Neonatology Practice Questions

Q: Which of the following is NOT a feature of acute bilirubin encephalopathy?

Exaggerated Moro reflex. **Explanation:** Acute Bilirubin Encephalopathy (ABE) refers to the acute clinical manifestations of bilirubin toxicity in the neonatal brain. The correct answer is **Exaggerated Moro reflex** because, in the early and intermediate phases of ABE, the Moro reflex is typically **depressed or absent**, not exaggerated. **Analysis of Options:** * **A. Lethargy:** This is a hallmark of the **Early Phase** of ABE. Infants typically present with poor feeding, hypotonia, and a decreased level of consciousness (lethargy). * **B. Opisthotonus:** This occurs during the **Intermediate and Advanced Phases**. As toxicity progresses, hypertonia of the extensor muscles leads to retrocollis (neck arching) and opisthotonus (back arching). * **D. Choreoathetosis:** This is a classic feature of **Chronic Bilirubin Encephalopathy (Kernicterus)**. While ABE refers to the acute stage, the question asks for features of the encephalopathy process; choreoathetosis represents the permanent extrapyramidal damage to the basal ganglia. * **C. Exaggerated Moro reflex (Correct):** In ABE, the Moro reflex is characteristically **depressed**. An exaggerated Moro reflex is more commonly associated with Neonatal Abstinence Syndrome or early Hypoxic-Ischemic Encephalopathy (Stage 1). **NEET-PG High-Yield Pearls:** 1. **Kernicterus Triad:** Choreoathetoid cerebral palsy, sensorineural hearing loss (SNHL), and upward gaze palsy. 2. **Brain MRI:** The most common finding in the acute phase is increased T1 signal intensity in the **Globus Pallidus**. 3. **Phases of ABE:** * *Phase 1 (Early):* Hypotonia, lethargy, poor suck, depressed Moro. * *Phase 2 (Intermediate):* Hypertonia (opisthotonus), high-pitched cry, fever. * *Phase 3 (Advanced):* Pronounced opisthotonus, seizures, coma, death.

Q: A baby is born with meconium-stained liquor. All of the following are taken into account in terming a baby 'vigorous' EXCEPT:

Colour. In the management of a neonate born through **Meconium-Stained Amniotic Fluid (MSAF)**, the clinical decision-making process depends on whether the baby is "vigorous" or "non-vigorous." ### **Why "Colour" is the Correct Answer** According to the **Neonatal Resuscitation Program (NRP)** guidelines, the definition of a **vigorous** infant is based on three specific clinical parameters: 1. **Strong respiratory effort** (crying or regular breathing) 2. **Good muscle tone** (active movement or flexed extremities) 3. **Heart rate > 100 beats per minute** **Colour** is excluded from this definition because peripheral cyanosis (acrocyanosis) is a physiological finding in the first few minutes of life and is not a reliable indicator of the need for immediate tracheal suctioning or resuscitation in the context of meconium. ### **Analysis of Incorrect Options** * **Tone (Option A):** A vigorous baby must have good muscle tone. Limp or floppy extremities indicate a non-vigorous state. * **Heart Rate (Option C):** A heart rate of >100 bpm is a core requirement for being termed vigorous. * **Respiration (Option D):** Strong respiratory efforts or a loud cry are essential criteria. ### **Clinical Pearls for NEET-PG** * **Current Protocol:** Routine endotracheal suctioning for non-vigorous infants is **no longer recommended** by the latest NRP guidelines. Initial steps (warming, drying, stimulating) should be performed first. * **Suctioning:** If the baby is non-vigorous and has poor respiratory effort, the priority is **Positive Pressure Ventilation (PPV)**. Direct laryngoscopy and tracheal suctioning are only considered if the airway is obstructed. * **Apgar vs. Vigorous Criteria:** Do not confuse these. While "Colour" is a component of the **APGAR score**, it is specifically omitted from the "Vigorous" criteria used for MSAF management.

Q: A term infant has initial Apgar scores of 8 and 10 at 1 and 5 minutes. On auscultation of the chest, a heart murmur is audible. There is hepatosplenomegaly. Cataracts of the crystalline lens are noted. The infant is at the 30th percentile for height and weight. Echocardiography shows a patent ductus arteriosus. Which of the following events is the most likely risk factor for the findings in this infant?

Congenital rubella infection. ### Explanation The clinical presentation of **cataracts**, **Patent Ductus Arteriosus (PDA)**, and **hepatosplenomegaly** in a term infant is the classic triad of **Congenital Rubella Syndrome (CRS)**. **1. Why Option A is Correct:** CRS occurs due to maternal infection with the Rubella virus (a Togavirus) during the first trimester. The virus is teratogenic and leads to: * **Ocular defects:** "Pearly white" nuclear cataracts (most common) and glaucoma. * **Cardiac defects:** PDA (most common) and peripheral pulmonary artery stenosis. * **Auditory defects:** Sensorineural hearing loss (the most common overall finding). * **Systemic signs:** Hepatosplenomegaly, jaundice, and "Blueberry muffin" spots (extramedullary hematopoiesis). **2. Why Incorrect Options are Wrong:** * **B. Dietary folate deficiency:** Primarily associated with **Neural Tube Defects** (e.g., spina bifida, anencephaly), not cataracts or PDA. * **C. Dispermy at conception:** This leads to **Triploidy** (69 chromosomes), which usually results in spontaneous abortion or severe multi-organ anomalies and growth restriction, but does not specifically present with this classic triad. * **D. Erythroblastosis fetalis:** Caused by Rh/ABO incompatibility. It presents with severe anemia, hydrops fetalis, and hepatosplenomegaly due to hemolysis, but it does not cause congenital cataracts or structural heart defects like PDA. **3. High-Yield Clinical Pearls for NEET-PG:** * **Gregg’s Triad:** Cataracts, Deafness, and Cardiac defects (PDA). * **Timing:** The risk of malformation is highest (up to 80%) if the mother is infected within the first **12 weeks** of gestation. * **Diagnosis:** Detection of **Rubella-specific IgM** in the cord blood or infant sera. * **Prevention:** Vaccination with the **MMR vaccine** (Live attenuated). Note: MMR is contraindicated during pregnancy; women should avoid pregnancy for 1 month after vaccination.

Q: Which of the following features is characteristic of a premature baby compared to a baby with intrauterine growth restriction?

Sole creases all over the feet. ### Explanation The key to distinguishing a **Preterm baby** from a **Small for Gestational Age (SGA/IUGR)** baby lies in assessing physical maturity versus nutritional status. Physical maturity markers (like sole creases, ear recoil, and breast nodules) progress with gestational age, regardless of the baby's weight. **1. Why Option A is Correct:** In a **term baby with IUGR**, the gestational age is $\geq$ 37 weeks. Therefore, physical maturity markers will be well-developed. **Sole creases all over the feet** (extending to the heel) are a hallmark of a term baby. In contrast, a premature baby would have creases only on the anterior one-third or two-thirds of the sole, or none at all. **2. Analysis of Incorrect Options:** * **Option B (Breast nodule 2 mm):** This is a feature of **prematurity**. In a term IUGR baby, the breast nodule is typically $>5$ mm. * **Option C (Ear cartilage well formed):** This is a feature of **maturity (IUGR/Term)**. A preterm baby has thick, pliable ears with little cartilage and slow or no recoil. * **Option D (Skin glistening and thin):** This is characteristic of a **preterm baby**. A term IUGR baby typically has skin that is dry, cracked, leathery, or peeling (parchment-like) due to the loss of subcutaneous fat and vernix. **Clinical Pearls for NEET-PG:** * **New Ballard Score:** The standard tool used to estimate gestational age by assessing 6 neuromuscular and 6 physical criteria. * **IUGR vs. Preterm:** IUGR babies have a **higher Head Circumference to Abdominal Circumference (HC/AC) ratio** (asymmetric) and are at higher risk for hypoglycemia and polycythemia. * **Neuromuscular maturity:** Preterm babies are hypotonic ("froglike" posture), while term IUGR babies maintain good muscle tone and recoil.

Q: An infant born 3 hours previously to a mother with poorly controlled insulin-dependent gestational diabetes presents with abnormal breathing. Examination reveals cyanosis, irregular and labored breathing, decreased breath sounds on the right side, and decreased tone in the right arm. A stat portable chest radiograph is normal. Which of the following studies is most likely to confirm the diagnosis?

Chest ultrasound. **Explanation:** The clinical presentation points toward **Phrenic Nerve Palsy**, a birth injury often associated with macrosomia and difficult deliveries (common in infants of diabetic mothers). The combination of respiratory distress (cyanosis, labored breathing), unilateral decreased breath sounds, and ipsilateral **Erb’s palsy** (decreased tone in the right arm) is classic. 1. **Why Chest Ultrasound is correct:** In phrenic nerve palsy, the affected side of the diaphragm is paralyzed. While a chest X-ray may show an elevated hemidiaphragm, it can often appear normal in the early hours or if the infant is on positive pressure. **Chest Ultrasound (or fluoroscopy)** is the gold standard for confirmation as it demonstrates **paradoxical diaphragmatic movement** (the affected side moves upward during inspiration while the healthy side moves downward). 2. **Why other options are incorrect:** * **Nasal wash:** Used for bronchiolitis (RSV); however, the focal lung findings and associated arm weakness make a viral etiology unlikely. * **Fiberoptic bronchoscopy:** Used for internal airway obstructions (e.g., laryngomalacia). It cannot evaluate diaphragmatic excursion. * **Chest CT:** Provides detailed anatomy but is unnecessary, involves high radiation, and does not show the dynamic movement of the diaphragm as effectively as ultrasound. **Clinical Pearls for NEET-PG:** * **Association:** 80-90% of phrenic nerve palsies are associated with **ipsilateral Brachial Plexus injury** (C3-C5 roots). * **Management:** Most cases are managed conservatively with positioning (affected side down); surgical plication is reserved for refractory cases. * **Differential:** Always differentiate from **Congenital Diaphragmatic Hernia (CDH)**; however, CDH typically shows a scaphoid abdomen and bowel loops on X-ray.

Q: An infant presents with cleft lip, cleft palate, polydactyly, microcephaly with holoprosencephaly, and ectodermal scalp defect. Which of the following genetic conditions is the infant likely suffering from?

Trisomy 13. **Explanation:** The clinical presentation described—**cleft lip/palate, polydactyly, and holoprosencephaly**—forms the classic triad of **Patau Syndrome (Trisomy 13)** [1]. This condition results from a failure of the prosencephalon to divide (holoprosencephaly), leading to midline facial defects [1]. The presence of **cutis aplasia** (ectodermal scalp defects) is a highly specific, pathognomonic finding for Trisomy 13 in medical entrance exams. **Analysis of Options:** * **Trisomy 13 (Correct):** Characterized by "3 Ps": **P**olydactyly, **P**alate (cleft), and **P**rosencephalon defects (holoprosencephaly) [1]. Microphthalmia and rocker-bottom feet are also common. * **Trisomy 21 (Down Syndrome):** Presents with flat facial profile, upslanting palpebral fissures, Simian crease, and Sandal gap [2, 3]. It lacks the severe midline structural malformations like holoprosencephaly. * **Trisomy 18 (Edwards Syndrome):** Characterized by "PRINCE" features: **P**rominent occiput, **R**ocker-bottom feet, **I**ntellectual disability, **N**ondisjunction, **C**lenched fists (overlapping fingers), and **E**ars (low-set). While it shares rocker-bottom feet with Trisomy 13, it does not typically feature polydactyly or clefting. * **Turner Syndrome (45, XO):** Presents in females with cystic hygroma, webbing of the neck, and coarctation of the aorta. It does not involve polydactyly or holoprosencephaly. **High-Yield NEET-PG Pearls:** * **Cutis Aplasia:** If you see "punched-out scalp lesion" or "scalp defect" in a neonate, think Trisomy 13. * **Holoprosencephaly:** Associated with Sonic Hedgehog (SHH) gene mutations and Trisomy 13 [1]. * **Survival:** Most cases of Trisomy 13 and 18 result in stillbirth or death within the first year of life, unlike Trisomy 21.

Q: What is the most likely diagnosis for a boy born at 36 weeks gestation weighing 1800 g?

Neonatal thyrotoxicosis. **Explanation:** The correct answer is **Neonatal thyrotoxicosis**. **1. Why Neonatal Thyrotoxicosis is correct:** Neonatal thyrotoxicosis (Neonatal Graves' Disease) occurs due to the transplacental passage of maternal **Thyroid Stimulating Immunoglobulins (TSI)**. A classic clinical triad seen in these neonates is **preterm birth, low birth weight (IUGR), and microcephaly**. The hypermetabolic state induced by excess thyroid hormone leads to poor weight gain despite adequate feeding, tachycardia, irritability, and occasionally hepatosplenomegaly. In this question, a 36-weeker (preterm) weighing 1800g (Low Birth Weight/SGA) fits this clinical profile perfectly. **2. Why other options are incorrect:** * **Congenital Parvovirus B19:** Typically presents with **Hydrops Fetalis** due to severe fetal anemia and high-output cardiac failure, rather than simple low birth weight at 36 weeks. * **Fetal Alcohol Syndrome (FAS):** While it causes IUGR and microcephaly, it is characterized by distinct facial dysmorphism (smooth philtrum, thin upper lip, short palpebral fissures) which is not mentioned here. * **Nesidioblastosis:** This refers to persistent hyperinsulinemic hypoglycemia of infancy. It typically presents with **macrosomia** (large for gestational age) and severe refractory hypoglycemia, the opposite of the low birth weight seen in this case. **High-Yield Clinical Pearls for NEET-PG:** * **Pathogenesis:** It is a transient condition, resolving as maternal antibodies are cleared from the infant's circulation (usually by 3–4 months). * **Treatment:** Indicated if the infant is symptomatic. **Propranolol** is used for tachycardia; **Methimazole** or Lugol’s iodine is used to achieve euthyroidism. * **Mortality:** If untreated, mortality can be as high as 15% due to heart failure.

Question 1

A newborn infant presents with excessive frothing and choking upon attempted feeding, despite a normal APGAR score at birth. What is the investigation of choice?

Accepted Answer

X-ray chest and abdomen with a red rubber catheter passed per orally into the esophagus

Answer

Esophagoscopy

Answer

Bronchoscopy

Answer

MRI chest

Question 2

Which of the following is NOT a feature of acute bilirubin encephalopathy?

Accepted Answer

Exaggerated Moro reflex

Answer

Lethargy

Answer

Opisthotonus

Answer

Choreoathetosis

Question 3

A baby is born with meconium-stained liquor. All of the following are taken into account in terming a baby 'vigorous' EXCEPT:

Accepted Answer

Colour

Answer

Tone

Answer

Heart Rate

Answer

Respiration

Question 4

A child presented with severe respiratory distress two days after birth. On examination, he was observed to have a scaphoid abdomen and decreased breath sounds on the left side. He was managed by prompt endotracheal intubation. After ET tube placement, the maximal cardiac impulse shifted further to the right side. What should be the next step in management?

Accepted Answer

Remove tube and reattempt intubation

Answer

Confirm the position of the endotracheal tube by chest X-ray

Answer

Nasogastric tube insertion and decompress the bowel

Answer

Chest X-ray to confirm diagnosis

Question 5

A term infant has initial Apgar scores of 8 and 10 at 1 and 5 minutes. On auscultation of the chest, a heart murmur is audible. There is hepatosplenomegaly. Cataracts of the crystalline lens are noted. The infant is at the 30th percentile for height and weight. Echocardiography shows a patent ductus arteriosus. Which of the following events is the most likely risk factor for the findings in this infant?

Accepted Answer

Congenital rubella infection

Answer

Dietary folate deficiency

Answer

Dispermy at conception

Answer

Erythroblastosis fetalis

Question 6

Which of the following features is characteristic of a premature baby compared to a baby with intrauterine growth restriction?

Accepted Answer

Sole creases all over the feet

Answer

Breast nodule 2 mm

Answer

Ear cartilage is well formed with good elastic recoil

Answer

Skin is glistening and thin

Question 7

An infant born 3 hours previously to a mother with poorly controlled insulin-dependent gestational diabetes presents with abnormal breathing. Examination reveals cyanosis, irregular and labored breathing, decreased breath sounds on the right side, and decreased tone in the right arm. A stat portable chest radiograph is normal. Which of the following studies is most likely to confirm the diagnosis?

Accepted Answer

Chest ultrasound

Answer

Nasal wash for viral culture

Answer

Fiberoptic bronchoscopy

Answer

Chest CT

Question 8

An infant presents with cleft lip, cleft palate, polydactyly, microcephaly with holoprosencephaly, and ectodermal scalp defect. Which of the following genetic conditions is the infant likely suffering from?

Accepted Answer

Trisomy 13

Answer

Trisomy 21

Answer

Trisomy 18

Answer

Turner syndrome

Question 9

Which of the following supports the diagnosis of respiratory distress syndrome (RDS) in a newborn?

Accepted Answer

Air bronchogram in chest x-ray

Answer

Receipt of antenatal steroids

Answer

Manifests after 6 hours of life

Answer

Occurs after term gestation

Question 10

What is the most likely diagnosis for a boy born at 36 weeks gestation weighing 1800 g?

Accepted Answer

Neonatal thyrotoxicosis

Answer

Congenital parvovirus B19 infection

Answer

Fetal alcohol syndrome

Answer

Nesidioblastosis

Neonatology — MCQs

Neonatology — MCQs

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