A 26-week neonate, now 4 days old and weighing 820 g, is on conventional ventilation. Over the past 12 hours the FiO2 has risen from 0.25 to 0.40 and feeds have been held for abdominal distension. Which assessment finding MOST strongly suggests a hemodynamically significant patent ductus arteriosus?

Bounding pedal pulses, blood pressure 52/22 mm Hg, and an active precordium

Preductal SpO2 of 96% with a postductal SpO2 of 84% on the same FiO2

A harsh holosystolic murmur at the lower left sternal border with normal pulses

Weak brachial pulses, capillary refill of 5 seconds, and mottled extremities

A 2.5 kg term neonate was intubated with a 3.5 mm tube secured at 10.5 cm at the lip. Breath sounds are louder on the right, the left chest rises less, and SpO2 is 84% on FiO2 0.40. Which action is MOST appropriate?

Prepare to withdraw the tube to about 8.5 cm at the lip and reassess

Prepare for needle aspiration of the left chest for a pneumothorax

Advance the tube to 11.5 cm to settle the tip in a midline position

Replace it with a 4.0 mm tube because of a large air leak around it

A 24-week neonate on day 2 of life has a nonhemolyzed potassium of 7.3 mEq/L. The monitor shows tall, peaked T waves and brief runs of widened QRS complexes. Which medication should the nurse prepare to give FIRST?

IV calcium gluconate given slowly with continuous cardiac monitoring

Regular insulin with dextrose infused to shift potassium into the cells

Inhaled albuterol by in-line nebulizer through the endotracheal tube

Rectal sodium polystyrene sulfonate to increase potassium excretion

A 27-week neonate is about to be delivered. The delivery room is 24 °C and the radiant warmer is preheated. Which additional thermal intervention is MOST appropriate at birth?

Place the infant, without drying the body, into a polyethylene bag or wrap on a thermal mattress

Bathe the infant in warm water to remove vernix before placing under the radiant warmer

Dry the infant thoroughly with warm towels and then swaddle in two prewarmed cotton blankets

Place the infant skin-to-skin on the mother's chest and cover both with warmed blankets

A 1 kg neonate has a new order for morphine 1 mg IV every 4 hours for pain. The nurse calls the resident, who says, "That's what I meant, just give it." Which action should the nurse take NEXT?

Withhold the dose and escalate the concern to the charge nurse and attending

Give the dose as ordered and document the resident's verbal confirmation

Ask the pharmacist to dispense the dose so that pharmacy shares the decision

Give half of the ordered dose and monitor the infant closely for apnea

A term neonate has SpO2 of 62% in both the right hand and a foot at 2 hours of age despite an alprostadil infusion and FiO2 1.0. There is no murmur, and the echocardiogram shows d-transposition of the great arteries with an intact ventricular septum and a restrictive foramen ovale. Arterial pH is 7.12 and lactate is 8 mmol/L. Which intervention should the nurse prepare for?

Urgent balloon atrial septostomy to improve atrial-level mixing

Stopping the alprostadil to reduce excess pulmonary blood flow

Emergency arterial switch operation within the first hour of life

Hyperventilation to a PaCO2 of 25 mm Hg to dilate the pulmonary bed

A 38-week neonate is apneic after initial steps, and face-mask positive-pressure ventilation was started at 30 seconds of age. After 15 seconds, the heart rate remains 70/min, the chest is not moving, and the pulse oximeter has not yet picked up a signal. Which action should the team take FIRST?

Reapply the mask to improve the seal and reposition the head and neck

Raise the inflation pressure to 40 cm H2O for the next several breaths

Give epinephrine through an emergency umbilical venous catheter

Begin chest compressions coordinated at a 3:1 ratio with ventilation

A 2-week-old former 35-week neonate is being treated for GBS meningitis. Over 24 hours the infant has gained 110 g and urine output has fallen to 0.7 mL/kg/h. There are no seizures, and perfusion is normal. The laboratory results are listed. Test Result Serum sodium 125 mEq/L Serum osmolality 262 mOsm/kg Urine osmolality 470 mOsm/kg Urine sodium 48 mEq/L Based on the data, which order should the nurse anticipate?

Restrict total fluid intake and monitor serum sodium and weight closely

Give a 10 mL/kg normal saline bolus to treat sodium depletion and hypovolemia

Give 3% saline as a rapid bolus to raise the sodium by 10 mEq/L in 2 hours

Increase the IV fluid rate to improve urine output and dilute the urine

A well-appearing 35-week, 2,300 g neonate is given a tub bath at 6 hours of age. One hour later the axillary temperature is 35.7 °C, respiratory rate is 72/min, and point-of-care glucose is 36 mg/dL. Which mechanism BEST explains these findings?

Cold stress increasing oxygen and glucose use through nonshivering brown fat thermogenesis

Hyperinsulinism from maternal diabetes, which lowers the glucose and then the temperature

Shivering thermogenesis using muscle glycogen, which depletes the infant's glucose supply

Transient tachypnea of the newborn that increases the work of breathing and caloric needs

A NICU nurse sees that a coworker has posted a photo on her personal social media of herself holding a NICU infant, with the caption "Our little fighter is finally off the vent!" The infant's face is visible. Which action is MOST appropriate?

Ask the coworker to remove the post right away and report it per the privacy policy

Do nothing, because the post leaves out the infant's name and shares good news

Comment on the post to remind the coworker that the parents may not approve of it

Tell the infant's parents about the post so that they can decide what should be done

Neonatal CCRN Exam

Free Neonatal CCRN Practice Questions

10 sample questions for the Neonatal CCRN Exam, with the correct answer and an explanation for each. No account needed. Try each one before you open the answer.

Sections covered on the exam: Cardiovascular, Respiratory, Endocrine and Metabolic Disorders, Hematology and Immunology, Gastrointestinal Disorders and Nutrition, Renal and Genitourinary, Integumentary, Neurological and Musculoskeletal, Multisystem I: Thermoregulation, Sepsis, Shock, Fluids and Hyperbilirubinemia, Multisystem II: Genetics, Maternal Factors and Special Conditions, Professional Caring and Ethical Practice.

Question 1 · Cardiovascular
A 26-week neonate, now 4 days old and weighing 820 g, is on conventional ventilation. Over the past 12 hours the FiO2 has risen from 0.25 to 0.40 and feeds have been held for abdominal distension. Which assessment finding MOST strongly suggests a hemodynamically significant patent ductus arteriosus?
- A.Bounding pedal pulses, blood pressure 52/22 mm Hg, and an active precordium
- B.Preductal SpO2 of 96% with a postductal SpO2 of 84% on the same FiO2
- C.A harsh holosystolic murmur at the lower left sternal border with normal pulses
- D.Weak brachial pulses, capillary refill of 5 seconds, and mottled extremities
Show answer and explanation
Answer: A. Bounding pedal pulses, blood pressure 52/22 mm Hg, and an active precordium
A large left-to-right ductal shunt steals diastolic flow, producing bounding pulses, a low diastolic pressure with a wide pulse pressure (30 mm Hg here), and a hyperdynamic precordium, along with rising ventilator needs. Weak pulses and slow refill point to low cardiac output, while a pre-to-postductal saturation gap reflects right-to-left ductal shunting as in PPHN.
Question 2 · Respiratory
A 2.5 kg term neonate was intubated with a 3.5 mm tube secured at 10.5 cm at the lip. Breath sounds are louder on the right, the left chest rises less, and SpO2 is 84% on FiO2 0.40. Which action is MOST appropriate?
- A.Prepare for needle aspiration of the left chest for a pneumothorax
- B.Prepare to withdraw the tube to about 8.5 cm at the lip and reassess
- C.Advance the tube to 11.5 cm to settle the tip in a midline position
- D.Replace it with a 4.0 mm tube because of a large air leak around it
Show answer and explanation
Answer: B. Prepare to withdraw the tube to about 8.5 cm at the lip and reassess
The estimated tip-to-lip depth is weight in kilograms plus 6 cm, so 2.5 + 6 = 8.5 cm. At 10.5 cm the tube has likely entered the right mainstem bronchus, causing louder right breath sounds and poor left expansion; withdrawing it to the estimated depth and confirming placement is appropriate. A pneumothorax is less likely given the excessive insertion depth.
Question 3 · Renal and Genitourinary
A 24-week neonate on day 2 of life has a nonhemolyzed potassium of 7.3 mEq/L. The monitor shows tall, peaked T waves and brief runs of widened QRS complexes. Which medication should the nurse prepare to give FIRST?
- A.Regular insulin with dextrose infused to shift potassium into the cells
- B.Inhaled albuterol by in-line nebulizer through the endotracheal tube
- C.IV calcium gluconate given slowly with continuous cardiac monitoring
- D.Rectal sodium polystyrene sulfonate to increase potassium excretion
Show answer and explanation
Answer: C. IV calcium gluconate given slowly with continuous cardiac monitoring
ELBW infants can develop non-oliguric hyperkalemia in the first days of life, and ECG changes such as peaked T waves and QRS widening signal risk of a lethal dysrhythmia. Calcium gluconate stabilizes the cardiac cell membrane within minutes and is the first drug when ECG changes are present. Insulin with dextrose and albuterol shift potassium afterward, and sodium polystyrene resin is generally avoided in extremely preterm infants because of bowel injury risk.
Question 4 · Multisystem I: Thermoregulation, Sepsis, Shock, Fluids and Hyperbilirubinemia
A 27-week neonate is about to be delivered. The delivery room is 24 °C and the radiant warmer is preheated. Which additional thermal intervention is MOST appropriate at birth?
- A.Bathe the infant in warm water to remove vernix before placing under the radiant warmer
- B.Dry the infant thoroughly with warm towels and then swaddle in two prewarmed cotton blankets
- C.Place the infant, without drying the body, into a polyethylene bag or wrap on a thermal mattress
- D.Place the infant skin-to-skin on the mother's chest and cover both with warmed blankets
Show answer and explanation
Answer: C. Place the infant, without drying the body, into a polyethylene bag or wrap on a thermal mattress
For infants under about 32 weeks, NRP recommends a warm room (about 23 to 25 °C), a preheated radiant warmer, and placing the infant without drying the body into polyethylene wrap or a bag, often with a thermal mattress and a hat. The plastic sharply reduces evaporative loss through very thin skin while allowing access for resuscitation. Drying and swaddling impair access and are less effective for extremely preterm infants, skin-to-skin is not appropriate for a 27-week infant needing stabilization, and bathing increases heat loss.
Question 5 · Professional Caring and Ethical Practice
A 1 kg neonate has a new order for morphine 1 mg IV every 4 hours for pain. The nurse calls the resident, who says, "That's what I meant, just give it." Which action should the nurse take NEXT?
- A.Withhold the dose and escalate the concern to the charge nurse and attending
- B.Give the dose as ordered and document the resident's verbal confirmation
- C.Ask the pharmacist to dispense the dose so that pharmacy shares the decision
- D.Give half of the ordered dose and monitor the infant closely for apnea
Show answer and explanation
Answer: A. Withhold the dose and escalate the concern to the charge nurse and attending
A typical neonatal morphine dose is about 0.05-0.1 mg/kg, so 1 mg/kg is a roughly tenfold error; when the prescriber does not correct it, the nurse withholds the drug and uses the chain of command. Altering the dose independently is practicing outside scope, and documenting confirmation does not make an unsafe dose safe. Shifting responsibility to pharmacy does not meet the nurse's own duty under the ANA Code of Ethics.
Question 6 · Cardiovascular
A term neonate has SpO2 of 62% in both the right hand and a foot at 2 hours of age despite an alprostadil infusion and FiO2 1.0. There is no murmur, and the echocardiogram shows d-transposition of the great arteries with an intact ventricular septum and a restrictive foramen ovale. Arterial pH is 7.12 and lactate is 8 mmol/L. Which intervention should the nurse prepare for?
- A.Stopping the alprostadil to reduce excess pulmonary blood flow
- B.Urgent balloon atrial septostomy to improve atrial-level mixing
- C.Emergency arterial switch operation within the first hour of life
- D.Hyperventilation to a PaCO2 of 25 mm Hg to dilate the pulmonary bed
Show answer and explanation
Answer: B. Urgent balloon atrial septostomy to improve atrial-level mixing
In d-TGA the systemic and pulmonary circulations run in parallel, so survival depends on mixing; with an intact septum and a restrictive foramen ovale, keeping the ductus open is not enough. Balloon atrial septostomy enlarges the atrial communication and is the urgent step. The arterial switch is done electively in the first weeks once the infant is stable, and stopping alprostadil would worsen mixing.
Question 7 · Respiratory
A 38-week neonate is apneic after initial steps, and face-mask positive-pressure ventilation was started at 30 seconds of age. After 15 seconds, the heart rate remains 70/min, the chest is not moving, and the pulse oximeter has not yet picked up a signal. Which action should the team take FIRST?
- A.Raise the inflation pressure to 40 cm H2O for the next several breaths
- B.Give epinephrine through an emergency umbilical venous catheter
- C.Begin chest compressions coordinated at a 3:1 ratio with ventilation
- D.Reapply the mask to improve the seal and reposition the head and neck
Show answer and explanation
Answer: D. Reapply the mask to improve the seal and reposition the head and neck
When the chest is not moving, NRP directs the ventilation corrective steps in order, beginning with mask adjustment and head repositioning, then suctioning, opening the mouth, increasing pressure gradually, and an alternative airway. Compressions and epinephrine are indicated only when the heart rate stays below 60/min after effective ventilation. Jumping to high pressure skips simpler fixes and risks air leak.
Question 8 · Renal and Genitourinary
A 2-week-old former 35-week neonate is being treated for GBS meningitis. Over 24 hours the infant has gained 110 g and urine output has fallen to 0.7 mL/kg/h. There are no seizures, and perfusion is normal. The laboratory results are listed.
Test Result
Serum sodium 125 mEq/L
Serum osmolality 262 mOsm/kg
Urine osmolality 470 mOsm/kg
Urine sodium 48 mEq/L
Based on the data, which order should the nurse anticipate?
- A.Give a 10 mL/kg normal saline bolus to treat sodium depletion and hypovolemia
- B.Give 3% saline as a rapid bolus to raise the sodium by 10 mEq/L in 2 hours
- C.Restrict total fluid intake and monitor serum sodium and weight closely
- D.Increase the IV fluid rate to improve urine output and dilute the urine
Show answer and explanation
Answer: C. Restrict total fluid intake and monitor serum sodium and weight closely
Hyponatremia with low serum osmolality, inappropriately concentrated urine, low urine output and weight gain in an infant with meningitis indicates SIADH. Free water excess, not sodium loss, is the problem, so fluid restriction is the primary treatment, with close sodium and weight monitoring. Hypertonic saline is reserved for severe symptomatic hyponatremia such as seizures and is given cautiously, while extra fluid or saline boluses worsen water retention.
Question 9 · Multisystem I: Thermoregulation, Sepsis, Shock, Fluids and Hyperbilirubinemia
A well-appearing 35-week, 2,300 g neonate is given a tub bath at 6 hours of age. One hour later the axillary temperature is 35.7 °C, respiratory rate is 72/min, and point-of-care glucose is 36 mg/dL. Which mechanism BEST explains these findings?
- A.Hyperinsulinism from maternal diabetes, which lowers the glucose and then the temperature
- B.Cold stress increasing oxygen and glucose use through nonshivering brown fat thermogenesis
- C.Shivering thermogenesis using muscle glycogen, which depletes the infant's glucose supply
- D.Transient tachypnea of the newborn that increases the work of breathing and caloric needs
Show answer and explanation
Answer: B. Cold stress increasing oxygen and glucose use through nonshivering brown fat thermogenesis
Newborns respond to cold mainly through nonshivering thermogenesis in brown fat, which raises oxygen consumption and glucose use and can lead to tachypnea, hypoglycemia and, if prolonged, metabolic acidosis. A late preterm infant has limited brown fat and glycogen stores, so an early bath can trigger this cascade. Neonates do not shiver effectively, and the clear temporal link to the bath in a previously well infant points to cold stress rather than hyperinsulinism or a primary lung problem; rewarming and glucose treatment follow.
Question 10 · Professional Caring and Ethical Practice
A NICU nurse sees that a coworker has posted a photo on her personal social media of herself holding a NICU infant, with the caption "Our little fighter is finally off the vent!" The infant's face is visible. Which action is MOST appropriate?
- A.Do nothing, because the post leaves out the infant's name and shares good news
- B.Comment on the post to remind the coworker that the parents may not approve of it
- C.Ask the coworker to remove the post right away and report it per the privacy policy
- D.Tell the infant's parents about the post so that they can decide what should be done
Show answer and explanation
Answer: C. Ask the coworker to remove the post right away and report it per the privacy policy
Posting an identifiable patient photo without authorization violates privacy regulations and professional standards even without a name, so the nurse addresses it directly and reports it according to policy. Public comments spread the post further, and ignoring it accepts a breach. Informing the family is handled through the organization's disclosure process, not by the individual nurse.

Test	Result
Serum sodium	125 mEq/L
Serum osmolality	262 mOsm/kg
Urine osmolality	470 mOsm/kg
Urine sodium	48 mEq/L

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