Neonatology — MCQs

Neonatology Indian Medical PG Practice Questions and MCQs

Question 811: A newborn presents with snuffles, hepatosplenomegaly, and osteochondritis. Mother's VDRL is 1:32. Most appropriate initial investigation is:

A. Dark field microscopy of nasal discharge
B. Quantitative VDRL of newborn (Correct Answer)
C. CSF examination
D. X-ray long bones

Explanation: ***Quantitative VDRL of newborn*** - Given the mother's VDRL (1:32 positive) and the newborn's symptoms (snuffles, hepatosplenomegaly, osteochondritis), **congenital syphilis** is highly suspected, making a quantitative VDRL of the newborn the most appropriate initial investigation to confirm infection and guide treatment. - A **four-fold higher titer** in the neonate's VDRL compared to the mother's (i.e., ≥1:128) is diagnostic of congenital syphilis, while a titer equal to or lower than the mother's might indicate passive transfer of maternal antibodies. - This test establishes the diagnosis and determines whether full treatment is needed versus observation only, making it the **key initial diagnostic test**. *Dark field microscopy of nasal discharge* - While **dark field microscopy** can identify *Treponema pallidum* directly from active lesions, it is not readily available in most settings and has variable sensitivity. - It requires expertise and immediate examination of fresh specimens, making it impractical as the primary initial investigation. - Most centers rely on serological testing rather than direct visualization. *CSF examination* - **CSF examination** (including VDRL, cell count, and protein) is an essential component of the **initial comprehensive evaluation** of all neonates with suspected or confirmed congenital syphilis to assess for neurosyphilis. - However, it is performed as part of the workup **after** the quantitative VDRL establishes the diagnosis and confirms the need for full evaluation and treatment. - CSF findings determine whether 10 days of IV penicillin (if neurosyphilis present) versus 10 days of IM penicillin (if no neurosyphilis) is needed. *X-ray long bones* - **X-rays of long bones** can reveal characteristic findings of congenital syphilis, such as **osteochondritis, periostitis, and metaphyseal lucencies**. - While part of the comprehensive evaluation for skeletal involvement, it is an imaging study that confirms bone disease rather than establishing the primary diagnosis. - Bone changes may be present in up to 60-90% of cases with early congenital syphilis but are not required for diagnosis.

Question 812: A newborn has positive VDRL but no clinical signs. Mother was treated for syphilis at 32 weeks gestation. Newborn's titer is 1:2, mother's current titer is 1:8. Most appropriate management is:

A. CSF analysis followed by treatment
B. Close clinical monitoring only (Correct Answer)
C. Aqueous penicillin for 10 days
D. Single dose benzathine penicillin

Explanation: ***Close clinical monitoring only*** - The newborn's **VDRL titer** (1:2) is **less than fourfold** the mother's current titer (1:8), indicating **passively transferred maternal antibodies** rather than active congenital infection. - The mother was **adequately treated at 32 weeks gestation** (>4 weeks before delivery), and the newborn has **no clinical signs** of congenital syphilis. - According to **CDC and AAP guidelines**, this scenario requires **monthly serological follow-up** until titers decline or become non-reactive, with treatment only if titers rise or plateau. - Expected course: Passively acquired antibodies should decline and become non-reactive by **3-6 months of age**. *Single dose benzathine penicillin* - This would be appropriate if the newborn's titer was **≥4-fold the maternal titer** (e.g., 1:32 vs 1:8), suggesting active infection rather than passive transfer. - Also indicated if maternal treatment was **inadequate, undocumented, or with non-penicillin regimens**, or if maternal treatment occurred **<30 days before delivery**. - In this case, with adequate maternal treatment and appropriate titer ratio, empiric treatment is **not indicated**. *CSF analysis followed by treatment* - **CSF analysis** is indicated when there are **clinical signs** of congenital syphilis, **abnormal physical examination**, or when newborn titer is ≥4-fold maternal titer with clinical concerns. - This asymptomatic newborn with appropriate titer ratio does not meet criteria for invasive testing and full treatment course. *Aqueous penicillin for 10 days* - A **10-day course of aqueous crystalline penicillin G** is reserved for **proven or highly probable congenital syphilis**: clinical/radiographic evidence, abnormal CSF, or newborn titer ≥4-fold maternal titer. - Also used when maternal treatment was **inadequate** or occurred **<4 weeks before delivery**. - This scenario does not meet criteria for full treatment, as adequate maternal therapy and low newborn titers suggest passive antibody transfer only.

Question 813: Which of the following should be considered a 'High risk infant'?

A. Folic acid tablet not consumed
B. Antenatal preeclampsia (Correct Answer)
C. Working mother
D. Mal-presentation

Explanation: ***Antenatal preeclampsia*** - **Preeclampsia** is a serious pregnancy complication characterized by high blood pressure and signs of damage to other organ systems, posing significant risks to both mother and fetus. - Infants born to mothers with preeclampsia are at higher risk for **preterm birth**, **intrauterine growth restriction (IUGR)**, and complications like **respiratory distress syndrome**, classifying them as high-risk. *Folic acid tablet not consumed* - Maternal non-consumption of **folic acid** primarily increases the risk of **neural tube defects (NTDs)** in the fetus, but this alone does not classify the infant as high-risk after birth unless an NTD is diagnosed. - While important for healthy fetal development, a lack of folic acid intake is a risk factor for a specific congenital anomaly, rather than a general high-risk infant indicator post-birth without further complications. *Working mother* - A mother's employment status, while potentially affecting access to childcare or breastfeeding routines, does not inherently categorize an infant as **high-risk** from a medical standpoint. - This is a social factor and not a direct indicator of increased medical vulnerability or adverse health outcomes for the infant. *Mal-presentation* - **Malpresentation** refers to an abnormal position of the fetus in the uterus at the time of delivery (e.g., breech). While it poses risks during labor and delivery, often necessitating a **cesarean section**, it does not automatically classify the infant as high-risk post-birth unless complications arose during delivery. - The risk is primarily associated with the birth process itself, and if the delivery is managed appropriately with no resulting trauma or compromise, the infant may not be considered high-risk.

Question 814: What is the preferred management for patent ductus arteriosus (PDA) in a preterm infant?

A. Surgical ligation
B. Diuretics
C. IV Indomethacin (Correct Answer)
D. Oxygen therapy

Explanation: ***IV Indomethacin*** - **Indomethacin** is a **prostaglandin synthesis inhibitor** that promotes the constriction and closure of the patent ductus arteriosus. - It is preferred due to its effectiveness in closing PDA non-invasively in preterm infants. *Surgical ligation* - This is an **invasive procedure** reserved for cases where medical management with indomethacin fails or is contraindicated. - While effective, it carries surgical risks such as **infection** and potential **vocal cord paralysis**. *Diuretics* - **Diuretics** are used to manage **pulmonary edema** or **heart failure symptoms** associated with a large PDA by reducing fluid overload. - They do not directly cause the closure of the patent ductus arteriosus itself. *Oxygen therapy* - **Oxygen therapy** is crucial for managing respiratory distress and maintaining adequate oxygen saturation in preterm infants. - However, oxygen can sometimes *inhibit* ductal closure in preterm infants by reducing pulmonary vascular resistance, and therefore, it is not the primary intervention for PDA closure.

Question 815: In neonatal sepsis, which of the following organisms is the MOST common cause?

A. Mycoplasma
B. Shigella
C. Escherichia coli
D. Group B Streptococcus (Correct Answer)

Explanation: ***Group B Streptococcus*** - **Group B Streptococcus (GBS)**, or *Streptococcus agalactiae*, is a leading cause of both early-onset and late-onset neonatal sepsis. - **Vertical transmission** from mother to neonate during birth is the most common route of infection, especially in early-onset cases. *Mycoplasma* - While *Mycoplasma hominis* and *Ureaplasma urealyticum* can be associated with **chorioamnionitis** and premature birth, they are less common causes of overt neonatal sepsis compared to GBS. - Their detection often requires specialized culture media, and their clinical presentation can be more insidious. *Shigella* - **Shigella species** primarily cause **bacillary dysentery** (shigellosis) characterized by bloody diarrhea. - While it can cause systemic illness, it is a very rare cause of neonatal sepsis, especially in the absence of a primary gastrointestinal infection. *Escherichia coli* - **E. coli** is a significant cause of neonatal sepsis, particularly strains with **K1 capsular antigen**, which are known for causing meningitis and sepsis in neonates. - Although *E. coli* is a common pathogen, **Group B Streptococcus** is generally considered the *most common* cause, especially in early-onset sepsis.

Question 816: A child presented with microcephaly, hepatomegaly and periventricular calcification. What is the best specimen for diagnosis of CMV by PCR?

A. CSF
B. Blood
C. Liver biopsy
D. Urine (Correct Answer)

Explanation: ***Urine*** - **Urine** is the most sensitive and commonly used specimen for diagnosing **congenital CMV infection** via PCR, especially in neonates, due to high viral shedding in urine. - A positive urine CMV PCR within the first 2-3 weeks of life is highly indicative of **congenital CMV**, which can cause symptoms like **microcephaly**, **hepatomegaly**, and **periventricular calcifications**. *CSF* - While CMV can be detected in **CSF** in congenital infections, particularly in symptomatic cases with neurological involvement, it is less sensitive than urine for initial diagnosis. - **CSF PCR** is typically reserved for evaluating central nervous system involvement and may not detect systemic infection as reliably as urine. *Blood* - **Blood PCR** for CMV can be positive in congenital infection, but it can also be positive in postnatal CMV acquisition or maternal viremia without congenital transmission. - The presence of viral DNA in blood is transient, and its sensitivity for diagnosing congenital infection is generally lower than that of urine. *Liver biopsy* - **Liver biopsy** is an invasive procedure and is not the primary diagnostic method for CMV infection, although histological examination can reveal characteristic viral inclusions if there is significant hepatic involvement. - It carries risks and is typically performed only when other diagnostic methods are inconclusive or when assessing the extent of liver damage.

Question 817: 4 day old breastfed neonate, otherwise well, term neonate presented with jaundice, on testing the bilirubin level was found to be 18 mg/dl. Which of the following is the best step of management?

A. Stop breast feeding and do phototherapy
B. Initiate exchange transfusion
C. Start iv fluids and give phototherapy
D. Start phototherapy and continue breast feeding (Correct Answer)

Explanation: ***Start phototherapy and continue breast feeding*** - For a 4-day-old, otherwise healthy, term neonate with a bilirubin level of 18 mg/dL, **phototherapy** is the recommended initial treatment to lower bilirubin levels and prevent **kernicterus**. - **Breastfeeding should be continued** as it is crucial for hydration and nutrition, and interruption is generally not needed unless the bilirubin levels are extremely high and unresponsive to phototherapy. *Stop breast feeding and do phototherapy* - **Stopping breastfeeding is usually not necessary** for a bilirubin level of 18 mg/dL in a healthy, term neonate, as the benefits of breast milk outweigh the risks associated with this level of jaundice. - While **phototherapy** is appropriate, discontinuing breastfeeding can lead to complications such as dehydration and decreased milk supply. *Initiate exchange transfusion* - **Exchange transfusion** is typically reserved for much higher bilirubin levels (e.g., >25 mg/dL in a term neonate) or when there are signs of **acute bilirubin encephalopathy**, which are not present here. - It is an invasive procedure with potential risks, making it unsuitable as a first-line treatment for this bilirubin level. *Start iv fluids and given phototherapy* - **Intravenous fluids** are generally not indicated for an otherwise well, breastfed neonate unless there are signs of significant dehydration, which is not mentioned in this scenario. - While **phototherapy** is appropriate, routine IV fluid administration can lead to **fluid overload** and is not standard practice in uncomplicated neonatal jaundice.

Question 818: Neonatal tetanus most commonly presents with:

A. Seizures
B. Poor feeding (Correct Answer)
C. Respiratory failure
D. Fever

Explanation: ***Poor feeding*** - The initial signs of neonatal tetanus include **irritability**, **poor sucking**, and **difficulty feeding**, usually appearing between 3 and 14 days of life. - This symptom is due to the toxin affecting cranial nerves and early muscle spasms, making it difficult for the infant to open their mouth or swallow. *Seizures* - While seizures can occur in severe neonatal tetanus, they are typically a **later manifestation** after initial symptoms like poor feeding and muscle rigidity. - **Generalized muscle spasms** and opisthotonus usually precede frank seizures. *Respiratory failure* - **Respiratory failure** is a serious complication of neonatal tetanus, often leading to death, but it results from severe, sustained muscle spasms of the respiratory muscles. - It usually occurs **after the initial signs** of poor feeding and generalized rigidity have developed. *Fever* - **Fever** is not a primary or most common initial symptom of neonatal tetanus, though a low-grade fever may be present in some cases. - The disease is primarily characterized by neurological symptoms due to the action of **tetanospasmin**, not direct pyrogenic effects.

Question 819: A sick intubated neonate is having bilateral jerk of both right and left upper limbs with some occasional twitching of neck as well. Likely type of seizures:

A. Multifocal clonic (Correct Answer)
B. Multifocal tonic clonic
C. Focal tonic
D. Focal clonic

Explanation: ***Multifocal clonic*** - This description fits **multifocal clonic seizures**, characterized by **migratory clonic activity** observed in different body parts at varying times, sometimes simultaneously. - The **bilateral jerk** of upper limbs and occasional neck twitching point to this pattern, as the involvement is not uniform or generalized, but rather appears in multiple, distinct locations. *Multifocal tonic clonic* - This option incorrectly combines multifocal activity with a **tonic component**, which is described as stiffening or sustained contraction, not just jerking. - While activity may be multifocal, the specific description of "jerk" primarily suggests a **clonic nature**, without a clear tonic phase. *Focal tonic* - **Focal tonic seizures** involve sustained **stiffening or contraction** of muscles in a specific, localized area of the body, which is not described. - The term "jerk" indicates a **clonic movement**, and the involvement of multiple areas (bilateral upper limbs, neck) rules out a single focal onset. *Focal clonic* - **Focal clonic seizures** are characterized by rhythmic jerking movements limited to a **single, localized part** of the body without spreading to other areas. - The presence of jerking in **both upper limbs** and occasional neck twitching indicates activity in multiple sites, not restricted to a single focal area.

Question 820: A 3 week neonate with ambiguous genitalia presented with Na+ 127 meq/L, K+ 7.2 meq/L with BP 52/24 mm Hg and was managed with IV fluids. What is the next step of management?

A. Hydrocortisone administration (Correct Answer)
B. Calcium gluconate
C. Broad spectrum antibiotics
D. Spironolactone

Explanation: ***Hydrocortisone administration*** - The combination of **ambiguous genitalia**, low **sodium**, high **potassium**, and **hypotension** in a neonate strongly suggests **congenital adrenal hyperplasia (CAH)** due to 21-hydroxylase deficiency, leading to salt-wasting adrenal crisis. - **Hydrocortisone** is crucial for replacing deficient **cortisol** and addressing the underlying adrenal insufficiency, which is the definitive treatment for this endocrine emergency. - Cortisol replacement helps restore hemodynamic stability and, along with fluid resuscitation, addresses the electrolyte imbalance. *Calcium gluconate* - While **hyperkalemia** is present at 7.2 meq/L, which is severe and potentially life-threatening, **calcium gluconate** provides only **cardiac membrane stabilization** without treating the underlying cause. - In clinical practice, calcium gluconate may be given for immediate cardiac protection in severe hyperkalemia, but the **definitive management** of CAH-related adrenal crisis requires **hormonal replacement**. - The question asks for the next step after IV fluids are initiated, and hydrocortisone addresses the root cause of the metabolic derangements. *Broad spectrum antibiotics* - There is no clinical indication in the stem to suggest a bacterial infection that would warrant **broad-spectrum antibiotics**. - Although critically ill neonates may sometimes receive empiric antibiotics, the presentation clearly points to an **endocrine emergency** rather than sepsis. *Spironolactone* - **Spironolactone** is an **aldosterone antagonist** and a **potassium-sparing diuretic**. - Administering it would worsen the already existing **hyperkalemia** and **hyponatremia**, making it absolutely contraindicated in this clinical scenario.

Practice by Chapter

Neonatal Resuscitation

Practice Questions

Care of the Normal Newborn

Practice Questions

Prematurity and Low Birth Weight

Practice Questions

Respiratory Distress Syndrome

Practice Questions

Neonatal Jaundice

Practice Questions

Neonatal Sepsis

Practice Questions

Necrotizing Enterocolitis

Practice Questions

Intraventricular Hemorrhage

Practice Questions

Persistent Pulmonary Hypertension

Practice Questions

Perinatal Asphyxia

Practice Questions

Neonatal Seizures

Practice Questions

Congenital Anomalies

Practice Questions

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