NICU Flashcards
1
Q
Child with brachial plexus injury. How long before if no change in exam is prognosis poor?
a. 1 month
b. 3 month
c. 9 month
d. 1 year
A
b. 3 month
- surgery indicated if function not improving by 3 months - more likely to be total nerve disruption or nerve root avulsion
2
Q
A term newborn is born to a heroin addicted mom. On initial assessment the baby is apneic but HR is greater than 100. After 30 seconds, the baby continues to be apneic despite adequate bag and mask ventilation. What is the next step in your management?
a. IM Narcan
b. Intubate and give Narcan down the ETT
c. Continues to support ventilation until baby breathes on his own
d. Epinephrine 1:10000
A
c. Continues to support ventilation until baby breathes on his own
3
Q
Full term baby delivered after traumatic forceps delivery. Now 1 month old with vomiting, lethargy and red plaque on back of hand. What lab test would you check.
- Glucose
- calcium
- potassium
- alp
- creatinine
A
- calcium
- subcutaneous fat necrosis - rubbery/firm red/violaceous plaques or nodules on cheek, butt, back, thigh, arm
A rare but potentially life-threatening complication is hypercalcemia. It manifests at 1-6 mo of age as lethargy, poor feeding, vomiting, failure to thrive, irritability, seizures, shortening of the QT interval on electrocardiography, or renal failure
4
Q
In counseling a woman who has had a child with a meningomyelocele, what would you tell her as regards her next pregnancy:
a. take folic acid prior to conception and then for 10 weeks afterwards
b. ultrasound at 16 weeks
c. amniocentesis at 16 weeks
d. alpha-fetoprotein at 16 weeks
A
ANSWER: a. take folic acid prior to conception and then for 10 weeks afterwards (PROBABLY THE MOST CORRECT BUT TECHNICALLY SOGC SAYS FOR FULL T1 and NELSON SAY TILL WEEK 12)
- b. ultrasound at 16 weeks (typically week 18-22)
c. amniocentesis at 16 weeks (no only if US (+) then discuss)
d. alpha-fetoprotein at 16 weeks (PIR routine in past; SOGC not routine now)
5
Q
IUGR neonate with bony changes, cataracts and hepatosplenomegaly. What’s the most likely diagnosis?
a. congenital syphilis
b. congenital rubella
c. congenital CMV
d. congenital toxoplasmosis
A
b. congenital rubella
- neonatal findings:
- IUGR, interstitial pneumonitis, radiolucent bone disease, HSM, TCP, dermal erythropoiesis (blueberry muffin lesions)
6
Q
Mom ivdu. Early latent syphilis. Titer from 6 months ago and now. They have dropped by 8 times. Baby is born. What do you do to for the baby:
a) Observe
b) Tryomonial screen and RPR
c) CSF RPR
d) Swab baby
A
b) Treponemal screen and RPR
- mom with primary, secondary or early latent syphilis treated at least 4 weeks prior to delivery with at least 4 fold drop in titres - RPR and TT at 0, 3, 6, 18 months as well as clinical assessment monthly x3 months and with each additional serum screen
7
Q
Mom is IVDU. Her blood work: HEB B + HepC +. Baby’s blood work at 6 mo, hep B and hep C ab negative. What to do:
a) Rest Hepc in 6 months
b) No further investigations
c) PCR
A
b) No further investigations
- for a child at any age born to a mother with hep C who has absent Hep C antibodies, there is no need to test PCR and the interpretation is that either vertical transmission did not occur or the child cleared the infection
8
Q
Mom hep B positive. What do you do for baby ?
A
- Hep B vaccine at birth, 1-2m, 6m and HBIG as soon after delivery as possible (<12h)
9
Q
Klehauer betke test - question about what it is
A
Used to determine if there is fetal blood in maternal circulation such as fetal maternal haemorrhage (test done on maternal blood sample)
10
Q
EcG: baby is thrombocytopenic, mild elevated liver enzymes, ecg shows complete heart block. What does mom have?
A
SLE (or other autoimmune condition like RA or Sjogren) - baby has congenital lupus
11
Q
You are examining a newborn infant, born at full term, 2600g. He has a flat nasal bridge, a thin upper lip and a smooth philtrum. He is mildly hyptonic. Which of the
following ingestions is it important to inquire about in your history of the mother’s pregnancy:
a. Cocaine
b. Alcohol
c. Marijuana
d. Heroin
A
b. Alcohol
12
Q
Mother of 2 hour newborn who has a mass on the scalp that crosses suture lines. The mother took phenytoin during pregnancy and the child was delivered via vacuum
delivery. Give two reasons why the child has this lesion.
A
in utero use of phenytoin (can predispose to bleeding) and caput succedaneum from vacuum
13
Q
Picture of a CT scan of the head with intracranial calcifications. What is the diagnosis?
A
Congenital CMV (periventricular calcifications, ventriculomegaly, microcephaly, HSM, TCP, SNHL, chorioretinitis), congenital toxoplasmosis (chorioretinitis, hydrocephalus and CNS lesions), HIV
14
Q
A 24 hr old newborn is seen with a report of scant U/O, the creat is 85. What is this most consistent with:
a. Maternal creat
b. Creat cannot be interpreted without a urea
c. Creat is elevated for this newborn
d. Creat cannot be interpreted without a urine creat
A
a. Maternal creat
15
Q
Which of the following are true?
(a) fetal p02 is 25-30
(b) the incidence of asymptomatic PFO in the adult population is 10%
c) Umbilical veins close before umbilical arteries
A
ANSWER: (a) fetal p02 is 25-30 (umbilical venous pO2 is 30-35 (highest pO2 in fetus), but it mixes with systemic blood so pO2 entering the RA is 26-28mmHg)
(b) the incidence of asymptomatic PFO in the adult population is 10% - also true, it’s 10-25%
16
Q
2-week old child with a 1 week history of stool mixed with blood in an infant? Bottlefeeding well, passed stool in first 24 hours. Most likely dx?
a. anal fissure
b. cow milk protein allergy enterocolitis
c. Meckel’s diverticulum
A
b. cow milk protein allergy enterocolitis
17
Q
A 1 week old breastfed baby comes in to your office for newborn care. There is bright red blood mixed in with the stool. The baby did not have any bleeding or bruising with the Vitamin K injection at birth or with the newborn screen. The anus appears normal and there is no evidence of a fissure. List the most likely cause of the blood in the stool.
A
Cow’s milk protein intolerance
18
Q
All of the following are normal in term newborns except:
a) Hypotonia post feed
b) Irregular respiratory pattern in REM sleep
c) Sigh following a brief period of apnea
d) Mild cyanosis with feeding
A
d) Mild cyanosis with feeding
19
Q
1 mo 2 day old with a vesicle noted on the upper lip?
a. Sucking blister
b. HSV
c. Varicella
d. Epidermolysis bullosa
A
a. Sucking blister
- Sucking Pads
o Calluses/vesicles found on lips in first few months
o Confirmed by observing neonate sucking the affected area
20
Q
2 month old baby with poor feeding, hepatomegaly, crackles, soft systolic murmur. What is the most likely diagnosis?
- congenital infection
- CHF
- Sepsis
A
- CHF
21
Q
Newborn was recently extubated after a course of systemic corticosteroids. What is the likely side effect?
- hypotension
- hypoglycemia
- leucopenia
- hypertrophic cardiomyopathy
A
- hypertrophic cardiomyopathy
- SE of steroids include HTN, hyperglycaemia, GI bleed and perforation
22
Q
A 12 hour old infant born at term had mild polyhydramnios on 20 week U/S. Now the baby is grunting intermittently with lots of secretions. He improves with intermittent
suctioning. What diagnosis is this most consistent with:
a. TEF/esophageal atresia
b. Duodenal atresia
A
a. TEF/esophageal atresia
23
Q
Child with bubbling oral secretions, difficulties passing an NG tube. Also noted to have a hemivertebrae. What to do?
a. echocardiography
b. spine MRI
c. MRI head
A
a. echocardiography
VACTERL association
- cardiac abnormalities in 50% of patients with TEF
24
Q
2-day old baby with antenatal hydro, confirmed on post-natal U/S to have moderate-severe hydronephrosis. BW shows normal renal function, baby seems to be peeing well. a. consult urology prior to discharge b. DMSA c. arrange for an outpatient VCUG d. follow up in 2 months
A
a. consult urology prior to discharge
25
Newborn with persistent bradycardia. ECG given. Looks like heart block... identify the problem. What 2 things is this child at risk for?
1. Cardiac arrest/Death
2. Syncope
3. Dizziness
4. For infants and toddlers → night terrors, tiredness with frequent naps & irritability
26
Which of the following is associated with polyhydramnios
a. IUGR
b. Hirschsprung’s disease
c. esophageal atresia
d. renal agenesis
c. esophageal atresia (can't swallow fluid)
* renal issues - get oligohydramnios (can't pee fluid out)
* IUGR + polyhydramnios - think trisomy 18
27
What to do with a mom who is about to deliver at 23-weeks?
a. resuscitation is not indicated
b. all babies born >22 completed weeks should be resuscitated
c. parents ideas about resuscitation and palliation should be taken into account
c. parents ideas about resuscitation and palliation should be taken into account
28
You are counseling a pregnant teenage girl and her boyfriend at 23 weeks gestation. She is in labour. You discuss the high morbidity at this gestational age, if the
baby survives at all. What is true about the resuscitation of this newborn:
a. Since they are teenagers, the physician decides.
b. There is legislation in Canada that says all babies 22 weeks and older require resuscitation.
c. The parents’ wishes should be supported whether they want to resuscitate or not.
d. Given the high mortality at this gestation, the baby should not be resuscitated.
c. The parents’ wishes should be supported whether they want to resuscitate or not.
22 weeks - palliative care recommended
23-24 weeks - could go either way (parent preference)
25+ weeks - recommend early intensive care as default
Above is in context of no additional risk factors (SGA, multiple gestation, no antenatal corticosteroids, delivering outside tertiary care centre)
29
Expected survival rate for an infant born at 25 weeks gestation:
a) >90%
b) 75%
c) 50%
d) 25%
e) <10%
b) 75%
30
The outcome in neonates since the introduction of surfactant is best described as:
a. decreased mortality
b. decreased BPD
c. increased air leaks
d. increased IVH
e. decreased PDA
a. decreased mortality
| * and decreased air leaks
31
Newborn baby born at 27 weeks, no spontaneous resps. What to do?
a. put in polyethylene plastic bag and stimulate
b. warm, dry and stimulate
c. positive-pressure ventilation
a. put in polyethylene plastic bag and stimulate
| - plastic bag for all babies <32 weeks, stimulate, if apneic then start PPV
32
Newborn, a 30-week premie. Not breathing after stimulation. What do you do?
a. self-inflating bag, room air
b. self-inflating bag, oxygen reservoir
c. self-inflating bag, oxygen reservoir with O2 being blown through
d. anesthesia bag, connected to oxygen source
d. anesthesia bag, connected to oxygen source
33
Newborn baby has copious oral secretions and respiratory distress. What is the most appropriate next test?
a) Insertion of orogastric catheter
b) CXR
c) Abdominal U/S
d) Barium swallow
a) Insertion of orogastric catheter
| - concern with lots of secretions and resp distress is TEF
34
Which of the following newborns requires surfactant administration according to recent guidelines:
a. Any newborn being transferred between centres
b. A 29 week infant with no symptoms being transferred between centres
c. A critically ill infant who has required 3 doses of surfactant in the first 18 hours
d. An infant with RDS who is intubated and requiring more than 50% O2 after 72 hours
b. A 29 week infant with no symptoms being transferred between centres - ?best answer, none are really right
- CPS: - infants delivered at <29 weeks gestation outside tertiary care centre should be considered for immediate intubation and surfactant after stabilization
NRP- prior studies suggested babies born at <30 weeks should get prophylactic surfactant even if they weren’t intubated… now immediate use of CPAP is considered an alternative to surfactant administration
35
```
Term male, delivered by emergency C-section for fetal distress. Meconium present, suctioned below cords. Now needing 100% O2. Radial Gas PaO2 80. Umbilical gas
PaO2 40. What is the diagnosis?
a) PPHN
b) Meconium aspiration
c) TGA
```
a) PPHN
- PPHN should be suspected in all infants with cyanosis
- hypoxemia is present in all cases
- intermittently unresponsive to 100% O2
- oxygen saturation or PAO2 gradient between preductal (right radial artery) and post ductal (umbilical artery) sites of sampling imply shunting across PDA
36
Unstable premature neonate on Ventilator with ++02 needs. Desating frequently with handling and recovering with bagging. What do you do?
d) Increase sedation
e) Steroids
f) surfactant
a) Minimize handling, increase sedation
a) Minimize handling, increase sedation
| - suspect PPHN - labile sats that recover well with bagging
37
Newborn has significant respiratory distress and CXR that is consistent with pneumonia. She is ventilated with PIP 36, PEEP 5 rate 60 bpm, FiO2 1.0, she is not saturating very well. What is the likely diagnosis? What intervention should you start now?
1. Hypoxic Respiratory failure or PPHN
| 2. iNO - effective in term infants with hypoxemic resp failure
38
You are taking care of a newborn ventilated baby born at 26 weeks who is now 29 weeks CGA with pulmonary interstitial emphysema on CXR. He is currently ventilated with the following settings: rate 40, PIP 18, PEEP 4, 60% O2. You receive the following blood gas: pH 7.20, pCO2 58, pO2 56, HCO3 19, base deficit -6.
a. What change in ventilator settings do you make?
b. 48 hours later the baby is suddenly mottled, and has the following bloodwork: Na 139, K6.8, pH 7.18, pCO2 38, pO2 68, HCO3 12, base deficit -12. The baby’s urine output is 2.5 cc/kg/hr. What complication has most
likely occurred?
a. increase rate (best strategy for ventilation in PIE is permissive hypercapnia since escalating support can worsen PIE - increase rate over pressures to control ventilation)
b. Metabolic acidosis from poor cardiac output from bad PIE or pneumothorax
39
You are treating a 38 week old newborn who was flat at birth but improved with 2 minutes of PPV. Now at 12 hours of age the baby is tachypneic at 70, BP is 38/20 (mean 32). You take the following CXR. (CXR with left-sided pneumothorax, RUL collapse but no mediastinal shift)
c. What is your management?
Needle decompression
40
A newborn term infant had thin meconium at delivery but had good APGAR scores and required only 2 minutes of free flow O2. Now at 12 hours of age he has increasing
work of breathing. On CXR there is hyperinflation of the RUL with mediastinal shift. What is the most likely diagnosis:
a. Meconium aspiration syndrome
b. Neonatal pneumonia
c. CCAM
d. Congenital lobar emphysema
d. Congenital lobar emphysema
● Congenital lobar emphysema (CLE), also known as congenital alveolar overdistension, is a developmental anomaly of the lower respiratory tract that is characterized by hyperinflation of one or more of the pulmonary lobes - intrinsic obstruction creates ball-valve mechanism
41
What are 4 ways in which meconium aspiration causes respiratory problems?
1. inactivation of surfactant
2. airway obstruction - can lead to distal atelectasis/ball valve mechanism can lead to pneumothorax
3. reactive pneumonitis
4. pneumonia (meconium is sterile but an excellent growth medium for bacteria like e. coli, and inhibits phagocytosis by PMNs)
42
16 week male born at 28 weeks GA. Hospitalized with RSV
bronchiolitis. pCO2=60; pO2=94 in 50% oxygen. Chest X-ray shows RML infiltrate. Tachypneic. Best management:
a. intubate and ventilate
b. humidified oxygen and monitor closely
c. ribavirin
d. steroids
e. antibiotics
a. intubate and ventilate
| - best option, IRL would probably try CPAP first
43
Description of a newborn with respiratory distress. What are your 4 management options.
1. suction mouth and nose and ensure nares patent
2. supplemental O2 by nasal prongs
3. CPAP
4. intubate and ventilate
44
Newborn term, AGA baby , cried at birth, Apgars 9 and 9. Few hours later found to be in respiratory distress. RR 80, HR high. Cap refill 4-5 seconds, BP 48/32. Hyperinflated chest with minimal indrawing. Cannot hear breath sounds on left, cannot hear heart sounds. Baby is turning cyanotic. What investigation do you do (1)? What is your possible diagnosis (1) Baby’s heart rate is now 80 and is more cyanotic. What one investigation do you want to do
1. transillumination
2. pneumothorax
3. needle decompression
45
12h old Newborn has a sat of 80%. Increases to 85% with 100% 02. Mild tachypnea rr65. CXR has no abnormalities. What next initial management should be done?
a. Intubate and ventilate
b. Prostaglandins
c. Antibiotics
b. Prostaglandins
46
(CXR of a newborn with ?narrow mediastinum and ?normal pulmonary vasculature) You are asked to see a term newborn in the delivery room after an uneventful delivery and resuscitation. The baby has a RR of 70 and is cyanotic.
a. What is the most likely diagnosis?
b. What one treatment will you start immediately?
a. Cyanotic congenital heart disease (?TGA given narrow mediastinum)
b. PGE
47
A 3 day old is tachypneic, cyanosed despite 100% O2. Bilateral crackles on exam with weak peripheral pulses and no heart murmur. What is the diagnosis:
1. HLHS
2. Sepsis
3. AV fistula
1. HLHS
48
Child with cyanosis, O2 sat 80% doesn’t improve with oxygen. Pan systolic murmur grade III/IV. CXR normal and ECG shows right axis deviation. What is the diagnosis?
?TOF
49
A 3-day-old infant develops poor perfusion, diminished peripheral pulses, and decreased urine output. What medication would you administer:
a) atropine
b) morphine
c) bicarbonate
d) furosemide
e) prostaglandins
e) prostaglandins
| - if antibiotics were an option that could also be a good consideration
50
```
3 day infant cyanosis with crying, investigation
a ECG
b CXR
c ABG
d bld cx
e echo
```
e echo
| - crying increases right sided pressure which increases right to left shunting (and therefore increases cyanosis)
51
Bili question. 37 weeker. Mild lethargy. Total bili 280 @ 30 weeks (?meant hours). No ABO. Give 3 bili charts. Mgt?
a. Follow-up in 24 hours
b. Phototherapy and repeat bili in 6 hours
c. Exchange
d. IVIG
b. Phototherapy and repeat bili in 6 hours
- medium risk line (only significant lethargy counts as a risk factor)
- at/above exchange line; no use for IVIG if no ABO
52
3 week old infant has jaundice. His birth weight was 3250g and he now weighs 3490g. He is breastfeeding well. Hemoglobin is 127 and total bilirubin is 270, conjugated bilirubin is 8. Coombs test is negative. What should be done?
a) Admit for phototherapy
b) Referral to gastroenterology
c) Reassess in 1 week
d) Recommend switching from breastfeeding to formula
c) Reassess in 1 week
Breast milk jaundice
53
What are risk factors for unconjugated hyperbilirubinemia in a neonate?
a) Prematurity
b) LGA
c) male
a) Prematurity
54
Which of the following is the best predictor of risk of Rh autoimmune hemolytic disease at the time of delivery?
a. Bili in the cord
b. Hb in the cord
c. Mom’s Anti-Rh titres
d. Gestational age
c. Mom’s Anti-Rh titres
o Any infant of Rh-negative mom should be tested for DAT, type, Hg
▪ If DAT positive, baseline bili should be measured
55
A baby has a direct hyperbilirubinemia. He was treated for an E. coli sepsis. He has hepatomegaly on exam. Which test will likely yield the diagnosis
a. RBC GALT function
b. G6PD level
c. Osmotic Fragility
d. RBC glucose-phosphate-1 deficiency
a. RBC GALT function
Galatosemia
56
```
You are seeing a 1 wk old Chinese boy with 1 day of jaundice. His bili is 270 (mostly indirect), Hg 95 retics 9%, Mom is AB+ and he is B+. He otherwise looks well. What is
the diagnosis?
a. Sepsis
b. Thalassemia
c. G6PD def
d. ABO incompatibility
```
c. G6PD def
57
Baby with bili of 280 and conjugated 200? What is the most likely cause based on incidence?
a. Breastfeeding jaundice
b. Hemolysis ABO
c. Neonatal hepatitis
d. Galactosemia
c. Neonatal hepatitis
58
4 risk factors for increased chance of kernicterus in a baby with hyperbilirubinemia.
1. prematurity
2. sepsis/acidosis
3. Rh/ABO incompatibility
4. jaundice within first 24 hours of life
5. very high bilirubin level
6. asphyxia
7. G6PD deficiency
59
You are called from a family doctor about a 5 day old jaundiced baby. Well looking. Total bili is 355, direct is normal. He is breastfed. What do you recommend?
1. septic work up
2. investigate for a metabolic disease
3. coombs test and hg
4. start phototherapy
5. observe
4. start phototherapy
60
Baby with jaundice, low platelet count, looks septic. What is the cause? (Lab values given).
(a) TORCH infection
(b) galactosemia
(c) bacterial sepsis
could be TORCH infection or sepsis
| - might lean toward sepsis since that would be worse to miss
61
A 32 week gestation infant with Rh incompatibility has received 5 exchange transfusions. He now has vomiting, diarrhea, and abdominal distension. Most likely diagnosis:
a) sepsis
b) acute gastroenteritis
c) portal vein thrombosis
d) necrotizing enterocolitis
d) necrotizing enterocolitis
| - exchange transfusion or any blood transfusion is a risk factor for NEC
62
3 week old who is brought to the office because mother thinks he is too yellow. Breastfed. Otherwise well. Total bili is 180. Direct is 8. What do you do?
A) septic workup
B) investigate for blood group incompatibility
C) reassure mother that condition may last for 4-12 weeks
D) investigate for metabolic disease
C) reassure mother that condition may last for 4-12 weeks
- breastfeeding jaundice
63
36 wk baby 2.1 kg (5lbs) at birth, day 7 jittery, irritable, on exam HR 218, T 37.5, RR 70 bp 90/60. Face is flushed, eyes wide open, alert but irritable, normal tone and normal cry, jaundiced, DTR's 2/4 and symmetric. There is hepatosplenomegaly. What is the likely diagnosis (1), List 2 tests to confirm your diagnosis
1. Likely diagnosis is congenital hyperthyroidism
2. Two tests to confirm= T4 and TSH
- mom with Graves - antibodies that bind to TSH receptor in thyroid (stimulating release of T3 and T4 even though there is no TSH) cross placenta
- Ix: low TSH, high T3 and T4
64
33 week premature infant is born to a mother with hypertension. Baby is SGA. What other associated findings do you expect?
a) polycythemia
b) hyperglycemia
c) hypomagnesimia
d) hypercalcemia
a) polycythemia
65
Baby with symmetric IUGR. Cause?
a) smoking
b) preeclampsia
c) congenital infection
d) placental insufficiency
c) congenital infection
66
Baby with low apgars at birth. Picture of hypoxia. What complications would you expect over the next few days
Neurological - Seizures, HIE, ischemic brain injury
Pulmonary - RDS, PPHN
Cardiac - cardiac ischemia leading to dysfunction → muscle and conduction
Renal - AKI
GI - feeding intolerance, increased risk of NEC
Metabolic - mitochondrial dysfunction leading to a catabolic state, decreased energy reserve
Heme - thrombocytopenia, polycythemia, coagulopathies
67
GBS positive mom with antibiotics given 4hrs before delivery. Would like to go home. What would be your plan? (no risk factors were given!)
a. can be discharged at 48 hrs
b. normal newborn care
b. normal newborn care
68
Mom with unknown GBS. First baby. List 3 criteria for offering intrapartum abx therapy.
- preterm labour with imminent risk of delivery
- preterm, prelabour rupture of membranes
- rupture of membranes >18 hours
- intrapartum fever 38 or higher
69
Mom with fever, PROM but inadequate abx therapy. Unknow GBS. Babe is born and perfectly well. Obstetrician tells you mom has chorio. What do you do:
a) Cultures and abx
b) CBC and observe 24 hrs
c) Observe 24 hrs
d) Full septic work up
c) Observe 24 hrs
- observe for 24-48 hours
- could consider CBC at 4 hours
70
A newborn with 37.3 axillary temperature. What should be done next?
a) Repeat after 20 minutes of unbundling
b) Do a tympanic temperature
c) Do CBC
d) Full Septic W/U
a) Repeat after 20 minutes of unbundling
71
Newborn with axillary temperature of 37.8 degrees, well normal exam. What do you do?
a) Full septic work up and antibiotics
b) Rectal temperature
c) Take off all clothes for 20 minutes and recheck temperature
d) CBC and diff
b) Rectal temperature
| - axillary temp recommended for screening given very small risk of perforation with rectal temp
72
Mother with +ve GBS never got treated intrapartum abx. Baby born 32 wk now 9 days. Has been having increasing apneas in the past 24 h. Blood culture done shows GP cocci in clusters after 18 h of culture. What most diagnosis
a. GBS
b. Strep viridans
c. S aureus
d. Coag neg staph
d. Coag neg staph (clusters)
- staph in cluster, strep in chains
- CONS is most common cause of late onset sepsis, especially in very low BW infants
73
3 week old with previous e coli sepsis and persistent jaundice. What is the likely problem.
1. Increased osmotic fragility
2. RBC galactose phosphate uradyl transferase deficiency
3. RBC glu – 1 – phosphate dehydrogenase deficiency
2. RBC galactose phosphate uradyl transferase deficiency
- galactosemia
- dx: positive reducing substances in urine (galactosuria)
tx: soy formula (NO lactose)
74
Pregnant mom who has a previous child. She is GBS positive, comes in at 6:00pm and gets IV penicillin. At 8:00pm, she delivers a healthy baby boy at 39 weeks. Babe is well and has a normal CBC. She is wondering when she can go home (she lives close to the hospital)
a. start amp/gent
b. observe until 24 hours
c. observe until 48 hours
d. full septic work-up
b. observe until 24 hours → for at least 24 h and then reassess prior to discharge.
75
You are working in the NICU, and are called to see a 4 day old female born at 28 weeks. She has vomited with her last 2 NG feeds and now is noted to be distended with
discoloration of the abdominal skin. You are concerned about necrotizing enterocolitis. You place the baby NPO, start antibiotic treatment and order an abdominal XR.
a. Name 3 XR signs of NEC.
a. pneumatosis intestinalis
- portal venous air
- pneumoperitoneum
- loss of normal bowel gas pattern (distended bowel, loss of hexagonal pattern, stacking of bowel loops)
- bowel wall edema
76
2 day old infant presents with fever of 39.5 ax. He is breastfed and his weight has fallen from 3.8 to 3.5 kg. He is lethargic but rouses during the examination. His fontanelle is normal. Na 150, K 7.3, Cl 110, BUN 8, Cr 110, uncong bili 190, normal CBC. What is the likely diagnosis?
a) hypernatremic dehydration due to decreased fluid intake
b) hypertonic breast milk
c) diabetes insipidus
d) sepsis
e) meningitis
d) sepsis
77
SGA prem, now 2 weeks old in NICU, baby presents with septic picture.
a. ) List 3 bacteria that could be responsible.
b. ) Initial choice of antibiotic treatment
a. GBS, E. coli, staph aureus, coag negative staph
| b. cloxacillin and tobramycin (CONS most likely), or vanco and tobra if have resistance
78
Premature baby with apneas, temp instability, abdo distention with bowel loops palpable, not tolerating feeds.
a.) Management/treatment x4 lines
a. NPO
- NG to LIS
- ampicillin, tobramycin, metronidazole
- IV fluids/TPN
- blood culture
- refer to tertiary care centre with pediatric surgery
79
Newborn with a TSH of 25. What do you do?
a. start thyroxine
b. repeat neonatal screen
c. bring them into the office as soon as possible
d. thyroid ultrasound
c. bring them into the office as soon as possible
80
Term BB, mom with gestational diabetes. DOL 1. Glucose 1.4. What is your next step in management?
a. Bolus glucose by NG
b. Bolus 1 cc/kg of D50W
c. Run IV D10 @ 80 cc/kg/day
d. Frequent breastfeeding
c. Run IV D10 @ 80 cc/kg/day
81
Male 3 weeks old. Presents with shock, hyperpigmented scrotum, low NA 115, K 6.8. What is your most important investigation? What is your immediate management?
Concern for CAH
- ABCs - in shock therefore needs IV access and fluid bolus
- hydrocortisone
- Ix: 17-OHP
82
3 week old has hypocalcemia. Most likely diagnosis?
transient hypoparathyroidism
83
A 6 day old infant presents in shock with a glucose of 1.8 and cardiomegaly on CXR. Which of the following is the most likely etiology of the shock:
a. Cardiac
b. Sepsis
c. Endocrine
d. Metabolic
d. Metabolic - big heart? either muscle cell hypertrophy or deposition of lipids or glycogen
IEMs:
- amino acid: maple syrup urine disease
- glycogen: hepatic glycogen storage disease
- glucose: hereditary fructose intolerance
- fatty acid: galactosemia, MCAD/SCAD/LCAD/VLCAD deficiency, carnitine palmitoyl transferase deficiency
84
You are called to see a 2.5 kg term newborn with jitteriness. You do a bedside glucose, which is 1.7. You decided to insert an IV and give the baby a bolus of
2cc/kg of D10.
a. Please write an ongoing fluid order for this baby, to be started after the bolus is complete (1 line).
D10W IV at TFI 80ml/kg/day
85
A 2.2 kg term newborn breast feeds well at birth and then is seen at 2 hours of age with a BS of 1.9. He is asymptomatic. What is the best initial management:
a. feed and recheck BS in 1 hour
b. IV dextrose at 4-6 mg/kg/hr
c. IV D10 2cc/kg then dextrose at 4-6 mg/kg/hr
d. Supplement BF with bottle and recheck BS
a. feed and recheck BS in 1 hour
86
Infantile cystinosis. What do you get?
a. cataracts
b. end stage renal failure
c. nephrocalcinosis
c. nephrocalcinosis (the first clinical signs of infantile cystinosis appear between three and six
months of age; they are largely due to impaired proximal tubular reabsorptive capacity - hypercalciuria part of this)
- renal failure is later presentation if not treated
- cataracts by 12-16 months
87
Picture of rocker bottom feet (aka congenital vertical talus)– what condition do you need to think about?
T18
T13
18q deletion syndrome
spina bifida, arthrogryposis
88
TPN – list four metabolic complications
1. hypernatremia
2. TPN cholestasis
3. hypertriglyceridemia
4. hypoalbuminemia
89
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3 week male infant with vomiting, lethargy, decr. po intake
Na 118, K 8. Most important lab test?
A) vasopression
B) 17OHP
C) cortisol
D) calcium
E) renin
```
B) 17OHP
90
Newborn weighs 1.8 kg. Jittery and found to have glucose 1.3. Repeat glucose is 0.8 What is this baby’s glucose requirement in mg/kg/min (1)?. Write your IV order (1)
1. GIR = 5.5mg/kg/min
| 2. bolus 2cc/kg of D10W IV over 5 minutes, then run D10W at TFI of 80ml/kg/day
91
10 day old baby with failure to thrive, jaundice, hepatomegaly, blood culture positive for E.Coli. What underlying disorder may the child have? What test can you do to confirm this diagnosis (1)?
1. galactosemia
| 2. RBC GALT (galactose-1-phosphate uridyl transferase) activity
92
You are discussing with a mother the prognosis of her child born at 31 weeks gestation. There was thin meconium at birth. APGARs were 8 and 9. Head ultrasound showed a small intraventricular hemorrhage at one week of age. She is concerned because he is not yet walking and has stiff legs.
a) the child likely has spastic diplegia which is often associated with prematurity and intraventricular hemorrhage
b) the history is unusual in that children with CP usually have a history suggestive of birth asphyxia
c) IVH would cause PVL which would result in hemiplegia
d) there will be progressive decline in his development
a) the child likely has spastic diplegia which is often associated with prematurity and intraventricular hemorrhage
93
Ex-29 week prem with hyperreflexia and gross motor delay. Had history of Grade II IVH and PVL. Advise the mother about the likely cause of CP in this child. What would you see on a CT that is specific to this?
- IVH leading to PVL is the cause of this child's CP (PVL in prems is the most common cause of spastic diplegia)
- CT would show focal areas of necrosis in the periventricular white matter
94
What is the number one cause of central apnea in a 34 week prem who is now at 8 week of age?
a) Seizure
b) RSV
c) Apnea of prematurity
d) IEM
c) Apnea of prematurity
95
Ex-30 week prem, now at 39 weeks corrected has had an uneventful course. He had apnea of prematurity treated with caffeine. He is still having apneas with occasional
bradycardia 5-6 times a day. What is the likely cause?
a) Apnea of prematurity
b) Seizures
c) GERD
a) Apnea of prematurity
96
An ex-1500g premature infant presents with a prolonged apnea spell at 5 weeks of age. Extensive laboratory workup is unremarkable. On sending the parents
home, you suggest:
a. infant should always sleep on side
b. infant should sleep in parents' room
c. infant should sleep in own room, but parents should check on infant hourly
d. an audio monitor should be placed on infant's room
e. parents should not use heavy blankets in the crib
b. infant should sleep in parents' room
97
A 4-hour-old term infant has developed tachypnea, RR 60, and has had several episodes of apnea. After initial investigations, what would you do:
a) observe for further deterioration
b) intubate
c) antibiotics
d) prostaglandins
c) antibiotics
98
2 month old ex 32 weeker who was ventilated with Ua/Uv lines. Now has HSM but has an otherwise normal physical exam. What is the likely cause?
1. hepatic hemangioma
2. portal vein thrombosis
3. hereditary spherocytosis
4. congenital CMV
5. fungal infection
2. portal vein thrombosis
| - leading to portal hypertension
99
Baby prem 33 weeks with RDS. Heart rate is 50 apneic and limp? What are your next 2 management steps?
1. give positive pressure ventilation with flow-inflatig bag and prepare for intubation
2. start chest compressions
100
Neonate with BPD being treated with furosemide. List 4 side effects.
1. hyponatremia
2. hypokalemia
3. hypochloremia
4. hypercalciuria
5. nephrocalcinosis
6. dehydration
101
An infant born at 26 weeks gestation is now 28 weeks (2 weeks old). He is doing well and is going to be transferred to a level II nursery. When should he be screened for ROP.
a) if normal now, no need to do further follow-up
b) do eye exam now
c) do eye exam at 32 weeks
d) do eye exam at 38 weeks
e) do eye exam at 52 weeks
c) do eye exam at 32 weeks (technically should be 31 weeks)
| - if born at less than 28 weeks, screen at 31 weeks CGA, if born at 28+ weeks, screen at 4 weeks of life
102
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Which is an indication of seizure activity in a neonate?
A. tachycardia
B. abnormal eye movements
C. irregular breathing
D. irritability
E. vomiting
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B. abnormal eye movements
103
Newborn with trisomy 21, non-bilious vomiting after feeds. What’s the test?
a. Abdominal ultrasound
b. Barium swallow with follow through
c. Abdominal Xray
d. observe for now
c. Abdominal Xray
Usually duodenal atresia would present with bilious emesis, but initially may be non bilious and then progress to bilious
- AXR shows double bubble
104
Newborn diagnosed with interrupted aortic arch, what to start?
a. dopamine
b. prostaglandin
c. nitric oxide
d. indomethacin
b. prostaglandin
105
You are called to the newborn nursery to see a 4 hour old newborn female in respiratory distress. The RR is 70 and you note increased working of breathing. The nurses have also noted that the baby has a significant amount of oral
secretions.
a. What one test is required to make the diagnosis?
a. attempt to insert NG with CXR showing NG coiled in esophagus
106
What advice should you give to parents to prevent positional plagiocephaly:
a. Children should be put to sleep in car seats
b. Children should be put to sleep on their sides
c. Children should be put on their stomachs as much as possible when awake
c. Children should be put on their stomachs as much as possible when awake
107
Child with distress, can’t pass NG through nare. List 3 other findings on physical exam you’d look for?
50% associated with other anomalies; 10-20% have full CHARGE
- coloboma
- heart murmur
- GU abnormalities
- ear abnormalities
- square face, arched eyebrows, prominent forehead
108
Baby with constipation. Barium enema shows rectal ampulla narrow with dilated proximal bowel.
a. ) 2 investigations to confirm the diagnosis.
b. ) What would you expect as the result of each investigation.
- rectal biopsy: aganglionic cells
| - rectal manometry: failure of internal anal sphincter to relax with rectal distension
109
Question where neonate has thrombocytopenia and mom’s plts are normal. Mgt?
Neonatal alloimmune thrombocytopenia
| - mgmt: platelet transfusion with maternal washed platelets or HPA1a (PLA1) negative platelets
110
Description of newborn with petechiae. WBC normal, Hgb normal, plt 9. Rest of exam is normal. List 3 most likely causes aside from sepsis.
1. neonatal alloimmune thrombocytopenia
2. autoimmune thrombocytopenia (maternal ITP)
3. TORCH infection - congenital rubella or CMV
111
Fullterm baby delivered to an O+ mom. Looks well but pale. Hb is 70, he is hemodynamically stable. What is the most likely diagnosis?
1. ABO incompatability
2. Chronic fetal maternal hemorrhage
3. Rh incompatability
1. ABO incompatability
112
Which of the following predisposes to late hemorrhagic disease of the newborn:
1. breastfeeding
2. prematurity
3. cystic fibrosis
4. maternal phenytoin
5. oral antibiotics
1. breastfeeding
| - maternal phenytoin is a risk factor for early HDN
113
Newborn with platelets of 12, transfused and post-transfusion platelets were 16. Mom’s CBC was normal. What do you do?
a. transfuse single donor platelets
b. transfuse PLA-1 negative platelets
c. give IVIG
d. give steroids
b. transfuse PLA-1 negative platelets (same thing as HPA-1: for alloimmune)
114
Most likely cause of late hemorrhagic disease of the newborn?
a. phenytoin use in mom
b. baby did not get Vit K prophylaxis
c. oral antibiotics
d. cystic fibrosis
b. baby did not get Vit K prophylaxis
115
Newborn with plethora and lethargy. HCR 0.72, Hb 240, Glu 3.2 on venous blood. What to do?
a) Exchange transfusion
b) IV D10W
c) Septic workup
a) Exchange transfusion
116
Polycythemic newborn. Hb 240, Hct 0.75. Wt 2000g. Child requires a partial exchange transfusion. What fluid do you use as the diluent? How much blood do you replace to decrease the Hct to 0.5?
1. NS
2. Volume = blood volume x (observed-desired hct)/observed hct
= (2kg x 80ml/kg) x (0.75-0.5)/0.75
= 160ml x 0.25 / 0.75
= 40/0.75 = 53.3ml
117
Baby born at home at 38 wks by midwife. Now presents at 7 days with melena. Hb 70, MCV 112, plts normal. What is the most likely diagnosis?
Vitamin K deficient bleeding (previously hemorrhagic disease of the newborn)
118
You are called to see a 2 day old newborn male with jitteriness. At birth he was found to have a cleft palate, but has been bottle feeding well since. On physical examination, you note that the baby has a harsh systolic murmur.
a. What is the most likely diagnosis?
b. What is the reason for the baby’s jitteriness?
a. Di George
| b. Hypocalcemia
119
Newborn is sneezing, what medication in mom could this be associated with?
a. methadone
b. IDM on insulin
c. clindamycin
a. methadone
120
3 day old baby with tachypnea, jitteriness, myoclonus and normal glucose. Treatment?
a. Amp/gent
b. Vit B
c. Morphine
c. Morphine (NAS)
121
Abstinence from methadone? Neonatal symptoms?
a. Hyporeflexia
b. Constipation
c. Sneezing
d. Lethargy
c. Sneezing
122
Baby born to heroin addicted mom. Apneic despite bag and mask ventilation. Best management?
a. Narcan
b. Intubate until baby breathes on his own
c. Bag and mask ventilation until baby breathes on his own
c. Bag and mask ventilation until baby breathes on his own
123
A mother is given Demerol 90 minutes prior to delivery. The baby is suctioned and stimulated but remains apneic with a pulse of 80. Next step in management:
a. bag and mask
b. more stimulation
c. Narcan
d. Antibiotics
a. bag and mask
124
In utero exposure to cocaine results in which of the following in the newborn:
a) hearing deficits
b) microcephaly
c) hypotension
d) spinal dysraphism
b) microcephaly
125
What is true about neonatal chest compressions:
1. ? Required after 30 seconds of PPV with HR less than 60
2. Chest compressions to be done at a ratio of 5:1 with every breath
3. 2 finger technique is preferred
4. Required after no response to stimulation
1. Required after 30 seconds of PPV with HR less than 60 → there should effective ventilation PPV and an advanced airway before chest compressions
126
Baby born at 41 wks. Meconium staining. Flat babe requiring resuc. Apgars 2 at 1 min 3 at 5 min and 6 at 7 min. what 5 things may you expect with this baby in the near future. What 2 tests at discharge, if normal would suggets a good neurological outcome for this child
1. seizures, hypotonia, hypertonia, hypotension, respiratory distress, acute tubular necrosis/AKI, GI perforation, SIADH or electrolyte abnormalities (low Na, Ca, hypoglycemia), DIC
2. Good neuro outcome: normal EEG and MRI
127
Newborn with an Erb’s palsy. Which is true?
a. extension at the wrist
b. preserved grasp
c. symmetric moro
b. preserved grasp
128
Baby with renal mass and hematuria. Most likely associated with?
a. IDM
b. polycythemia
c. dehydration
d. UVC
a. IDM
Presentation of RVT: Sudden onset gross hematuria (can also be microscopic), Unilateral or bilateral flank masses, Hypertension, Oliguria
- perinatal risk factors including asphyxia present in 31% of cases
- maternal diabetes in 8%
- dehydration in 1.5%
- polycythemia not mentioned
129
Antenatal U/S shows moderate hydro. U/S at 24 hrs normal. What to do next and why.
repeat U/S after first 3 days of life, as can have false negative results prior to this while baby still digressing
130
Description of child with prune belly. Weak abdominal musculature. Cryptocidism. Baby in intubated in NICU. Bilateral abdominal masses on exam. What is this associated with.
a) Bilateral wilms
b) Polycystic kidneys
c) Multicystic kidneys
d) Hydronephrosis
d) Hydronephrosis
131
List 4 non-infectious risk factors of hearing loss in the newborn period.
1. hyperbilirubinemia
2. anatomic ear abnormalities (atresia or stenosis of ear canal)
3. ototoxic medications (aminoglycosides, loop diuretics)
4. family history of childhood SNHL
5. mechanical ventilation >5 days
6. BW <1500g
7. apgars <5 at 1 minute, <7 at 5 minutes
132
4 biologic determinants of child development.
1. genetics
2. in utero exposure to teratogens
3. low birth weight
4. post natal illness
5. prematurity
6. exposure to toxic/hazardous substances
