (C) peptic ulcer disease (D) necrotizing enterocolitis (E) diabetic enteropathy

20. A male infant is delivered with very little amniotic fluid. He is noted to have low-set ears,

contractures of the extremities, and prominent epicanthal folds. He does not void and dies during the first day of life. What is the most likely diagnosis?

(A) glycogen storage disease (B) renal agenesis

(E) trisomy 18

21. Fetal anencephaly is commonly associated with which of the following?

(A) pituitary hyperplasia (B) oligohydramnios (C) bradycardia

(D) adrenal hypertrophy (E) postterm labor

22. What is the most common manifestation of fetal anoxic brain injury?

(A) choroid plexus hemorrhage

(B) rupture of the cerebral vein at the junction of the falx and tentorium (C) mental retardation

(D) cerebral palsy (E) hemiplegia

23. Neurologic abnormalities are found in greatest proportion in infants with which of the following?

(A) high Apgar scores and normal birth weight (B) low Apgar scores and normal birth weight (C) low Apgar scores and low birth weight (D) high Apgar scores and high birth weight (E) low Apgar scores and high birth weight

24. An infant was born 10 hours previously to a mother whose membranes ruptured 27 hours prior to delivery. The mother was febrile in labor. The infant develops respiratory distress, apnea, and an unstable blood pressure. What is the most likely explanation of this infant’s symptoms?

(A) group A streptococcus (B) group B streptococcus (C) listeriosis

(D) herpetic encephalopathy (E) infant rubella

25. A patient who is a practicing veterinarian is concerned about contracting toxoplasmosis from her feline patients. In counseling the patient, what do you note as the most common sequela of a fetal toxoplasmosis infection?

(A) phocomelia (B) anencephaly (C) mental retardation (D) ambiguous genitalia

(E) respiratory distress in the first 24 hours of life

26. While counseling a mother on the risks of a child having a trisomy 21 after second-trimester screening, you note that the general background incidence of significant fetal malformations (birth defects) is approximately which of the following?

(A) <1%

(B) 3–5%

(D) 10–13%

(E) 14–18%

27. Widespread use of thalidomide in Europe in the mid-1980s was clearly associated with birth defects.

As thalidomide has been reapproved by the FDA for certain indications, it is important that all women in the reproductive age who are prescribed this medication or whose partner is taking thalidomide use

very effective contraception. This is because when used in the first trimester, thalidomide is associated with phocomelia, which is defined as a defect in the development of which of the following?

(A) color vision (B) the digits (C) the long bones (D) the great vessels

(E) the cytochrome P450 system

28. A child is born with genital ambiguity. The genital folds (scrotum and labia minora) are adherent in the midline, and there is severe hypospadias. The parents ask you about the gender of their child. Your best response, based on the information given, should be which of the following?

(A) The child has female pseudohermaphroditism and should be raised as female.

(B) The diagnosis is most likely testicular feminization and the child should be raised as a male.

(D) It is likely the child has vaginal atresia but should be raised as a female

(E) While the sex of rearing will most likely be female, assignment must await further investigation.

29. A patient who reports episodes of binge drinking in the first trimester wants evaluation of the fetus for fetal alcohol syndrome so she might terminate the pregnancy if it is affected. You inform her that

antenatal testing is unable to detect the physical manifestations of fetal alcohol syndrome and it is associated with which of the following?

(A) fetal hypospadias (B) postmaturity

(E) congenital cataracts

30. The perinatal death rate is defined as which of the following?

(A) deaths in utero of fetuses weighing 500 g or more per 1,000 population (B) the sum of the fetal death rate and neonatal death rate per 1,000 live births (C) infant deaths (younger than 1 year) per 1,000 live births

(D) deaths in utero of fetuses weighing 1,000 g or more per 1,000 births

(E) fetal and neonatal deaths occurring after 36 weeks’ gestation and until 3 months of life, expressed per 1,000 population

31. A patient with no prenatal care delivers shortly after arriving in the labor and delivery suite. Fetal prematurity would be suggested by finding which of the following?

(A) labia majora that are in contact with one another (B) one or both testes in the scrotum

(E) lanugo hair

32. Which of the following is the most common cause of a “large-for-gestational age” (LGA) infant?

(A) maternal diabetes

(B) congenital abnormalities (C) in utero infections

(D) erroneous last menstrual period (LMP) (E) maternal hypertension

Questions 33 and 34 refer to the following patient:

You deliver an infant who has a moderate shoulder dystocia and at 1 minute it does not cry, as well as has flexed extremities, irregular respiration, a bluish color, and a heart rate of 90 bpm.

33. What is the most appropriate Apgar score for this infant?

(A) 1 (B) 3 (C) 5 (D) 7 (E) 9

34. At 5 minutes after resuscitation efforts, the infant has a pink body, blue fingers, vigorous cry and active motion, good respiration, and heart rate of 120 bpm. What is the most appropriate Apgar score for this infant?

(A) 1 (B) 3 (C) 5 (D) 7 (E) 9

35. A Simian line or crease is most closely associated with which of the following?

(A) Turner syndrome (B) Down syndrome (C) cri du chat syndrome (D) Klinefelter syndrome (E) trisomy 13

36. A mother presents with no prenatal care and proceeds to deliver an apparently term infant with a normal trunk, shortened arms, short bowlegs, a globular skull, and blue sclerae. This collection of neonatal findings is most suggestive of which of the following?

(A) Wilson’s copper storage disease (B) Down syndrome

(E) osteogenesis imperfecta

37. You deliver a preterm appropriately grown infant at approximately 36 weeks’ gestation. Active resuscitation is begun and it becomes apparent that endotracheal intubation is needed. Based on the infant’s gestational age of 36 weeks and estimated weight of 2,500 g, what is the most appropriate endotracheal tube size (inside diameter, mm)?

(A) 2.0 (B) 2.5 (C) 3.0

(D) 3.5 (E) 4.0

38. Antimicrobial therapy is routinely applied to the eyes of newborns to prevent blindness caused by which of the following?

(A) Neisseria gonorrhoeae (B) Chlamydialconjunctivitis (C) Herpes simplex

(D) Group B streptococcus (E) Hemophilus Ducreyi

39. While counseling a patient who is in preterm labor at 28 weeks, you review a number of strategies to minimize adverse outcomes. In this discussion, you note that which of the following interventions has been shown to reduce the rate of intraventricular hemorrhage in preterm neonates?

(A) antibiotics (B) corticosteroids (C) magnesium sulfate (D) artificial surfactant

(E) calcium channel blockers

40. A 16-year-old G1P0 patient who is a recent immigrant from Mexico presents at 24 weeks’ estimated gestational age (EGA) with a recent onset of a rash. It is determined to be rubella. You reassure her that an in utero infection with rubella virus is unlikely to result in congenital rubella syndrome when it occurs after how many weeks of pregnancy?

(A) 9 weeks (B) 11 weeks (C) 13 weeks (D) 15 weeks (E) 17 weeks

41. Which of the following neonatal findings would suggest congenital rubella syndrome rather than a congenital cytomegalovirus infection?

(A) thrombocytopenia (B) hepatosplenomegaly (C) fetal growth restriction (D) cataracts

(E) hemolytic anemia

42. What is the most common cause of clonic seizures in the initial 24-hour newborn period?

(A) hypoxic-ischemic encephalopathy (B) intracranial hemorrhage

43. What is the approximate caloric need of a normal full-term infant through the first year of life?

(A) 25kcal/kg/d

(B) 50kcal/kg/d (C) 75kcal/kg/d (D) 100kcal/kg/d (E) 125kcal/kg/d

Answers and Explanations

1. (B) The Apgar scoring system, described by anesthesiologist Virginia Apgar in 1952, is a technique to assess the well-being of a newborn. An Apgar score is awarded to the infant at 1 and 5 minutes of life.

In some cases, the Apgar score may be assessed again at 10 minutes of life or beyond. The infant gets a score of 0,1, or 2 points in each of five categories: heart rate, respiratory effort, reflex irritability, muscle tone, and color. An Apgar score of 3 or less at 5 minutes in infants is associated with an

increased risk of anomalies or developmental problems (goes from 0.3% to 1%). The change from 1 to 5 minutes is a good indicator of the successful neonatal resuscitation. See Table 14–1.

TABLE 14–1. Apgar Scoring

2. (A) The normal infant who is cool will resist metabolic acidosis and maintain pH by compensatory respiratory alkalosis. If the infant is in trouble from asphyxia, it may be unable to compensate, and the acidosis is accentuated. Ventilation will usually restore normal function. A common error in the resuscitation of infants is to do the resuscitation on a cold table rather than in an infant warmer.

3. (C) In the majority of infants, respiratory effort will be initiated between 30 and 60 seconds after birth.

Fetal acidosis, drugs given to the mother, upper airway obstruction, a premature infant, pneumothorax, congenital anomalies, infection, and trauma can all be severe enough to inhibit an infant’s respiratory effort. The cause must be sought and corrected. Most often, the cause is upper airway obstruction by fluids and mucus, which may be easily cleared by bulb suction.

4. (C) Other identifying features are decreased subcutaneous fat, wrinkled skin, decreased vernix,

polycythemia, dehydration, and meconium staining. Such infants are classically described as having the features of “a little old man.” If good nutrition is maintained throughout pregnancy, an infant of a long gestation can be macrosomic. Fusion of the eyelids is characteristic of a very immature fetus.

5. (B) This infant is undergrown or small for dates (SGA). He has grown too slowly in utero and may have been nutritionally compromised for some time. Postmaturity and growth retardation are risks often found together, often with poor infant outcomes.

6. (B) As bilirubin pigment appears to break down in ultraviolet light, such treatment may keep it from reaching a dangerous level that could necessitate an exchange transfusion. Putting the bassinet in

daylight is treatment enough for some; others will need a special treatment system exposing them to higher levels of ultraviolet light.

7. (E) The normal newborn will lose 5 to 7 oz of his birth weight soon after delivery and gain it back by 10 days postpartum. He should then continue to gain weight rapidly. Feeding generally does not go well at first, accounting for the weight loss.

8. (C) Mothers often ask how long the umbilical stump will remain and what to do to care for it. Leaving it open and washing the area with soap and water seems to be adequate care. The umbilical stump should be cultured in cases of neonatal sepsis. It will normally slough spontaneously in about 10 days.

9. (E) The breech delivery, bulging fontanel, and progressive worsening of the condition all point to CNS bleeding. A subdural hematoma should be treated by immediate aspiration. The breech places the newborn at greater risk for head entrapment and resultant trauma even with an abdominal delivery.

Also, it has been noted that infants that are breech at term have a higher risk of congenital anomalies.

10. (B) Asphyxia is a condition in which the arterial blood is hypoxic, acidotic, and hypercapnic. The heart rate is decreased and the anal sphincter may relax, causing loss of meconium. It is often

associated with cooling of the infant, narcosis, brain hemorrhage, or metabolic acidosis.

11. (C) Drugs, fetal immaturity, fetal trauma, fetal anomalies, fetal infection, and fetal hypoxia are the major causes of newborn apnea. Most of these result in depression of the fetal CNS. Naloxone, stimulation, and assisted ventilation are all used to overcome apnea.

12. (C) In the newborn, both Erb’s and Klumpke’s paralysis usually result from trauma to the brachial plexus during a difficult delivery. The brachial plexus is made of C5, T6, C7, C8, and T1, C2.

Klumpke’s paralysis affects only the hand and involves C7, C8, and T1. Ptosis and miosis can also occur if sympathetic fibers of these nerves are involved in the injury. The injury most often occurs when pressure on the fetal head and neck (and therefore the brachial plexus) is too great. Lateral pressure on the head during vertex delivery (especially with shoulder dystocia) or hyperextension of the arms over the head during breech birth may cause this injury. This is also called Duchenne’s paralysis.

13. (C) This is a moderately to severely depressed infant (estimated Apgar score 2–4). Respiration must be established. Gentle or rough handling is unlikely to help. If the baby is hypoxic, respiration by assisted ventilation is the key to helping the neonate. Establishing effective ventilation will speed the heart, and acidosis will correct with ventilation.

14. (B) Minimal handling, a warm environment, and supplemental oxygen are indicated for any premature newborn, with more vigorous resuscitation and treatment utilized only as indicated by the fetal

condition. Drugs to stimulate respiration have not proven to be effective and may be dangerous.

15. (B) Prematurity from whatever etiology is the most common factor associated with neonatal death.

Respiratory difficulty is often the major problem with these infants. However, many organs can fail in these small infants. Although intrauterine growth restriction is often associated with premature delivery or pregnancies with poor outcomes, growth restriction by itself does not appear to be an independent factor in neonatal death. The second most common cause of neonatal death is congenital malformations.

16. (C) RDS is most common in premature infants and is due to a decreased amount of phospholipid surfactants in the alveoli. It is treated with assisted ventilation and artificial surfactant.

17. (D) One twin can get a progressively larger amount of blood than the other because of placenta

anastomoses. This is called twin–twin transfusion and classically results in one small, anemic twin and one large, plethoric twin who is subject to CHF. Acute fetal bleeding could cause anemia but should not result in significant size discrepancy. Poor maternal iron stores or an Rh incompatibility would affect both infants.

18. (E) The time to onset of the bleeding associated with a normal bleeding time and with a prolonged prothrombin time points to hemorrhagic disease of the newborn. The infant has hypoprothrombinemia as a result of low placental transport of vitamin K. Infants of mothers with epilepsy are at an increased risk for this disease. Infants of those mothers should be given supplemental vitamin K at birth. Routine administration of vitamin K is recommended for all neonates. Vitamin K in small doses given to the mother in labor or the infant at the time of delivery is prophylactic for hemorrhagic disease of the newborn. One milligram of vitamin K given to the infant is also used in therapy of hemolytic disease of the newborn.

19. (D) Necrotizing enterocolitis is a disease seen in both low-birth-weight and premature infants. The cause is unknown, but it is believed that the cause is related to immaturity of the gastrointestinal system rather than ischemia, as previously thought. It can be prevented by administration of immunoglobulin. In mild forms, the disease can be treated by dietary restriction; in severe forms, the bowel may need to be resected.

20. (B) Defects in the urinary system are associated with defects in the genital tract, low-set ears, and other anomalies. Low-set ears and cardiac defects are also seen in trisomy 18. Ultrasound studies performed during pregnancy will reveal oligohydramnios.

21. (E) In fetuses with anencephaly, the pituitary is either absent or markedly hypoplastic. Whether the lack of adrenocorticotropic hormone (ACTH) causes the associated adrenal atrophy is disputed. Lack of an intact CNS delays the onset of labor. There is no effect on fetal heart rate. Face presentations are common with anencephaly; because of the lack of a cranium, the head will not stay flexed. Fetal CNS malformations tend to occur with pregnancies in very young or very old mothers. Diabetics also are at increased risk, unless the hydramnios caused by the fetal inability to swallow prompts labor earlier.

22. (A) Ventricular hemorrhages from the choroid plexus are the result of hypoxia. Rupture of the great cerebral vein at the junction of the falx and tentorium is more likely to occur from mechanical trauma and to result in subdural hematomas and/or dural tears. Studies suggest that the majority of cases of cerebral palsy occur before birth or are acquired after birth as a result of factors such as sepsis or fever. Cerebral palsy due to birth anoxia is much less common than choroid plexus hemorrhage.

23. (C) This concept is both important and logical. The premature or undergrown infant who is depressed at birth has a higher incidence of neurologic abnormalities than term normal-weight, high-Apgar

infants. In some cases, both the newborn’s low birth weight and poor Apgar scores are the result of an underlying process that results in neurologic abnormalities as well; that is, the low Apgar and birth weight are the result, not the cause, of the infant’s developmental problems. Long-term follow-up is needed.

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