Neonatology Practice Questions

Q: An 18-day-old newborn has difficulty feeding and diarrhea for 2 days. During this period he has vomited after each of his feeds. He was born at 28 weeks' gestation and weighed 1100-g (2-lb 7-oz). His feeds consist of breast milk and cow milk based-formula. He appears lethargic. His temperature is 36.4°C (97.5°F), pulse is 120/min, respirations are 67/min and blood pressure is 70/35 mm Hg. Examination shows diffuse abdominal tenderness; rigidity and guarding are present. Bowel sounds are absent. Test of the stool for occult blood is positive. His hemoglobin concentration is 12.8 g/dL, leukocyte count is 18,000/mm3 and platelet count is 78,000/mm3. An x-ray of the abdomen is shown. Which of the following is the most likely diagnosis?

Necrotizing enterocolitis. ***Necrotizing enterocolitis*** - The clinical presentation of a **premature newborn** with **feeding difficulties**, **abdominal distention** and **tenderness**, **bloody stools**, and **lethargy**, combined with an **abdominal X-ray demonstrating pneumatosis intestinalis**, is highly suggestive of **necrotizing enterocolitis (NEC)**. - The associated **thrombocytopenia** and **leukocytosis** further support a severe inflammatory process characteristic of NEC in preterm infants. *Intussusception* - Typically presents with **sudden onset of intermittent, severe abdominal pain**, often marked by drawing up of legs, and **currant jelly stools** (mucus and blood). - Although it can cause abdominal tenderness and lethargy, it's less common in neonates and pneumatosis intestinalis is not a feature. *Meckel diverticululum* - Often causes **painless rectal bleeding** due to ectopic gastric mucosa, or symptoms of obstruction (e.g., intussusception, volvulus). - It does not typically present with diffuse abdominal tenderness, rigidity, feeding intolerance, and pneumatosis intestinalis. *Hypertrophic pyloric stenosis* - Characterized by **projectile, non-bilious vomiting** and a **palpable olive-shaped mass** in the epigastrium, usually appearing between 3-6 weeks of age. - It does not cause bloody diarrhea, diffuse abdominal tenderness, or pneumatosis intestinalis.

Q: A boy born vaginally in the 36th week of gestation to a 19-year-old woman (gravida 3, para 1) is assessed on his 2nd day of life. His vitals include: blood pressure is 85/40 mm Hg, pulse is 161/min, axillary temperature is 36.6°C (98.0°F), and respiratory rate is 44/min. He appears to be lethargic; his skin is jaundiced and slight acrocyanosis with several petechiae is noted. Physical examination reveals nystagmus, muffled heart sounds with a continuous murmur, and hepatosplenomegaly. The boy’s birth weight is 1.93 kg (4.25 lb) and Apgar scores at the 1st and 5th minutes were 5 and 8, respectively. His mother is unaware of her immunization status and did not receive any antenatal care. She denies any history of infection, medication use, or alcohol or illicit substance use during pregnancy. Serology for suspected congenital TORCH infection shows the following results: Anti-toxoplasma gondii IgM Negative Anti-toxoplasma gondii IgG Positive Anti-CMV IgM Negative Anti-CMV IgG Positive Anti-Rubella IgM Positive Anti-Rubella IgG Positive Anti-HSV IgM Negative Anti-HSV IgG Negative Which cardiac abnormality would be expected in this infant on echocardiography?

Patent ductus arteriosus. ***Patent ductus arteriosus*** * The clinical presentation with **jaundice**, **petechiae**, **hepatosplenomegaly**, and **positive anti-Rubella IgM and IgG** strongly indicates **congenital rubella syndrome**. A continuous murmur is also characteristic. * **Patent ductus arteriosus (PDA)** is a classic cardiac manifestation of **congenital rubella infection**, along with pulmonary artery hypoplasia. *Pulmonary valve stenosis* * While pulmonary valve stenosis can occur congenitally, it is more commonly associated with conditions like **Noonan syndrome** or isolated defects, not typically **congenital rubella syndrome**. * The continuous murmur described is more consistent with a PDA rather than the typical ejection click and crescendo-decrescendo murmur of pulmonary stenosis. *Atrial septal defect* * An **atrial septal defect (ASD)** is a common congenital heart defect, but it is not specifically or commonly associated with **congenital rubella syndrome**. * ASD typically presents with a **fixed split second heart sound** and usually a systolic murmur, not a continuous murmur. *Atrialization of the right ventricle* * **Atrialization of the right ventricle** is characteristic of **Ebstein's anomaly**, a congenital heart defect affecting the tricuspid valve. * It is not associated with **congenital rubella infection** and presents with different clinical findings, such as cyanosis due to right-to-left shunting.

Q: A patient at 37 weeks' gestation came to the hospital without antenatal check-up and presented with onset of labor. On examination, the mother is Hep B positive. What management should be given to the neonate?

Hep B vaccine+ IG. ***Hep B vaccine + IG*** - Neonates born to mothers with **positive hepatitis B surface antigen (HBsAg)** should receive both the **hepatitis B vaccine** and **hepatitis B immune globulin (HBIG)** within **12 hours of birth**. - This combination provides both **passive immunity** (from HBIG) and **active immunity** (from the vaccine) to rapidly protect the newborn from perinatal hepatitis B transmission. *Hep B vaccine only* - Administering only the **hepatitis B vaccine** would provide active immunity, but the **onset of protection is slower**, leaving the neonate vulnerable during the immediate high-risk period of exposure. - While essential for long-term protection, the vaccine alone is **insufficient for immediate post-exposure prophylaxis** in a high-risk scenario. *Only IG* - Administering only **HBIG** provides immediate passive immunity, offering short-term protection, but it **does not confer long-lasting immunity**. - Without the vaccine, the infant would remain susceptible to future HBV infection once the passive antibodies wane, which typically occurs within a few months. *First IG then Hep B vaccine after 1 month* - Delaying the **hepatitis B vaccine** by a month would leave the neonate inadequately protected against subsequent exposure or potential continued viral replication after the HBIG's passive immunity declines. - The goal in this high-risk situation is to initiate **both passive and active immunity as quickly as possible** to maximize protection against perinatal transmission.

Q: A newborn loses maximum heat from:

Head. ***Head*** - Newborns have a **relatively large head surface area** compared to their total body surface area. - The head also has a rich **blood supply** and lacks subcutaneous fat for insulation, contributing to significant heat loss through **convection and radiation**. *Abdomen* - While the abdomen contributes to heat loss, it is covered by clothing and has a more proportionate surface area to mass ratio compared to the head, making it a **less significant site for maximal heat loss**. - Heat loss from the abdomen is not as pronounced as from the head due to its **central location** and typically greater insulation. *Neck* - The neck's surface area is comparably small, and it is often covered or in close proximity to the body, which helps to **reduce heat loss**. - It does not possess the same combination of large surface area and lack of insulating fat as the head. *Palms & soles* - While palms and soles have a high density of **sweat glands** and can contribute to heat loss through evaporation, their **total surface area is relatively small** in a newborn. - These areas are less significant for overall maximal heat loss compared to the head due to their limited size.

Q: Compression ventilation ratio in case of Neonatal CPR:

3:1. ***3:1*** - In **neonatal CPR**, a compression to ventilation ratio of **3 compressions per 1 breath** is recommended. This ratio prioritizes ventilation due to the most common cause of cardiac arrest in neonates being **hypoxia**. - This ratio aims to deliver sufficient oxygen while maintaining adequate cardiac output for the unique physiology of newborns. *30:2* - A 30:2 ratio is generally recommended for **adult CPR** when a single rescuer is present, as adults often have initial cardiac etiologies. - This ratio would provide insufficient ventilations for a neonate whose primary arrest cause is typically respiratory. *100:8* - This ratio is not a standard recommendation for any age group in Cardiopulmonary Resuscitation guidelines. - It would lead to an imbalance, offering a disproportionately high number of compressions relative to ventilations, which is not optimal for neonatal resuscitation. *15:2* - A 15:2 ratio is typically recommended for **pediatric CPR** when two or more rescuers are present. - While closer to the neonatal requirement for ventilation, it still does not provide the immediate and frequent ventilations needed for neonates.

Q: Differential cyanosis occurs in which of the following diseases:

PPHN. ***PPHN*** - **Persistent pulmonary hypertension of the newborn (PPHN)** is the **classic cause of differential cyanosis** in neonates. - High pulmonary vascular resistance leads to **suprasystemic pulmonary artery pressures**, causing **right-to-left shunting** across the **patent ductus arteriosus (PDA)**. - Desaturated blood from the pulmonary artery shunts into the **descending aorta** (post-ductal), perfusing the lower body and lower extremities with poorly oxygenated blood. - The upper extremities receive well-oxygenated blood from the **ascending aorta** (pre-ductal), resulting in **higher oxygen saturation in the right hand compared to the feet** (pre-ductal vs. post-ductal saturation difference >10%). - This is a **pathognomonic finding** in PPHN and helps differentiate it from cyanotic congenital heart disease. *Incorrect: Severe coarctation* - **Coarctation of the aorta** causes obstruction to blood flow, leading to **blood pressure differences** and **weak femoral pulses**, but does NOT primarily cause differential cyanosis. - While it may be associated with differential saturation in rare cases with severe pre-ductal coarctation and right-to-left ductal shunting, this is **not the typical presentation**. - The hallmark findings are **hypertension in upper extremities** and **hypotension in lower extremities**, not differential oxygenation. *Incorrect: Interrupted aortic arch* - While interrupted aortic arch relies on a **PDA for lower body perfusion**, the blood through the ductus is typically **well-oxygenated** unless there are associated complex cardiac defects causing desaturation. - The typical presentation is **poor perfusion and shock** rather than isolated differential cyanosis. - Differential cyanosis would only occur in specific anatomical variants with obligatory right-to-left shunting, which is not the standard presentation.

Q: Hypoglycemia in infants more than 24 hours of age is defined as blood glucose levels less than

45 mg/dl. ***45 mg/dl*** - Hypoglycemia in infants over 24 hours old is defined as a blood glucose level less than **45 mg/dL** due to their increased glucose demands and maturing metabolic systems. - Maintaining glucose levels above this threshold is crucial to prevent **neurodevelopmental injury** in vulnerable infants. *40 mg/dl* - While **40 mg/dL** might be considered critically low, the accepted threshold for hypoglycemia in infants >24 hours old is slightly higher to ensure a wider safety margin. - Using a lower value could delay intervention, potentially leading to **adverse neurological outcomes**. *50 mg/dl* - A blood glucose level of **50 mg/dL** is considered within the normal range for infants older than 24 hours and would not typically warrant intervention for hypoglycemia. - Setting the threshold too high could lead to **over-diagnosis** and unnecessary treatment. *55 mg/dl* - **55 mg/dL** is well above the clinically significant threshold for hypoglycemia in this age group and is generally considered a healthy blood glucose level. - Using this value as a diagnostic cutoff would result in a significant number of **false positives**.

Q: The mother of this newborn had fever with rash at 18 weeks of gestation. What is this baby probably suffering from?

Congenital Varicella. ***Congenital Varicella*** - Maternal chickenpox (fever with rash) during early to mid-pregnancy (13-20 weeks) can lead to **congenital varicella syndrome**. - This syndrome is characterized by **skin scarring**, limb hypoplasia, microcephaly, and **ocular abnormalities**. *Congenital Toxoplasmosis* - Maternal infection typically presents as **flu-like symptoms** or can be asymptomatic. - Classic triad in the infant includes **hydrocephalus**, **chorioretinitis**, and **intracranial calcifications**. *Congenital Rubella* - Maternal rubella infection often presents with a **maculopapular rash**, fever, and lymphadenopathy. - Congenital rubella syndrome is associated with **cataracts**, **sensorineural hearing loss**, and **cardiac defects** (e.g., patent ductus arteriosus). *Congenital CMV* - Maternal CMV infection is often **asymptomatic**, but can cause a mononucleosis-like illness. - Infants may present with **microcephaly**, **periventricular calcifications**, **jaundice**, and **hepatosplenomegaly**.

Q: Which of the following cardiac defects can be seen in Congenital Rubella Syndrome?

Conduction defect. ***Conduction defect*** - **Congenital Rubella Syndrome (CRS)** causes various **cardiac defects**, including **conduction abnormalities** such as **complete heart block** and **bundle branch blocks**. - These arise from the direct effect of the **rubella virus** on the developing fetal cardiac conduction system. - **Conduction defects** are well-recognized cardiac manifestations of CRS. *VSD* - **Ventricular Septal Defect (VSD)** **can indeed occur** in Congenital Rubella Syndrome and is documented in medical literature as one of the possible cardiac defects. - However, the **most characteristic and commonly emphasized cardiac defects** in CRS are **Patent Ductus Arteriosus (PDA)** - occurring in 60-70% of cases - and **Pulmonary Artery Stenosis/Branch Pulmonary Stenosis**. - While VSD is a recognized cardiac manifestation, **conduction defects** are more specifically highlighted in the context of CRS cardiac involvement in standard textbooks. *Microcephaly* - **Microcephaly** is a severe and common manifestation of **Congenital Rubella Syndrome**, but it is a **neurological defect**, **NOT a cardiac defect**. - This option tests whether candidates can differentiate between cardiac and non-cardiac manifestations. - Other common non-cardiac manifestations include **sensorineural hearing loss**, **cataracts**, and **intrauterine growth restriction**. *All of the options* - This option is **incorrect** because **Microcephaly** is a **neurological manifestation**, not a cardiac defect. - The question specifically asks for **cardiac defects** seen in the syndrome. - Both **Conduction defect** and **VSD** are cardiac manifestations, but only **Conduction defect** is marked as the answer, likely emphasizing the more specifically associated cardiac finding in CRS.

Q: The most characteristic manifestation of congenital toxoplasmosis is:

Intracranial calcifications. ***Intracranial calcifications*** - **Intracranial calcifications**, particularly scattered and diffuse throughout the brain parenchyma, are the most **characteristic and pathognomonic** finding of congenital toxoplasmosis - These calcifications result from the parasite's predilection for **neural tissue** and subsequent inflammatory necrosis - Along with **hydrocephalus** and **chorioretinitis**, they form the **classic triad** of congenital toxoplasmosis - The scattered pattern of calcifications helps differentiate toxoplasmosis from CMV (which causes periventricular calcifications) *Deafness* - **Sensorineural hearing loss** can occur but is not a characteristic feature of congenital toxoplasmosis - Deafness is more commonly associated with congenital **cytomegalovirus (CMV)** or **rubella** infection - When present in toxoplasmosis, it is typically a late sequela rather than a primary manifestation *Thrombocytopenia* - **Thrombocytopenia** may occur as part of generalized systemic involvement but is a **non-specific finding** - It can be seen in many congenital infections (TORCH complex) - Not diagnostically useful for distinguishing toxoplasmosis from other congenital infections *Hepatosplenomegaly* - **Hepatosplenomegaly** indicates systemic infection and may reflect **extramedullary hematopoiesis** - Common in many congenital infections, making it non-specific - The most **diagnostically valuable** findings in congenital toxoplasmosis are the neurological (intracranial calcifications, hydrocephalus) and ocular (chorioretinitis) manifestations

Question 1

An 18-day-old newborn has difficulty feeding and diarrhea for 2 days. During this period he has vomited after each of his feeds. He was born at 28 weeks' gestation and weighed 1100-g (2-lb 7-oz). His feeds consist of breast milk and cow milk based-formula. He appears lethargic. His temperature is 36.4°C (97.5°F), pulse is 120/min, respirations are 67/min and blood pressure is 70/35 mm Hg. Examination shows diffuse abdominal tenderness; rigidity and guarding are present. Bowel sounds are absent. Test of the stool for occult blood is positive. His hemoglobin concentration is 12.8 g/dL, leukocyte count is 18,000/mm3 and platelet count is 78,000/mm3. An x-ray of the abdomen is shown. Which of the following is the most likely diagnosis?

Accepted Answer

Necrotizing enterocolitis

Answer

Intussusception

Answer

Meckel diverticululum

Answer

Hypertrophic pyloric stenosis

Question 2

A boy born vaginally in the 36th week of gestation to a 19-year-old woman (gravida 3, para 1) is assessed on his 2nd day of life. His vitals include: blood pressure is 85/40 mm Hg, pulse is 161/min, axillary temperature is 36.6°C (98.0°F), and respiratory rate is 44/min. He appears to be lethargic; his skin is jaundiced and slight acrocyanosis with several petechiae is noted. Physical examination reveals nystagmus, muffled heart sounds with a continuous murmur, and hepatosplenomegaly. The boy’s birth weight is 1.93 kg (4.25 lb) and Apgar scores at the 1st and 5th minutes were 5 and 8, respectively. His mother is unaware of her immunization status and did not receive any antenatal care. She denies any history of infection, medication use, or alcohol or illicit substance use during pregnancy. Serology for suspected congenital TORCH infection shows the following results:
Anti-toxoplasma gondii IgM Negative
Anti-toxoplasma gondii IgG Positive
Anti-CMV IgM Negative
Anti-CMV IgG Positive
Anti-Rubella IgM Positive
Anti-Rubella IgG Positive
Anti-HSV IgM Negative
Anti-HSV IgG Negative
Which cardiac abnormality would be expected in this infant on echocardiography?

Accepted Answer

Patent ductus arteriosus

Answer

Pulmonary valve stenosis

Answer

Atrial septal defect

Answer

Atrialization of the right ventricle

Question 3

A patient at 37 weeks' gestation came to the hospital without antenatal check-up and presented with onset of labor. On examination, the mother is Hep B positive. What management should be given to the neonate?

Accepted Answer

Hep B vaccine+ IG

Answer

Hep B vaccine only

Answer

Only IG

Answer

First IG then Hep B vaccine after 1 month

Question 4

A newborn loses maximum heat from:

Accepted Answer

Head

Answer

Abdomen

Answer

Neck

Answer

Palms & soles

Question 5

Compression ventilation ratio in case of Neonatal CPR:

Accepted Answer

3:1

Answer

30:2

Answer

100:8

Answer

15:2

Question 6

Differential cyanosis occurs in which of the following diseases:

Accepted Answer

PPHN

Answer

Severe coarctation

Answer

Interrupted aortic arch

Answer

All of the options

Question 7

Hypoglycemia in infants more than 24 hours of age is defined as blood glucose levels less than

Accepted Answer

45 mg/dl

Answer

40 mg/dl

Answer

50 mg/dl

Answer

55 mg/dl

Question 8

The mother of this newborn had fever with rash at 18 weeks of gestation. What is this baby probably suffering from?

Accepted Answer

Congenital Varicella

Answer

Congenital Toxoplasmosis

Answer

Congenital Rubella

Answer

Congenital CMV

Question 9

Which of the following cardiac defects can be seen in Congenital Rubella Syndrome?

Accepted Answer

Conduction defect

Answer

VSD

Answer

Microcephaly

Answer

All of the options

Question 10

The most characteristic manifestation of congenital toxoplasmosis is:

Accepted Answer

Intracranial calcifications

Answer

Deafness

Answer

Thrombocytopenia

Answer

Hepatosplenomegaly

Neonatology — MCQs

Neonatology — MCQs

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