respiratory disorders of newborn/ hyperbilirubinemia/ hemolytic disease of the newborn/ IVH/ gestational DM/ neonatal Sepsis

Question 1

this must be established and maintained in order to develop a ventilation perfusion relationship that will provide optimal exchange of oxygen and carbon dioxide between alveoli and blood

Answer 1

functional residual capacity

Question 2

enhance lung fluid adsorption and trigger the change in lung epithelia from a chloride secretory to sodium reabsorptive mode

Answer 2

increase catecholamine, vasopressin, prolactin and glucocorticoids

Question 3

enhance aeration of gas-free lungs by reducing surface tension, thereby lowering the pressure required to open alveoli

Answer 3

surfactant

Question 4

opening pressure for infants requiring positive pressure ventilation at birth

Answer 4

13-32cm H2O

Question 5

range of expiratory esophageal pressure assoc with first few spontaneous breaths in term newborn

Answer 5

45-90cm H2O

Question 6

Air entry into the lung leads to…

Answer 6

displaced fluid
decreased hydrostatic pressure in pulmonary vasculature
increase pulmonary blood flow

Question 7

causes of impaired fluid removal

Answer 7

CS
surfactant deficiency
endothelial cell damage
hypoalbuminemia
high pulmonary venous pressure
neonatal sedation

Question 8

initiation of 1st breath is caused by

Answer 8

decline in PaO2 and pH
rise in PaCO2
as a result of interruption of placental circulation, redistribution of cardiac output, decrease body temperature and various tactile and sensory inputs.

Question 9

FRC is lowest in most immature infants due to..

Answer 9

decrease number in alveoli

Question 10

abnormalities in ventilation: perfusion may lead to hypoxemia and hypercarbia as a result of

Answer 10

atelectasis
intrapulmonary shunting
hypoventilation
gas trapping

Question 11

pulse oximetry at birth should be done at…

Answer 11

right upper extremity

Question 12

regular rhythmic to cyclic brief episodes of intermittent apnea

Answer 12

periodic breathing

Question 13

causes of apnea

Answer 13

hypoglycemia
meningitis
drug
hemorrhage
seizure
shock
sepsis
anemia
obstruction of airway
pneumonia
muscle weakness

Question 14

apnea that occurs in the absence of identifiable predisposing disease

Answer 14

idiopathic apnea

Question 15

absence of airflow but persistent chest wall motion

Answer 15

obstructive apnea

Question 16

apnea caused by decrease CNS stimuli to respiratory muscles, both airflow and chest wall motion are absent

Answer 16

central apnea

Question 17

most important determinant of respiratory control

Answer 17

gestational age

Question 18

most common pattern of idiopathic apnea in preterm

Answer 18

mixed apnea (50-70%)

Question 19

short episodes of apnea are usually CENTRAL, whereas prolonged ones are often ______

Answer 19

mixed apnea

Question 20

cessation of breathing for longer than 20sec or for any duration if accompanied by cyanosis and bradycardia

Answer 20

serious apnea

Question 21

treatment for recurrent apnea of prematurity

Answer 21

caffeine or theophylline

Question 22

increases central respiratory drive by lowering the threshold of response to hypercapnia as well as enhancing contractility of the diaphragm and preventing diaphragmatic fatigue.

Answer 22

methylxanthine

Question 23

loading dose of theophylline orally or aminophylline Iv

Answer 23

LD 5-7mg/kg followed by 1-2mg/kg q6-12

Question 24

loading dose of caffeine citrate

Answer 24

LD 20mg/kg followed by 5mg/kg/24 OD after 24hrs

Question 25

potent respiratory stimulant acts predominantly on chemoreceptors and is effective in neonates with apnea of prematurity that is unresponsive to methylxanthine

Answer 25

Doxapram

Question 26

at what age does apnea of prematurity resolves

Answer 26

37wks postconceptional age

Question 27

in absence of significant events, home monitoring can be safely discontinued at what age

Answer 27

44wks postconceptional age

Question 28

percentage of RDS in the ff age group…
<28wks:
32-36wks:
>37wks:

Answer 28

<28wks: 60-80%
32-36wks: 15-30%
>37wks: rare

Question 29

factors that increases RDS

Answer 29

maternal diabetes
multiple birth
CS
precipitous delivery
asphyxia
cold stress
maternal history of previously affected infant

Question 30

factors that decreases risk for RDS

Answer 30

chronic or pregnancy induced assoc hypertension
maternal heroin use
prolonged rupture of membranes
antenatal coritcosteroid prophylaxis

Question 31

primary cause of RDS

Answer 31

Surfactant deficiency (dec production and secretion)

Question 32

major constituents of surfactant

Answer 32

dipalmitoyl phosphatidylcholine (lecithin)
phosphatidylglycerol
apoproteins (surfactant proteins SP-A, SP-B, SP-C, SP-D
cholesterol

Question 33

During fetal transition, fluid removal may be impaired by all of the following, except:
1/1
A. Ceasarian section
B. Hypoalbuminemia
C. Low pulmonary venous pressures
D. Neonatal sedation
E. Surfactant Deficiency

Answer 33

C. Low pulmonary venous pressures

p 849 ..Fluid removal may be impaired after cesarean section or as a result of surfactant deficiency, endothelial cell damage, hypoalbuminemia, high pulmonary venous pressure, or neonatal sedation.

Question 34

True of periodic breathing patterns in newborn

Answer 34

Apneic pauses of 5-10 sec followed by a burst of rapid respirations at a rate of 50-60 breaths/min for 10-15 sec.

page 849… This periodic breathing pattern, which shifts from a regular rhythmicity to cyclic brief episodes of intermittent apnea, is more common in preterm infants, who may have apneic pauses of 5-10 sec followed by a burst of rapid respirations at a rate of 50-60 breaths/min for 10-15 sec

Question 35

most common pattern of idiopathic apnea in preterm neonates is

Answer 35

Mixed apnea

The most common pattern of idiopathic apnea in preterm neonates is mixed apnea (50-75% of cases), with obstructive apnea preceding (usually) or following central apnea.

Question 36

Which of the following maybe considered as serious apnea in a preterm infant
1/1
A. Cessation of breathing for 10-20 sec with apnea and bradycardia
B. Cessation of breathing for more than 20 secs
C. Cessation of breathing for 5-10 sec with apnea and bradycardia
D. All of the above

Answer 36

D. all of the above

Page 850. In preterm infants, serious apnea is defined as cessation of breathing for longer than 20 sec or for any duration if accompanied by cyanosis and bradycardia

Question 37

The risk for development of RDS increases with the following except
1/1
A. Maternal Diabetes
B. Asphyxia
C. Twin pregnancy
D. Pre-eclampsia

Answer 37

D. pre eclampsia
Page 850… The risk for development of RDS increases with maternal diabetes, multiple births, cesarean delivery, precipitous delivery, asphyxia, cold stress, and a maternal history of previously affected infants. The incidence is highest in preterm male or white infants. The risk of RDS is reduced in pregnancies with chronic or pregnancy-associated hypertension, maternal heroin use, prolonged rupture of membranes, and antenatal corticosteroid prophylaxis.

Question 38

Major composition of pulmonary surfactant

Answer 38

Lecithin

Question 39

The following mechanisms describe the pathophysiology of RDS, EXCEPT:
1/1
A. Alveolar atelectasis
B. Hyaline membrane formation
C. Interstitial edema
D. Pulmonary hemorrhages

Answer 39

D. Pulmonary hemorrhages

Page 851… Alveolar atelectasis, hyaline membrane formation, and interstitial edema make the lungs less compliant in RDS, so greater pressure is required to expand the alveoli and small airways

Question 40

Reduction of surfactant production/secretion can be seen in
0/1
A. Asphyxia
B. Hypoxia
C. Hyperoxia
D. A and B only 
E. All of the above

Answer 40

E. All of the above

Question 41

Contributing factors in the pathogenesis of Hyaline Membrane Disease:
0/1
A. Progressive atelectasis
B. Hypoventilation
C. Pulmonary vasoconstriction
D. A and B only
E. All of the above

Answer 41

D. A and B only

Question 42

Signs of worsening respiratory distress
1/1
A. Cyanosis and pallor
B. Decrease in grunting
C. Irregular respirations
D. A and C only
E. All of the above

Answer 42

E. All of the above

Page 851… If the condition is inadequately treated, blood pressure may fall; cyanosis and pallor increase, and grunting decreases or disappears, as the condition worsens. Apnea and irregular respirations are ominous signs requiring immediate intervention

Question 43

A 32-week male infant is born via spontaneous vaginal delivery after preterm labor. He is born in good condition with an AS 8,9. He did not require any resuscitation but does have a respiratory rate of 60 breaths/min, slight intercostal retractions, nasal flaring and an audible expiratory grunt when handled. He is admitted to the intensive care nursery, specimen for blood culture was collected and he was started on antibiotics and 10% dextrose water at 60 mL/kg per day. He is maintaining oxygen saturations of 92% in 25% oxygen via cannula (FiO2 25%). Which of the following would be the MAJOR BENEFIT of commencing him on nasal CPAP versus leaving him in oxygen?

Answer 43

A. Decreased chance that he will need to be intubated and ventilated

Page 853… CPAP reduces collapse of surfactant-deficient alveoli and improves both FRC and ventilation–perfusion matching. Early use of CPAP for stabilization of at-risk preterm infants beginning as early as in the delivery room reduces ventilatory needs.

Question 44

Treatment of RDS include
1/1
A. Avoid hypothermia by maintaining temperature at 36.5 to 37ºC
B. Provide adequate oxygen to maintain spO2 91-95%
C. Surfactant administration
D. Intubation for persistent apnea and respiratory failure
E. All of the above

Answer 44

E. All of the above

Question 45

The following are complications of respiratory distress syndrome, EXCEPT:
1/1
A. Pulmonary air leaks
B. Patent Ductus Arteriosus
C. Bronchopulmonary dysplasia
D. Necrotizing enterocolitis

Answer 45

D. Necrotizing enterocolitis

Question 46

Baby Aron, currently at his 37wks PMA will be discharged to home with 02 cannula at 1lpm. He was born 26-27 wks with a birthweight of 720grams. He was hooked to NCPAP FiO2 60% at birth and given surfactant at 3rd HOL. He had several bouts of infection and pneumonia for which appropriate antibiotics were given and completed. He was on NCPAP for 3 wks then shifted to O2 cannula at 2lpm. Attempts to wean off O2 were done but failed. What is your diagnosis?

Answer 46

BPD moderate

Question 47

True of Transient Tachypnea of the Newborn, EXCEPT:
1/1
A. Resolves within 24 hours
B. Chest radiograph shows prominent pulmonary vascular markings, fluid in the intralobar fissures, overaeration, flat diaphragms, and, rarely, small pleural effusions.
C. Secondary to slow absorption of fetal lung fluid, resulting in decreased pulmonary compliance and tidal volume and increased dead space.
D. Early onset of tachypnea, sometimes with retractions, or expiratory grunting and, occasionally, cyanosis that is relieved by minimal oxygen supplementation.

Answer 47

A. Resolves within 24 hours

Page 858… Most infants recover rapidly, usually within 3 days.

Question 48

You are asked to attend the delivery of a baby weighing 3500 grams who is at 40 weeks gestation. The mother is a 35 years old G2P1 scheduled for emergency cesarean section due to fetal distress and late decelerations. Rupture of maternal membranes occurred 28 hours before delivery with thick meconium stained amniotic fluid noted. The mother received four doses of Ampicillin prior to delivery. All prenatal ultrasound results were normal. Which of the following intervention should be done to the baby on delivery?

Answer 48

. Suction the oropharynx and nasopharynx before delivery of the shoulder

Question 49

At birth, What factor decreases the pulmonary vascular resistance?

Answer 49

Mechanical distention of the lungs

Question 50

All of the following may play a role in the management of persistent pulmonary hypertension (PPHN), EXCEPT:
1/1
A. Inotropes
B. Milrinone
C. Furosemide
D. Sildenafil

Answer 50

C. Furosemide

Question 51

Which of the following factors can lead to pulmonary hypertension?

Answer 51

A. Sepsis
B. Meconium aspiration
C. Respiratory distress syndrome
D. Diaphragmatic hernia

Question 52

True of congenital diaphragmatic hernia

Answer 52

Respiratory distress at less than 6 hours of life is a poor indicator of survival

page 861….Early respiratory distress, within 6 hr after birth, is thought to be a poor prognostic sign.

Question 53

You are attending to a full term, 4300 gram female infant who was delivered via cesarean section due to failed vaginal delivery after a long and difficult labor. Maternal membranes were ruptured for 26 hours but there was no sign of chorioamnionitis at delivery. The mother is 34 years old with a history of poorly controlled diabetes diagnosed when she was 15 years old. She has been non compliant with her insulin regimen. After routine care, what is the next step in the evaluation of this infant?

Answer 53

Blood glucose

Question 54

As you examine this patient, you note tachypnea and nasal flaring. What is the most likely cause of this infant’s increased work of breathing?

Answer 54

TTN

Question 55

Which of the following is the most important to exclude as a cause of jaundice presenting in the first 24 hours of life?

Answer 55

Hemolysis

Question 56

Which of the following is considered a major contributor to the development of physiologic jaundice

Answer 56

Enterohepatic circulation

Question 57

Phototherapy decreases unconjugated serum bilirubin levels by which one of the following mechanisms?

Answer 57

Isomerization of the bilirubin molecule to lumirubin, which is water soluble and then can be excreted by the kidneys

Page 877… The other major product from phototherapy is lumirubin, which is an irreversible structural isomer converted from native bilirubin that can be excreted by the kidneys in the unconjugated state

Question 58

Which of the following is the most important risk factor in the development of intraventricular hemorrhage (IVH)?

Answer 58

Extreme prematurity

page 835.. The risk is inversely related to gestational age and birthweight, with the smallest and most immature infants being at the highest risk;

Question 59

Major site of intraventricular hemorrhage in premature infants

Answer 59

Germinal matrix

page 835.. The major neuropathologic lesions associated with very-low-birthweight (VLBW) infants are IVH and PVL. IVH in premature infants occurs in the gelatinous subependymal germinal matrix.

Question 60

A 35-week preterm female infant is now 4 hours old tolerating room air. She was born via emergency LSCS for breech position after preterm labor. Her mother was given 1.2 g IV benzylpenicillin 3 hours before delivery. Apgars were 8 and 9 respectively, birth weight was 2600 g. In the last hour the baby has had 4 episodes of apnea for >20 seconds, her heart rate dropping to <80 bpm and O2 saturation to <70%. She requires firm stimulation by the nursing staff to resolve these episodes. Between episodes her oxygen saturation on pulse oximetry is 96% (room air) and clinical examination is normal. She is not currently on any medications. Which of the following options is the most appropriate subsequent step in the management of this infant?

Answer 60

perform a sepsis work up and commence IV antibiotic

Question 61

You are asked to review a newborn term male infant because his mother is a hepatitis B carrier. The baby is now 2 hours of age and is attempting a breastfeed with his mother. The mother’s serology is as follows: HBSAg positive, HBeAg negative, antiHBeAb positive. Which of the following options is the most appropriate next step in the management of this baby?

Answer 61

Arrange for both Hep B IG and Heb B vaccine to be administered within the next 10hrs

Question 62

maternal infections have been associated with microcephaly in fetus

Answer 62

A. Zika virus
B. CMV infection
C. Rubella