by Brian K. Walsh – Test Bank
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Sample Questions Posted Below
Walsh: Perinatal and Pediatric Respiratory Care, 3rd Edition
Chapter 5: Examination and Assessment of the Neonatal Patient
1. Which of the following factors are taken into consideration when assessing the gestational age of a neonate?
2. Previous maternal pregnancies
3. Prenatal ultrasound evaluations
III. Postnatal findings based on physical and neurologic examinations
1. Gestational duration based on the last menstrual cycle
A . I and III only
B . I, II, and III only
C . I, II, and IV only
D II, III, and IV only
ANS: D
A. Incorrect response: See explanation D.
B. Incorrect response: See explanation D.
C. Incorrect response: See explanation D.
D. Correct response: Ideally, gestational age assessment is performed before the neonate is 12 hours old, to allow the greatest reliability for infants less than 26 weeks of gestational age. Evaluating gestational age requires consideration of several factors. The three main factors are as follows:
• Gestational duration based on the last menstrual cycle
• Prenatal ultrasound evaluation
• Postnatal findings based on physical and neurologic examinations
OBJ: Recall
2. The gestational age of a newborn has been evaluated to be 34 weeks. The newborn’s birth weight is greater than the 90th percentile. How should the therapist classify this infant?
A . Small for gestational age
B . Average for gestational age
C Large for gestational age
D . Very large for gestational age
A. Incorrect response: See explanation C.
B. Incorrect response: See explanation C.
C. Correct response: Once gestational age is determined, weight, length, and head circumference are plotted on a standard newborn grid. Any infant whose birth weight is less than the 10th percentile for gestational age is classified as small for gestational age. Similarly, an infant whose birth weight is more than the 90th percentile is large for gestational age. When using intrauterine growth curves, considering specific charts that are race and gender specific may be necessary. Along with prematurity, abnormal gestational age and size for gestational age are associated with many neonatal disease processes.
D. Incorrect response: See explanation C.
OBJ: Application
3. An infant arrives in the newborn nursery with an axillary body temperature of 95.6º F. Which of the following events may be responsible for this infant’s temperature?
A The neonate was in an infant warmer in the delivery room.
B . The infant was swaddled in numerous blankets.
C . The delivery room temperature was low.
D . The newborn has protracted diarrhea.
ANS: C
A. Incorrect response: See explanation C.
B. Incorrect response: See explanation C.
C. Correct response: Normal values for temperature are 97.6° F 1° F axillary and 99.6° F 1° F rectally; however, temperature on arrival in the nursery may be lower if the delivery room was cold or may be higher if the radiant warmer was operating at a higher temperature because of incorrect probe position or warmer malfunction.
D. Incorrect response: See explanation C.
OBJ: Application
4. A physical examination is being performed on a newborn, and the therapist notices that the infant’s arms do not move symmetrically. Which of the following situations could account for this problem?
A An injury to the infant’s brachial plexus may have occurred during birth.
B The infant may have been born breach.
C . The baby was born via cesarean section.
D The infant experienced nuchal cords during birth.
ANS: A
A. Correct response: Observing the infant’s overall appearance is an important aspect of the physical examination. Ideally, examine the infant lying quietly and unclothed in a neutral thermal environment. Body position and symmetry, both at rest and during muscular activity, provide valuable information regarding possible birth trauma. For example, an infant who does not move the arms symmetrically could have a broken clavicle or an injury to the brachial plexus.
B. Incorrect response: See explanation A.
C. Incorrect response: See explanation A.
D. Incorrect response: See explanation A.
OBJ: Application
5. The therapist notices that an infant presents with irregular areas of dusky skin alternating with areas of pale skin. On the basis of this
observation, which of the following conditions should the therapist anticipate this patient having?
A . Polycythemia
B . Hypotension
C . Situs inversus with dextrocardia
D . Renal insufficiency
ANS: B
Feedback
A. Incorrect response: See explanation B.
B. Correct response: Observing skin and color often provides diagnostic clues. Mottling refers to irregular areas of dusky skin alternating with areas of pale skin. An extremely pale or mottled infant suggests hypotension or anemia. Situs inversus, or situs transversus, is a congenital condition in which the major visceral organs are reversed from their normal anatomic positions. The normal arrangement is known as situs solitus. The term situs inversus is a short form of the Latin phrase “situs inversus viscerum,” meaning “inverted position of the internal organs.”
C. Incorrect response: See explanation B.
D. Incorrect response: See explanation B.
OBJ: Application
6. Which of the following neonatal skin presentations at birth is associated with a high hematocrit value or polycythemia and neonatal hyperviscosity syndrome?
A . Mottling
B Lanugo
C Reddish blue appearance
D . Vernix
ANS: C
Feedback
A. Incorrect response: Mottling refers to irregular areas of dusky skin alternating with areas of pale skin. An extremely pale or mottled infant suggests hypotension or anemia.
B. Incorrect response: The presence of lanugo, the fine hair that covers premature infants mostly over the shoulders, back, forehead, and cheeks, indicates an even younger gestational age than one presenting with vernix.
C. Correct response: A ruddy, reddish blue appearance is frequently associated with a high hematocrit value, or polycythemia (hematocrit > 65%), and neonatal hyperviscosity syndrome. The yellow color associated with mild to moderate jaundice is common among newborns after the first day of life. Jaundice on the first day
of life, however, is always an indication for an immediate evaluation.
D. Incorrect response: Often a grayish white cheeselike substance, called vernix caseosa, is present in the skin folds of a term infant. However, vernix is even more abundant on a preterm infant and suggests an earlier gestational age.
OBJ: Recall
7. Why are chest retractions more prominent among neonates than among older children and adults?
A . Because neonates generate a greater subatmospheric intrapleural pressure.
B . Because newborns have relatively thin and weak musculature, and a less rigid thorax.
C Because neonates have a much higher respiratory rate.
D . Because airway resistance through the smaller caliber airways is higher.
ANS: B Feedback
A. Incorrect response: See explanation B.
B. Correct response: Chest wall retractions are more prominent and
easily observed among neonates than in an older children or adults. The newborn musculature is relatively thin and weak, and the thoracic cage is less rigid. The flexible chest wall and thoracic cage of the newborn exhibit noticeable retractions as lung compliance worsens.
C. Incorrect response: See explanation B.
D. Incorrect response: See explanation B.
OBJ: Recall
8. Why is it difficult to localize auscultation findings of the thorax of a newborn?
A . Because the neonate’s chest is small and sounds are difficult to differentiate.
B Because the newborn infant is frequently crying.
C . Because the neonate’s tidal volume is so small.
D . Because the newborn’s pulmonary compliance is low.
ANS: A
A. Correct response: Auscultation of the newborn can sometimes be difficult. The newborn’s chest wall is small, and sounds easily transmit from one lung region to another. Abdominal sounds may even transmit to the lungs, although bowel sounds heard from the chest in place of absent breath sounds may indicate a diaphragmatic hernia. Localizing auscultation findings in a preterm infant is frequently difficult or impossible with single-head stethoscopes. Auscultation with a double-head stethoscope has proved useful in some situations.
B. Incorrect response: See explanation A.
C. Incorrect response: See explanation A.
D. Incorrect response: See explanation A.
OBJ: Recall
9. While performing a physical examination on a newborn infant, the therapist notices that the point of maximal cardiac impulse is to the left of the sternal border. Which of the following conditions can cause this situation?
A . Atelectasis of the right lung
B Bilateral pulmonary consolidation
C . Right-sided pneumothorax
D . Left mainstem bronchus intubation
A. Incorrect response: See explanation C.
B. Incorrect response: See explanation C.
C. Correct response: The point of maximal cardiac impulse (PMI) is the position on the chest wall at which the cardiac impulse can be maximally seen. The PMI is usually seen in newborns because of the relatively thin and flexible chest wall. Typically, the PMI is relatively close to the sternal border because of the predominance of the right ventricle in the fetal period. A mediastinal shift due to a pneumothorax will move the PMI away from the affected side (ipsilateral lung) of the chest.
D. Incorrect response: See explanation C.
OBJ: Recall
10. Which of the following statements refers to the diagnostic procedure called transillumination?
A . Place a light source between the surface of the bed and the patient’s back, and orient the patient in a supine position.
B . Direct a light source toward the ipsilateral surface of the patient’s thorax.
C Position a beam of light against a patient’s chest wall in a well-lit room.
D . Insert a fiberoptic light source down a patient’s endotracheal tube and beyond the tube’s distal tip.
Feedback
A. Incorrect response: See explanation B.
B. Correct response: With suspected pneumothorax, perform transillumination of the chest wall, using a high-energy flashlight or fiberoptic device in a darkened room. Direct the light source on the chest wall of the suspected (ipsilateral) side. A large pneumothorax will reveal an excessively pink and illuminated, usually irregular area of light, or “glowing” area, through the chest wall when compared with the contralateral side.
C. Incorrect response: See explanation B.
D. Incorrect response: See explanation B.
OBJ: Recall
11. A neonate is found to have a bounding pulse. Which of the following conditions may contribute to this finding?
12. Patent ductus arteriosus
13. Hypoplastic left-sided heart syndrome
III. Coarctation of the aorta
1. Left-to-right shunt
A I and II only
C II and III only
D I, III, and IV only
ANS: B
Feedback
A. Incorrect response: See explanation B.
B. Correct response: Weak pulses suggest low cardiac output states such as shock and hypoplastic left-sided heart syndrome. Bounding pulses are seen in infants with patent ductus arteriosus and left-toright shunt. The bounding characteristic of the pulse results from rapid runoff of the blood into the low-resistance pulmonary circulation. This lowers the systolic blood pressure and produces a wider pulse pressure. Brachial and femoral pulses should be equal in intensity and felt simultaneously. A delayed or weak femoral pulse can indicate coarctation of the aorta.
C. Incorrect response: See explanation B.
D. Incorrect response: See explanation B.
OBJ: Recall
12. What condition would be responsible for the therapist observing a pulse oximeter indicating decreased perfusion while central blood pressure remains normal?
A Volume depletion with compensatory peripheral vasoconstriction
B . Hypoplastic left-sided heart syndrome
C . Hypervolemia with compensatory peripheral vasodilation
D . Hypoplastic right-sided heart syndrome
ANS: A
A. Correct response: A pulse oximeter will display a low pulse rate and perfusion signal as peripheral pulses and perfusion decrease. The cause of this poor perfusion status must be determined. However, if the pulse oximeter suggests decreased perfusion while central blood pressure remains normal, the cause may be volume depletion with compensatory peripheral vasoconstriction.
B. Incorrect response: See explanation A.
C. Incorrect response: See explanation A.
D. Incorrect response: See explanation A.
OBJ: Recall
13. For the purpose of assessing right-to-left shunting, as in the case of persistent pulmonary hypertension, which of the following sites would render postductal blood?
14. Right arm
15. Left arm
III. Right leg
1. Left leg
A . I only
B II only
C I, III, and IV only
D . II, III, and IV only
ANS: D
Feedback
A. Incorrect response: See explanation D.
B. Incorrect response: See explanation D.
C. Incorrect response: See explanation D.
D. Correct response: When assessing right-to-left shunting, as seen with persistent pulmonary hypertension of the newborn (PPHN), the right arm, or preductal site, will have a higher saturation than the postductal site, or left arm and lower extremities. Postductal blood
will have a lower saturation caused by venous admixture. Infants with PPHN have increased pulmonary vascular resistance (PVR) that prevents normal pulmonary blood flow. The increased PVR causes a right-to-left shunting of blood across the patent foramen ovale and patent ductus arteriosus. The diagnosis of PPHN is usually confirmed by echocardiography, along with analysis of blood gas samples from preductal and postductal sites. A simpler method to detect this right-to-left shunting is to use two pulse oximeters and measure preductal and postductal SpO2 (arterial oxygen saturation determined by pulse oximeter). Clinical research has revealed that arterial saturation in the right arm (preductal) of at least 3% above the lower limb (postductal) is evidence of right-to-left ductal shunting.
OBJ: Application
14. Which of the following conditions can cause abdominal distention?
15. Enterocolitis
16. Ascites
III. Congenital diaphragmatic hernia
1. Omphalocele
A . I and II only
B . I, II, and IV only
C . I, III, and IV only
D II, III, and IV only
ANS: A
A. Correct response: Distention is a significant finding characterized by tightly drawn skin through which engorged subcutaneous vessels can easily be seen. Distention can suggest a variety of pathologic conditions, including sepsis, obstruction, tumors, ascites, pneumoperitoneum, or necrotizing enterocolitis. Enterocolitis is a bowel infection characterized by sepsis, peritonitis, bowel perforation, and significant mortality. Any of these conditions may cause elevation of the diaphragm and therefore compromise lung expansion.
B. Incorrect response: See explanation A.
C. Incorrect response: See explanation A.
D. Incorrect response: See explanation A.
OBJ: Recall
15. Which of the following conditions are associated with scaphoid abdomen?
16. Necrotizing enterocolitis
17. Gastroschisis
III. Prune-belly syndrome
1. Sepsis
. I and IV only
B II and III only
C I, II, and III only
D . II, III, and IV only
ANS: B
A. Incorrect response: See explanation B.
B. Correct response: A scaphoid, hollowed, or unusually flattened abdomen may be associated with congenital diaphragmatic hernia, in which abdominal contents are misplaced into the chest through a defect in the muscular diaphragm. More noticeable abnormalities of the abdomen include prune-belly syndrome, which is a congenital lack of abdominal musculature. Omphalocele is a protrusion of the membranous sac that encloses the abdominal contents through an opening in the abdominal wall into the umbilical cord. Gastroschisis is a defect in the abdominal wall lateral to the midline with protrusion of the intestines.
C. Incorrect response: See explanation B.
D. Incorrect response: See explanation B.
16. While performing an examination of the abdomen of a neonate, the therapist is able to palpate the infant’s liver 1 to 2 cm below the right costal margin. Which of the following conditions can account for this development?
A . Hepatomegaly
B . Splenomegaly
C . Right ventricular failure
D Normal liver position
ANS: D
Feedback
A. Incorrect response: See explanation D.
B. Incorrect response: See explanation D.
C. Incorrect response: See explanation D.
D. Correct response: The liver is usually felt as a rounded edge that rolls under the lightly palpating hand. Palpation should begin in the right lower quadrant so that an enlarged liver is not missed. The liver edge is usually easily defined 1 to 2 cm below the right costal margin in newborns. Hepatomegaly may be associated with congenital heart disease, infection, or hemolytic disease.
OBJ: Recall
17. After the umbilical cord has been cut in the delivery room during the delivery of a large for gestational age infant, the therapist notices that the umbilical cord is large and fat. Which of the following maternal conditions is likely present?
A . Congestive heart failure
B . Renal insufficiency
C . Diabetes mellitus
D . Hypertension
ANS: C
Feedback
A. Incorrect response: See explanation C.
B. Incorrect response: See explanation C.
C. Correct response: The umbilical cord is yellowish white with three blood vessels. The two small and thick-walled arteries and one large and thin-walled vein are easily visible on the end of a freshly cut cord. Wharton’s jelly surrounds the vessels. A single umbilical artery
suggests congenital anomalies, especially those of the urinary tract. The presence of meconium in the amniotic fluid causes a greenish yellow staining of the umbilical cord. The umbilical cord of a large for gestational age infant born to a diabetic mother is frequently large and fat.
D. Incorrect response: See explanation C.
OBJ: Recall
18. A newborn who presents as pale, mottled, floppy, with little interest in feeding, and slightly irritable most likely has which of the following conditions?
A . Sepsis
B . Respiratory distress syndrome
C . Retinopathy of prematurity
D . Cri du chat
ANS: A Feedback
A. Correct response: Sepsis consumes the majority of infants energy.
This includes and inability to feeding and even crying in severe cases. Respiratory distress is typically very progressive and can appear the same with the exception of the infant being pale, mottled, and floppy. Without sepsis the infant will have enough energy to breath rapidly, be irritable, and have tone.
B. Incorrect response: See explanation A.
C. Incorrect response: See explanation A.
D. Incorrect response: See explanation A.
OBJ: Recall
19. The therapist has placed a pulse oximeter probe on a finger of the right hand of a newborn and another pulse oximeter probe on a toe of the infant’s left foot. The pulse oximeter on the right hand reads 80% and the one on the left foot indicates 65%. Which of the following disease conditions does this neonate possibly have?
A . Diaphragmatic hernia
B . Persistent pulmonary hypertension of the newborn
C . Choanal atresia
D Suprapubic aspiration
ANS: B
A. Incorrect response: See explanation B.
B. Correct response: The “gold standard” for diagnosing persistent pulmonary hypertension of the newborn (PPHN) involves having the neonate breathe 100% oxygen, and after a certain time to obtain a preductal blood sample from the right radial or temporal artery, and a postductal blood sample from the umbilical artery or lower limbs. If the preductal–postductal pressure of oxygen (PO2) difference is greater than 15 mm Hg, then the infant has ductal shunting. Two pulse oximeters can also be used to measure preductal SpO2 and postductal SpO2. The preductal SpO2 is measured by placing a probe on a finger of the infant’s right hand and the probe from the second oximeter on one of the toes of the newborn’s left foot. A preductal–postductal SpO2 difference greater than 10% indicates ductal shunting.
PPHN results when the pulmonary vascular resistance fails to decrease after birth, despite improved alveolar oxygenation and lung expansion. Despite an increase in systemic vascular resistance (with the loss of the placenta), pulmonary vascular resistance remains equal to or greater than systemic vascular resistance. This high pulmonary vascular pressure results in blood continuing to flow through the foramen ovale and ductus arteriosus. Subsequently, with the loss of placental gas exchange and the inability to increase pulmonary blood flow, arterial oxygen tension falls to low levels. If this situation is not reversed, the infant will die of severe hypoxemia.
C. Incorrect response: See explanation B.
D. Incorrect response: See explanation B.
OBJ: Application
20. Which of the following white blood cell counts constitutes the condition leukopenia?
A . Less than or equal to 3500/mm3
B . 5000 to 10,000/mm3
C . 10,000 to 20,000/mm3
D . Greater than or equal to 25,000/mm3
ANS: A
A. Correct response: Leukopenia refers to white blood cells less than 3500/mm3, and leukocytosis refers to white blood cells greater than 25,000/mm3, which is suggestive of infection.
B. Incorrect response: See explanation A.
C. Incorrect response: See explanation A.
D. Incorrect response: See explanation A.
OBJ: Recall