Newborn MCQ

MCQ OF NEWBORN

Abdulrahman Bashire

CHILDREN HOSPITAL –BENGHAZI

ABDULRAHMAN BASHIR

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1) Newborn infants commonly have:A. Capillary hemangioma on the forehead. B. Posterior cranial fontenalle. C. Metopic sutures. D. Impalpable coronal sutures. E. Skin tag in front of the ear. Ans:- ABC 2) The following should be investigated in five day old baby:A. Erythema Toxicum B. Cloudy cornea C. Divarication of rectii D. Subconjunctival hemorrhage E. Preauricular skin tags Ans:-BE 3) During morning rounds in the newborn nursery, you examine a healthy infant who has blotchy erythematous macules that are 2 to 3 cm in diameter. The macules are scattered over the trunk, face, and proximal extremities; the palms and soles are spared. Each macule has a 1- to 3-mm central vesicle or pustule.Of the following, the MOST likely additional finding in this patient is A. pigmented macules located at sites of resolving pustules B. presence of lesions at birth C. pustules coalescing into bullae D. Wright stain of a smear of the vesicopustular contents revealing a predominance of eosinophils E. Wright stain of a smear of the vesicopustular contents revealing a predominance of polymorphonuclear neutrophils Preferred Response: D The infant described in the vignette exhibits the classic presentation of erythema toxicum neonatorum. Tiny vesicles or pustules arise from blotchy erythematous macules, with lesions characteristically appearing at 24 to 48 hours after birth. The pustules do not coalesce into bullae. Wright staining of the pustular contents reveals a predominance of eosinophils, not neutrophils. Because the lesions are seen in healthy infants, it has been suggested that this benign condition be renamed; suggested names include “benign neonatal rash” or “benign erythema neonatorum.” Transient neonatal pustular melanosis (TNPM) is another well-recognized benign dermal eruption of infancy in which pustular lesions spontaneously resolve into transient pigmented macules . TNPM may be present at birth, and examination of pustular contents reveals a predominance of neutrophils. Infantile acropustulosis is a chronic or recurring benign condition manifested by intensely pruritic pustules on hands and feet. Characteristic papules and pustules may coalesce into bullae.

CHILDREN HOSPITAL –BENGHAZI

ABDULRAHMAN BASHIR

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Infantile acropustulosis frequently is confused with scabies infestation. The lesions resolve spontaneously at 1 to 2 years of age. 4) You are examining a newborn who is the product of an uneventful pregnancy, labor, and delivery. Apgar scores were 9 at both 1 and 5 minutes. Findings on the initial physical examination are unremarkable except for the presence of vesicopustules and frecklelike macules (Item Q33A), some of which have a collarette of surrounding scale. Wright stain of a smear of the vesicopustular contents reveals a predominance of polymorphonuclear neutrophils.Of the following, the MOST likely diagnosis is A. congenital candidiasis B. erythema toxicum neonatorum C. infantile acropustulosis D. miliaria rubra E. transient neonatal pustular melanosis Preferred Response: E Characteristic lesions of transient neonatal pustular melanosis (TNPM) may be present at birth as vesicles, pustules, or ruptured vesicles or pustules that have a collarette of surrounding scale. Pigmented macules (Item C33A) often develop at the sites of resolving pustules or vesicles. Primary lesions usually disappear by 5 days of age; the secondary pigmented lesions may remain up to 3 months. TNPM occurs more commonly in African-American infants. Lesions can occur on palms and soles. Pustular contents reveal a predominance of neutrophils on Wright stain examination, as reported for the newborn in the vignette. Infants who have congenital cutaneous candidiasis may present with scaling, erythematous papules and pustules (Item C33B) at birth. Candida albicans can penetrate through the amnion and chorion to cause congenital infections. Scrapings from lesions prepared with potassium hydroxide document pseudohyphae (Item C33C) or budding yeast. Term infants who have erythema toxicum neonatorum exhibit vesicopustular lesions (Item C33D) that usually overlie erythematous macules. Lesions of erythema toxicum rarely are present at birth, and Wright stain of smears of pustular contents reveals a predominance of eosinophils. Infantile acropustulosis presents as pustules or vesicles (Item C33E) localized to the hands and feet. It may be present at birth but more commonly develops in the first weeks and months after birth, possibly continuing or recurring throughout infancy and early childhood. Lesions are very similar to those of infantile scabies infestation. Pustular contents may reveal prominent neutrophils and occasional eosinophils without evidence of the mites, ova, or feces seen in scabies. An absence of hyperpigmentation in resolving lesions and a prolonged or recurring course distinguishes infantile acropustulosis from TNPM. Miliaria rubra (prickly heat or heat rash) is caused by intraepidermal obstruction of the sweat ducts. A secondary local inflammatory response is responsible for the erythema (Item C33F) associated with the papules and vesicles. Miliaria rubra occurs later than miliaria crystallina, usually beyond thefirst postnatal week. Hyperpigmented, frecklelike lesions are not expected in miliaria rubra. 5) The following is true regarding changes in the fetal cardiovascular system after birth: A. There is normally immediate closure of the ductus arteriosus

CHILDREN HOSPITAL –BENGHAZI

ABDULRAHMAN BASHIR

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B. Hypoxia-induced vasoconstriction is the mechanism of closure of the ductus arteriosus C. The ligamentum teres is the remnant of the umbilical vein D. Regression of right ventricular hypertrophy occurs postnatally E. Inferior vena caval pressure falls after birth Ans:-CDE Occlusion of the umbilical cord removes this low resistance capillary bed from the circulation; breathing results in a marked decrease in pulmonary vascular resistance, hence there is increased pulmonary blood flow returning to the left atrium raising the pressure in the left atrium causing the foramen ovale to close. As pressure in the systemic circulation rises, shunt through the ductus arteriosus reverses. As the pO2 rises, synthesis of bradykinin and prostacyclins is inhibited, thus causing closure of the ductus arteriosus. The ductus arteriosus can take up to 3 months to close in normal neonates. 6) Neonatal RDS:A. Seen in most babies of birth weight < 2.5 kg. B. More common in infants of diabetic mothers. C. Associated with prolonged rupture of membrane. D. Less sever in babies of Afro-Caribiean origin than Caucasians. E. Exacerbated by hypothermia. Ans:-BDE 7) The following are causes of generalized hypotonia in 2 days old infants:A. Prematurity B. Hypothyroidism C. Myotonic dystrophy D. Spinal dysraphyism E. Anterior horn cell disease Ans:-ACE 8) Regarding surfactant:A. Production begins at 30 weeks B. It is produced by Type II pneumocytes in the walls of the bronchi C. Testosterone stimulates surfactant production D. Production is increased during a stressful event like hypothermia E. Betamathasone given to the mother improves surfactant production in the premature baby Ans:- E Surfactant production begins at 20-22 weeks. It is produced by Type II pneumocytes which are in the walls of the alveoli. The hormones testosterone and insulin inhibit surfactant production; hence hyaline membrane disease is more common in males than females and more common in infants of diabetic mothers. Surfactant production is suppressed if the baby is hypothermic, hypoxic, acidotic or hypoglycemic. Although dexamethasone is more commonly used, betamethasone has an identical effect on lung maturation 9) Concerning fetal lung development:-

CHILDREN HOSPITAL –BENGHAZI

ABDULRAHMAN BASHIR

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A. Type ΙΙ pneumocytes are present at 24 week gestation B. Cuboidal cells are capable of gas transfer in utero C. There is virtually no smooth muscle in the terminal & respiratory bronchioles at 6 month of age D. The large airways are formed at 16 week gestation E. Alveoli are completely formed at birth Ans:-AD 10) Congenital CMV infection:A. Only 10% of affected pregnancies have resulting long term sequel at birth B. Diagnosis is by viral isolation from the urine C. Hearing loss can develop gradually over the first 5 years D. The affected newborn should be treated with ganciclovir E. Intracranial calcifications are seen in a periventricular distribution Ans:- ABCE Congenital CMV occurs in approximately 1% of all live births and only 10% of these infections result in clinical symptoms. Severe clinical disease is associated with primary maternal infection in pregnancy. Infection in early gestation carries a far greater risk of severe fetal disease. In CMV intra-cranial calcifications are in a periventricular distribution. Ganciclovir is only used if there is CNS involvement, chorioretinitis or pneumonitis. 11) The following conditions will present with cyanosis in the first week of life: A. Aortic stenosis B. Transposition of the great vessels C. Hypoplastic left heart syndrome D. Fallot's tetralogy E. Fallot's pentalogy Ans:- B Any cardiac lesion which allows a mixing of blood along with a right to left flow or any cardiac lesion wherein pulmonary perfusion is impaired results in cyanosis. Left heart problems or outflow tract obstructions present as cardiac failure. Fallot's pentalogy includes an ASD along with the tetrad of infundibular pulmonary stenosis, RVH, over-riding of the aorta and a VSD. Babies with tetralogy of Fallot usually have a patent ductus arteriosus at birth that provides additional pulmonary blood flow, so severe cyanosis is rare early after birth. As the ductus arteriosus closes, as it typically will in the first days of life, cyanosis can develop or become more severe. The degree of cyanosis is proportional to lung blood flow and thus depends upon the degree of narrowing of the outflow tract to the pulmonary arteries. 12) Pulmonary surfactant A. Is partly recycled by endocytosis into the synthesizing cell B. Is produced by type Ι alveolar cells C. Reduction in pulmonary flow can cause a decrease in surfactant production D. Synthesis is inhibited by thyroxine E. Synthesis is stimulated by glucocorticoids Ans:- ACE

CHILDREN HOSPITAL –BENGHAZI

ABDULRAHMAN BASHIR

5

Dipalmityl- phosphotidyl choline is the main component of surfactant and is produced by Type-ΙΙ alveolar cells (granular pneumocytes). Its half-life is 14 hours and its main function is to reduce the surface tension of the alveoli. 13) Lung surfactant A. Decreases the surface tension within an alveolus B. Causes an increase in chest wall compliance C. Is a glycoprotein D. Maintains the same surface tension for different sized alveoli E. Appears only after the 1st week of life Ans:- A Surfactant is a dipalmitoyl-phosphatidyl choline and is a phospholipid, which prevents alveolar collapse by reducing alveoli surface tension. It is produced by type-II pneumocytes and is seen at about 24 weeks gestation. It causes an increase in lung compliance only (not chest wall compliance). 14) The following organisms cause conjunctivitis:A. Epstein Barr virus B. Chlamydia trachomatis C. Adenovirus D. Haemophilus influenzae E. Neisseria gonorrhoeae Ans:- BCDE Chlamydia trachomatis causes conjunctivitis in 30-50% of neonates born to mothers with cervicitis. It is a purulent conjunctivitis, which develops 5-14 days after birth and is indistinguishable from gonococcal infection. It is diagnosed on a swab scraped over the lower eyelid (to allow cells to be collected – don’t forget it is an intracellular organism) by direct fluorescent antibody, ELISA or PCR. Tetracycline ointment topically is combined with oral erythromycin – the oral antibiotic is to prevent relapse after ointment is discontinued and to prevent progression to pneumonia. Gonococcal conjunctivitis presents earlier than chlamydial disease (usually within 2 days), is diagnosed on gram stain and culture and should be treated with IV penicillin and chloramphenicol eye drops. Don’t forget sexual health screening for the mother and informing public health of ophthalmia neonatorum. Adenovirus causes conjunctivitis in summer outbreaks; enterovirus, coxsackie and herpes simplex are other viral causes. 15) Concerning blood flow in the fetus:A. Blood flow from right to left through the foramen ovale B. Blood in the ascending aorta has higher oxygen content than in the descending aorta C. The ductus arteriosus is closed D. Pulmonary pressure equal systemic pressure E. Hemoglobin may be 20 gm/dl Ans:-ABE 16) -In a healthy baby the transition from fetal to neonatal circulation involves:A. Functional closure of the foramen ovale in the first 24 hours

CHILDREN HOSPITAL –BENGHAZI

ABDULRAHMAN BASHIR

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B. C. D. E.

Blood flow in the ductus arteriosus continues from right to left until its closure Decrease in pulmonary artery resistance following closure of the ductus arteriosus The ductus arteriosus closes in response to decreased oxygen concentrations The umbilical artery is a branch of the common iliac artery Ans:- A Functional closure of the ductus arteriosus occurs soon after birth but anatomical closure can take upto one week. As pulmonary pressures fall after birth, blood flow in the ductus is reversed ie from left to right. The umbilical artery is a branch of the internal iliac artery. Factors influencing closure of the ductus include:1. Increased oxygen concentrations 2. Decreased prostaglandin levels 3. Drop in pulmonary artery pressures N.B. Prostaglandin E2 keeps the ductus open. 17) A 10-day old male presents with bilious emesis. What is the most likely diagnosis? A. Appendicitis B. Pyloric stenosis C. Malrotation with midgut volvulus D. Feeding intolerance Ans:- C 18) A term newborn is delivered by emergent cesarean section because of intrauterine growth restriction, oligohydramnios, and nonreassuring fetal heart rate monitoring in labor. Delivery room resuscitation includes endotracheal intubation and assisted ventilation with 100% oxygen, chest compressions, intravenous epinephrine, and volume expansion. Apgar scores are 1, 2, and 3 at 1, 5, and 10 minutes, respectively. An umbilical cord arterial blood gas measurement documents a pH of 6.9 and a base deficit of 20 mmol/L. At 12 hours of age, the infant demonstrates tonic-clonic convulsive activity of the arms and legs with a concomitant decrease in heart rate and bedside pulse oximetry saturation. Of the following, the MOST likely cause for this infant's seizure is:A.Hypercalcemia. B. Hypercarbia. C. Hyperglycemia. D.Hypomagnesemia. E. Hypoxia. Preferred Response: E Seizures are the most frequent sign of central nervous system injury in the newborn. When seizures occur in a newborn who has depressed neuromotor tone, reflexes, and cardiopulmonary function at birth that requires assisted ventilation, perinatal asphyxia is likely. In this event, Apgar scores typically are depressed to less than 3 at 5 or more minutes after birth, and there is a severely acidotic umbilical cord arterial pH (