Neonatology Practice Questions

Q: Which of the following is considered harmful to a newborn baby in the immediate postnatal period?

Giving a bath immediately after birth. ***Giving a bath immediately after birth***- Immediate bathing is associated with a high risk of **neonatal hypothermia** due to rapid evaporative heat loss, as newborns have immature thermoregulatory systems.- Current guidelines (e.g., WHO) recommend delaying bathing for at least 6 hours, and ideally 24 hours, to allow for temperature stabilization and to preserve the protective **vernix caseosa**.*Cleaning the eyes with a wet sterile swab*- This is standard practice, usually followed by applying prophylactic eye ointment (e.g., erythromycin), to prevent **ophthalmia neonatorum** caused by organisms like *Neisseria gonorrhoeae* or *Chlamydia trachomatis*.- It is a safe and necessary procedure to prepare the eyes for prophylaxis, ensuring the area is free of potentially infectious material.*Initiating breastfeeding within 1 hour*- Early initiation of breastfeeding is part of **Essential Newborn Care** and is highly beneficial, helping to stabilize the neonate's blood glucose levels and preventing **hypoglycemia**.- Colostrum provides crucial passive immunity and facilitates strong **maternal-infant bonding**, stimulating uterine involution in the mother.*Placing the baby on the mother's chest*- This practice, known as **skin-to-skin contact** (SSC), is vital for maintaining the baby's temperature, as the mother’s chest provides optimal **thermal regulation**.- SSC reduces infant stress, stabilizes heart rate and respiration, and greatly facilitates the transition to **early breastfeeding**.

Q: A newborn, born to a diabetic mother, presents after 24 hours of life with a blood glucose level of <35 mg/dL. The baby is symptomatic. What is the next best step in management?

Administer IV glucose and recheck blood glucose after 20 minutes. ***Administer IV glucose and recheck blood glucose after 20 minutes*** - Symptomatic hypoglycemia (blood glucose <40–45 mg/dL, often <35 mg/dL) requires immediate treatment with an **IV dextrose bolus** (typically D10W at 2 mL/kg) to rapidly correct the glucose deficit and prevent **neurological injury**. - After administering the IV bolus, the effectiveness of the treatment must be confirmed by repeating the blood glucose level measurement within 15–30 minutes (recheck after 20 minutes) to ensure target levels are maintained. *Administer IV bolus of Hartmann solution* - **Hartmann solution (Lactated Ringer's)** is an isotonic crystalloid mainly used for volume expansion and contains negligible dextrose, making it ineffective for treating severe, symptomatic **hypoglycemia**. - Using an IV fluid without sufficient glucose will lead to a dangerous delay in restoring adequate **cerebral glucose delivery**. *Recheck blood glucose after 20 minutes* - Since the infant is **symptomatic**, there is an immediate risk of irreversible **neurological damage**; therefore, treatment cannot be delayed for confirmation. - Immediate intervention with **IV dextrose** is mandatory for all symptomatic neonates regardless of the time since the last measurement, followed by a recheck. *Start oral feeds and observe* - Oral feeds are appropriate only for managing **asymptomatic, mild to moderate hypoglycemia** (e.g., in high-risk infants who screen positive but are clinically well). - Given the symptoms and blood glucose <35 mg/dL, relying on slow absorption from oral feeds is inadequate and exposes the infant to the risk of seizures and **brain injury**.

Q: A neonate was born to a controlled gestational diabetes mother. At the time of birth, he was fine but 4 days later, he developed dyspnea with SpO2 80% at room air. What is the initial management?

Give 100% O2. ***Give 100% O2***- The infant is suffering from **severe hypoxemia** (SpO2 80%), which is a life-threatening emergency requiring immediate stabilization.- The initial step in managing severe, unexplained neonatal hypoxemia or respiratory distress is to administer **100% oxygen** (maximal FiO2) to quickly improve SpO2 above critical levels (typically targeting >90-95%) while investigations or ventilation preparations are made.*Give 21% to 30% O2*- This concentration range represents minimal supplementation and is insufficient for treating **severe hypoxemia** (SpO2 80%) in a neonate.- Such low levels of supplemental oxygen are typically reserved for patients with very **mild desaturations** or during the process of weaning oxygen support.*Give 50% O2*- While this is a higher concentration than room air, 50% O2 may still be inadequate for the initial stabilization of an infant with **SpO2 80%**.- In severe, life-threatening hypoxemia, the priority is maximum oxygen concentration (100% O2) delivery to ensure rapid correction of tissue hypoxia.*Observation*- An oxygen saturation of 80% signifies acute **respiratory failure** or severe compromise and must be treated as a medical emergency, not simply observed.- **Observation** without immediate intervention inevitably leads to worsening hypoxemia, potential end-organ damage, and cardiorespiratory arrest.

Q: A neonate on examination has bilateral cataracts and, after investigations, is found to have a patent ductus arteriosus and salt and pepper retinopathy. What is the most likely congenital infection?

Rubella. ***Rubella***- The constellation of **bilateral cataracts**, **patent ductus arteriosus (PDA)**, and **salt and pepper retinopathy** is highly characteristic, if not pathognomonic, of **Congenital Rubella Syndrome (CRS)**.- Other common findings in CRS include **sensorineural hearing loss**, microcephaly, and **pulmonary artery stenosis**.*CMV*- Congenital Cytomegalovirus (CMV) infection is classically associated with **periventricular calcifications** on neuroimaging, microcephaly, and **sensorineural hearing loss**.- While CMV can cause chorioretinitis, it rarely causes the specific combination of **cataracts** and **PDA** found in this neonate, which strongly favors rubella.*Toxoplasma*- Congenital toxoplasmosis typically presents with the classic triad of **hydrocephalus**, **intracranial calcifications** (often random or diffuse), and focal **chorioretinitis**.- It is not typically associated with common cardiovascular defects like **PDA** or the specific appearance of **salt and pepper retinopathy**.*Varicella*- Congenital Varicella Syndrome is characterized by **skin scarring** (often a zigzag pattern), **limb hypoplasia**, and cortical atrophy.- Ocular findings usually involve **microphthalmia** and severe scarring rather than the specific combination of **cataracts** and **PDA**.

Q: When is a blood sample taken to diagnose neonatal hypothyroidism?

72 hours after delivery. ***72 hours after delivery*** - Newborn screening for congenital hypothyroidism is ideally performed **48-72 hours after birth** - This timing avoids false-positive results from the **physiological TSH surge** that occurs in the first 24-48 hours of life - At 72 hours, TSH levels have stabilized and accurately reflect thyroid function - Early detection allows prompt treatment to prevent neurodevelopmental impairment *Immediately from the umbilical cord* - Too early - will capture the physiological TSH surge immediately after birth - Results in high false-positive rate - Not recommended for screening *24 hours after delivery* - Still within the period of physiological TSH elevation - May yield false-positive results - Not optimal timing for screening *23-48 hours after delivery* - The lower end (24-48 hours) is acceptable in some screening programs - However, 48-72 hours is preferred to ensure TSH has normalized from the physiological surge - 72 hours provides more reliable results

Q: What is the daily fluid requirement for a 3-day-old baby with a birth weight of 1500 grams?

80-90 ml/kg/day. ***80-90 ml/kg/day***- This range represents the typical fluid requirement for a very low birth weight (**VLBW**) infant on the second or third day of life (DOL 2-3).- It allows for a safe transition from the restricted fluids (60-80 ml/kg/day) of DOL 1 towards higher maintenance needs, minimizing the risk of conditions like **patent ductus arteriosus (PDA)**.*100-110 ml/kg/day*- This rate is usually required later in the first week (around **DOL 4 to DOL 7**) as the infant's renal function matures and catabolism increases.- Providing this high volume prematurely to a 3-day-old **VLBW** infant increases the risk of **fluid overload** and associated neonatal morbidities.*120-130 ml/kg/day*- This represents a standard high maintenance fluid rate, typically achieved by **DOL 7** or later, especially for infants utilizing **phototherapy**.- It is significantly above the required baseline for a **3-day-old** baby and would lead to potential hyponatremia and **pulmonary edema**.*130-150 ml/kg/day*- This is the usual **full maintenance** or "maximal" fluid requirement often seen after the first week of life (DOL 7+) or in situations requiring high replacement.- Administration of this rate on DOL 3 is strongly discouraged due to the extreme risk of **cardiovascular and pulmonary complications**.

Q: A neonate was brought with a history of frothiness from the mouth and respiratory distress. An X-ray of the neonate is given below. What is the diagnosis?

Esophageal atresia with tracheo-esophageal fistula. ***Esophageal atresia with tracheo-esophageal fistula*** - The clinical presentation of a neonate with excessive **frothiness from the mouth**, choking, and **respiratory distress** is highly suggestive of this diagnosis. - The X-ray confirms the diagnosis by showing a **coiled orogastric tube** (indicated by the arrow) in the blind-ending upper esophageal pouch. The presence of **gas in the stomach** indicates a communication between the trachea and the distal esophagus (a distal fistula). *Transient tachypnea of newborn* - This is a benign condition caused by delayed clearance of fetal lung fluid, presenting with rapid breathing shortly after birth, usually in term infants delivered by C-section. - The chest X-ray typically shows **perihilar streaking**, **fluid in the fissures**, and mild hyperinflation, not a coiled feeding tube. *Congenital diaphragmatic hernia* - This condition involves the herniation of abdominal contents into the chest, causing severe respiratory distress and a **scaphoid abdomen**. - The chest X-ray would show **bowel loops within the thoracic cavity** and displacement of the mediastinum, which are not seen in this image. *Respiratory distress syndrome* - Primarily seen in premature infants, this is caused by a deficiency of **pulmonary surfactant**. - The characteristic X-ray findings include low lung volumes, a diffuse **ground-glass appearance**, and **air bronchograms**.

Q: How much oxygen is given to a term infant with respiratory distress during resuscitation?

21%. ***Correct: 21% (Room Air)*** - **Current NRP and WHO guidelines** recommend starting resuscitation of **term infants with 21% oxygen (room air)** - Evidence shows room air is **equally effective** as 100% oxygen for initial resuscitation - Reduces **oxidative stress and potential harm** from hyperoxia - Oxygen can be **titrated up** if preductal SpO2 targets are not achieved within expected timeframes - This applies specifically to **term infants (≥37 weeks gestation)** *Incorrect: 70%* - Not a standard concentration used in neonatal resuscitation - Would expose infant to unnecessarily high oxygen levels without clear benefit *Incorrect: 100%* - **Outdated practice** - previously used but no longer recommended for term infants - Associated with increased **oxidative stress** and potential harm - May still be considered for **preterm infants <35 weeks** (start with 21-30% and titrate) *Incorrect: 50%* - Not the recommended starting concentration for term infants - May be used as an **intermediate step** when titrating oxygen if initial room air is insufficient **Key Point:** For term infants, always start with room air (21%) during resuscitation and titrate based on SpO2 targets.

Q: A neonate delivered at 36-week gestation develops respiratory distress soon after birth. CXR is as shown. Likely diagnosis?

Respiratory Distress Syndrome. ***Respiratory Distress Syndrome*** - The chest X-ray shows classic features of RDS, including a diffuse **reticulogranular pattern** (ground-glass appearance) and prominent **air bronchograms**, indicative of widespread alveolar atelectasis. - This condition is primarily caused by **surfactant deficiency** in preterm infants (like this 36-week neonate), leading to increased surface tension, alveolar collapse, and respiratory distress shortly after birth. ***Transient Tachypnea of Newborn*** - This is caused by delayed clearance of **fetal lung fluid** and is more common in term infants delivered by Caesarean section. - The chest X-ray typically shows **perihilar streaking**, fluid in the interlobar fissures, and hyperinflation, which are not the primary findings in the provided image. ***Neonatal Pneumonia*** - While it can present with respiratory distress, neonatal pneumonia typically shows **asymmetrical patchy infiltrates**, consolidation, or pleural effusions on chest X-ray. - The diffuse, symmetrical ground-glass appearance seen here is less characteristic of an infectious process like pneumonia, which is often more localized. ***Meconium Aspiration Syndrome*** - This condition occurs in term or post-term infants following aspiration of **meconium-stained amniotic fluid**, which is not mentioned in the history. - The characteristic X-ray findings are coarse, patchy opacities, **hyperinflation**, and potential air-leak syndromes (e.g., pneumothorax), which differ from the image.

Q: Which of the following best explains the mechanism of breast milk jaundice?

Enhanced enterohepatic circulation due to beta-glucuronidase in breast milk deconjugating bilirubin. ***Enhanced enterohepatic circulation due to beta-glucuronidase in breast milk deconjugating bilirubin*** - Breast milk contains high levels of **beta-glucuronidase** which deconjugates conjugated bilirubin in the intestine back to unconjugated form, greatly increasing the pool available for reabsorption (enhanced **enterohepatic circulation**). - This is the **PRIMARY mechanism** of breast milk jaundice, leading to prolonged unconjugated hyperbilirubinemia in otherwise healthy breastfed infants. - High concentrations of **non-esterified free fatty acids** and pregnane-3α,20β-diol in breast milk may also inhibit the conjugation enzyme UDP-glucuronyl transferase (secondary mechanism). *Incorrect: Hepatocellular injury by breast milk* - Breast milk jaundice is a benign, physiological process and is **NOT** associated with hepatocellular necrosis or cytotoxic liver injury. - Liver function tests (LFTs) are typically **normal**, differentiating it from pathological liver disease. *Incorrect: Increased RBC breakdown producing more unconjugated bilirubin* - This mechanism is responsible for **hemolytic jaundice** (e.g., ABO incompatibility, G6PD deficiency), implying excessive bilirubin production from red cell destruction. - Breast milk jaundice occurs in neonates with **normal rates of erythrocyte destruction** and hemoglobin turnover. *Incorrect: Reduced intestinal absorption of bilirubin* - The mechanism involves **increased** intestinal absorption of bilirubin due to enhanced enterohepatic circulation. - Beta-glucuronidase breaks down conjugated bilirubin to the absorbable unconjugated form, leading to **excessive reabsorption**, not reduced absorption.

Question 1

Which of the following is considered harmful to a newborn baby in the immediate postnatal period?

Accepted Answer

Giving a bath immediately after birth

Answer

Placing the baby on the mother's chest

Answer

Cleaning the eyes with a wet sterile swab

Answer

Initiating breastfeeding within 1 hour

Question 2

A newborn, born to a diabetic mother, presents after 24 hours of life with a blood glucose level of <35 mg/dL. The baby is symptomatic. What is the next best step in management?

Accepted Answer

Administer IV glucose and recheck blood glucose after 20 minutes

Answer

Administer IV bolus of Hartmann solution

Answer

Start oral feeds and observe

Answer

Recheck blood glucose after 20 minutes

Question 3

A neonate was born to a controlled gestational diabetes mother. At the time of birth, he was fine but 4 days later, he developed dyspnea with SpO2 80% at room air. What is the initial management?

Accepted Answer

Give 100% O2

Answer

Observation

Answer

Give 50% O2

Answer

Give 21% to 30% O2

Question 4

A neonate on examination has bilateral cataracts and, after investigations, is found to have a patent ductus arteriosus and salt and pepper retinopathy. What is the most likely congenital infection?

Accepted Answer

Rubella

Answer

Varicella

Answer

CMV

Answer

Toxoplasma

Question 5

When is a blood sample taken to diagnose neonatal hypothyroidism?

Accepted Answer

72 hours after delivery

Answer

Immediately from the umbilical cord

Answer

23-48 hours after delivery

Answer

24 hours after delivery

Question 6

What is the daily fluid requirement for a 3-day-old baby with a birth weight of 1500 grams?

Accepted Answer

80-90 ml/kg/day

Answer

100-110 ml/kg/day

Answer

130-150 ml/kg/day

Answer

120-130 ml/kg/day

Question 7

A neonate was brought with a history of frothiness from the mouth and respiratory distress. An X-ray of the neonate is given below. What is the diagnosis?

Accepted Answer

Esophageal atresia with tracheo-esophageal fistula

Answer

Transient tachypnea of newborn

Answer

Respiratory distress syndrome

Answer

Congenital diaphragmatic hernia

Question 8

How much oxygen is given to a term infant with respiratory distress during resuscitation?

Accepted Answer

21%

Answer

70%

Answer

100%

Answer

50%

Question 9

A neonate delivered at 36-week gestation develops respiratory distress soon after birth. CXR is as shown. Likely diagnosis?

Accepted Answer

Respiratory Distress Syndrome

Answer

Meconium Aspiration Syndrome

Answer

Transient Tachypnea of Newborn

Answer

Neonatal Pneumonia

Question 10

Which of the following best explains the mechanism of breast milk jaundice?

Accepted Answer

Enhanced enterohepatic circulation due to beta-glucuronidase in breast milk deconjugating bilirubin

Answer

Increased RBC breakdown producing more unconjugated bilirubin

Answer

Reduced intestinal absorption of bilirubin

Answer

Hepatocellular injury by breast milk

Neonatology — MCQs

Neonatology — MCQs

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