A 39-week infant is born to a mother with systemic lupus erythematosus who is positive for anti-Ro (SSA) antibodies. Fetal bradycardia was noted on the last prenatal visit. The infant is pink and well perfused with a steady heart rate of 58/min that does not change with stimulation. Which study should the NNP order FIRST to confirm the MOST likely diagnosis?

A 12-lead electrocardiogram to look for complete atrioventricular block

A serum potassium and calcium level to look for an electrolyte disorder

A blood culture and CBC to evaluate for early-onset bacterial sepsis

A 35-week infant is breathing but has labored respirations and receives CPAP with 21% oxygen. At 3 minutes of age the heart rate is 150/min and the right-hand preductal SpO2 is 72%. What is the MOST appropriate action regarding oxygen?

Continue 21% oxygen because the saturation is within the target range

Increase the oxygen to 40% because the saturation is below the 85% goal

Increase the oxygen to 100% until the saturation exceeds 90%

A mother in a stable buprenorphine treatment program has negative urine toxicology at delivery, is HIV negative, and asks whether she can breastfeed her term infant. What is the MOST appropriate counseling?

Encourage breastfeeding, which may lessen the infant's withdrawal signs

Advise formula, since buprenorphine in breast milk often causes infant apnea

Allow breastfeeding only after any infant opioid treatment ends

A 6-week-old born at 39 weeks has had intermittent high-pitched inspiratory noise since 2 weeks of age. It is louder when supine, crying or feeding and quieter when prone. He is gaining weight well and has no apnea, cyanosis or feeding difficulty. What is the MOST likely diagnosis and plan?

Laryngomalacia; reassure, monitor growth, and give return precautions

Subglottic stenosis; refer for urgent airway reconstruction surgery

Vascular ring; obtain chest CT angiography this week

A 60-hour-old term male of Greek ancestry has a TSB of 17.8 mg/dL (304 µmol/L). Mother and infant are both blood type A positive, and the DAT is negative. The hemoglobin is 12.9 g/dL, the reticulocyte count is 6%, and the smear shows bite and blister cells without spherocytes. What is the MOST appropriate next diagnostic test?

Quantitative glucose-6-phosphate dehydrogenase enzyme assay

Kleihauer-Betke test on a maternal blood sample for fetal cells

Osmotic fragility or eosin-5-maleimide binding test for spherocytosis

A pregnant woman with anti-D alloimmunization has a titer of 1:64. At 27 weeks, Doppler ultrasound shows a middle cerebral artery peak systolic velocity of 1.7 multiples of the median, and the fetus has early ascites. What is the MOST appropriate next step in fetal management?

Cordocentesis with intrauterine red cell transfusion if anemia is confirmed

Repeat the MCA Doppler study in 2 weeks and plan delivery at 37 weeks

Immediate delivery followed by double-volume exchange transfusion

A 38-week infant with a prenatally diagnosed left congenital diaphragmatic hernia is born with poor respiratory effort. Which delivery room management is MOST appropriate?

Intubate promptly and place a gastric tube to decompress the bowel

Provide nasal CPAP and place a gastric tube to decompress the bowel

Begin mask ventilation and prepare for elective intubation if needed

A former 25-week infant with bronchopulmonary dysplasia, now 38 weeks postmenstrual age, has received furosemide 1 mg/kg daily for 6 weeks. Renal ultrasound shows bilateral medullary nephrocalcinosis, and the urine calcium-to-creatinine ratio is high. What is the MOST appropriate change?

Stop furosemide and use chlorothiazide if diuresis is still needed

Continue furosemide and add oral calcium to replace the urine losses

Switch to bumetanide, which avoids urinary calcium wasting

A 3-day-old term male is still oozing blood from his circumcision site 10 hours after the procedure despite pressure dressings. He is otherwise well, and a maternal uncle has a bleeding disorder. The coagulation results are listed in the following lines. PT 13.1 seconds (normal for age) PTT 96 seconds (prolonged) Platelets 258,000/mm3 Fibrinogen 245 mg/dL What is the MOST appropriate next step in evaluation?

Factor VIII and IX activity levels and a head ultrasound

Von Willebrand panel only, as it is the most common cause

IV vitamin K and a repeat PT in 4 hours as the evaluation

Neonatal Nurse Practitioner Exam

Free Neonatal NP Practice Questions

10 sample questions for the Neonatal Nurse Practitioner 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: Maternal History and Fetal Assessment, Neurological, Family Integration and Discharge Planning, Thermoregulation, Resuscitation and Stabilization, Growth, Nutrition, Fluids and Electrolytes, Pharmacology, Endocrine and Metabolic, Hematopoietic and Hyperbilirubinemia, Musculoskeletal, Integumentary and EENT, Renal and Genitourinary.

Question 1 · Maternal History and Fetal Assessment
A 39-week infant is born to a mother with systemic lupus erythematosus who is positive for anti-Ro (SSA) antibodies. Fetal bradycardia was noted on the last prenatal visit. The infant is pink and well perfused with a steady heart rate of 58/min that does not change with stimulation. Which study should the NNP order FIRST to confirm the MOST likely diagnosis?
- A.A serum potassium and calcium level to look for an electrolyte disorder
- B.A blood culture and CBC to evaluate for early-onset bacterial sepsis
- C.A 12-lead electrocardiogram to look for complete atrioventricular block
Show answer and explanation
Answer: C. A 12-lead electrocardiogram to look for complete atrioventricular block
Maternal anti-Ro/La antibodies cross the placenta and damage the fetal conduction system, causing congenital complete heart block, which presents as a fixed slow rate in a well-appearing infant. An ECG showing AV dissociation confirms it, and an echocardiogram then checks function and structure. Sepsis and electrolyte disorders can cause bradycardia, but they would not explain a fixed rate that was already present before birth in a lupus pregnancy.
Question 2 · Thermoregulation, Resuscitation and Stabilization
A 35-week infant is breathing but has labored respirations and receives CPAP with 21% oxygen. At 3 minutes of age the heart rate is 150/min and the right-hand preductal SpO2 is 72%. What is the MOST appropriate action regarding oxygen?
- A.Continue 21% oxygen because the saturation is within the target range
- B.Increase the oxygen to 40% because the saturation is below the 85% goal
- C.Increase the oxygen to 100% until the saturation exceeds 90%
Show answer and explanation
Answer: A. Continue 21% oxygen because the saturation is within the target range
The NRP preductal SpO2 target at 3 minutes is 70% to 75%, so 72% is appropriate and the inspired oxygen should not be raised. Targets rise gradually to 80% to 85% at 5 minutes and 85% to 95% at 10 minutes, mirroring normal transition. Raising oxygen to chase a premature target of 85% or 90% exposes the infant to unnecessary hyperoxia and oxidative injury.
Question 3 · Neurological
A mother in a stable buprenorphine treatment program has negative urine toxicology at delivery, is HIV negative, and asks whether she can breastfeed her term infant. What is the MOST appropriate counseling?
- A.Advise formula, since buprenorphine in breast milk often causes infant apnea
- B.Allow breastfeeding only after any infant opioid treatment ends
- C.Encourage breastfeeding, which may lessen the infant's withdrawal signs
Show answer and explanation
Answer: C. Encourage breastfeeding, which may lessen the infant's withdrawal signs
Buprenorphine and methadone transfer into milk in small amounts, and breastfeeding is encouraged for mothers stable in treatment without other contraindications; it is associated with milder withdrawal and shorter hospital stays. Clinically significant respiratory depression from milk exposure is not expected. Delaying breastfeeding removes a benefit to the infant.
Question 4 · Pharmacology
A 6-week-old born at 39 weeks has had intermittent high-pitched inspiratory noise since 2 weeks of age. It is louder when supine, crying or feeding and quieter when prone. He is gaining weight well and has no apnea, cyanosis or feeding difficulty. What is the MOST likely diagnosis and plan?
- A.Subglottic stenosis; refer for urgent airway reconstruction surgery
- B.Vascular ring; obtain chest CT angiography this week
- C.Laryngomalacia; reassure, monitor growth, and give return precautions
Show answer and explanation
Answer: C. Laryngomalacia; reassure, monitor growth, and give return precautions
Laryngomalacia is the most common cause of neonatal stridor; it is inspiratory, begins in the first weeks, worsens supine and with feeding or agitation, and usually resolves by 12 to 18 months. With good growth and no apnea or cyanosis, observation is appropriate, and severe features would prompt ENT referral for possible supraglottoplasty. Subglottic stenosis usually follows intubation and causes biphasic stridor, and a vascular ring typically gives expiratory or biphasic noise with feeding problems.
Question 5 · Hematopoietic and Hyperbilirubinemia
A 60-hour-old term male of Greek ancestry has a TSB of 17.8 mg/dL (304 µmol/L). Mother and infant are both blood type A positive, and the DAT is negative. The hemoglobin is 12.9 g/dL, the reticulocyte count is 6%, and the smear shows bite and blister cells without spherocytes. What is the MOST appropriate next diagnostic test?
- A.Quantitative glucose-6-phosphate dehydrogenase enzyme assay
- B.Kleihauer-Betke test on a maternal blood sample for fetal cells
- C.Osmotic fragility or eosin-5-maleimide binding test for spherocytosis
Show answer and explanation
Answer: A. Quantitative glucose-6-phosphate dehydrogenase enzyme assay
DAT-negative hemolysis in a male of Mediterranean ancestry with bite and blister cells on the smear points to G6PD deficiency, a neurotoxicity risk factor under the current AAP guideline that lowers phototherapy thresholds. A quantitative G6PD assay is the test, with a repeat at about 3 months if normal during active hemolysis because the high reticulocyte count can raise the measured activity. Spherocytosis testing fits a smear with spherocytes, and a Kleihauer-Betke test evaluates fetomaternal hemorrhage, which causes anemia rather than hemolytic jaundice.
Question 6 · Maternal History and Fetal Assessment
A pregnant woman with anti-D alloimmunization has a titer of 1:64. At 27 weeks, Doppler ultrasound shows a middle cerebral artery peak systolic velocity of 1.7 multiples of the median, and the fetus has early ascites. What is the MOST appropriate next step in fetal management?
- A.Repeat the MCA Doppler study in 2 weeks and plan delivery at 37 weeks
- B.Cordocentesis with intrauterine red cell transfusion if anemia is confirmed
- C.Immediate delivery followed by double-volume exchange transfusion
Show answer and explanation
Answer: B. Cordocentesis with intrauterine red cell transfusion if anemia is confirmed
An MCA peak systolic velocity above 1.5 MoM predicts moderate to severe fetal anemia, and early ascites signals evolving hydrops. Fetal blood sampling with intrauterine transfusion of O-negative, irradiated, CMV-safe red cells is the treatment of choice at this gestational age. Waiting 2 weeks risks fetal death from hydrops, and delivery at 27 weeks adds the risks of extreme prematurity when the anemia can be treated in utero.
Question 7 · Thermoregulation, Resuscitation and Stabilization
A 38-week infant with a prenatally diagnosed left congenital diaphragmatic hernia is born with poor respiratory effort. Which delivery room management is MOST appropriate?
- A.Provide nasal CPAP and place a gastric tube to decompress the bowel
- B.Intubate promptly and place a gastric tube to decompress the bowel
- C.Begin mask ventilation and prepare for elective intubation if needed
Show answer and explanation
Answer: B. Intubate promptly and place a gastric tube to decompress the bowel
In congenital diaphragmatic hernia, bag-mask ventilation and CPAP push gas into the intrathoracic bowel and further compress the lungs, so the infant is intubated promptly and a gastric tube is placed to decompress the stomach and intestines. Ventilation then uses gentle pressures with preductal saturation targets and permissive hypercapnia. Mask ventilation and CPAP are the specific approaches to avoid.
Question 8 · Neurological
A former 25-week infant with bronchopulmonary dysplasia, now 38 weeks postmenstrual age, has received furosemide 1 mg/kg daily for 6 weeks. Renal ultrasound shows bilateral medullary nephrocalcinosis, and the urine calcium-to-creatinine ratio is high. What is the MOST appropriate change?
- A.Stop furosemide and use chlorothiazide if diuresis is still needed
- B.Continue furosemide and add oral calcium to replace the urine losses
- C.Switch to bumetanide, which avoids urinary calcium wasting
Show answer and explanation
Answer: A. Stop furosemide and use chlorothiazide if diuresis is still needed
Loop diuretics increase urinary calcium excretion and cause hypercalciuria and nephrocalcinosis with prolonged use. Thiazides such as chlorothiazide reduce urinary calcium loss, so they are preferred when ongoing diuresis is needed in BPD, often with potassium monitoring and sometimes spironolactone. Adding calcium increases the urinary calcium load, and bumetanide is also a loop diuretic with the same effect.
Question 9 · Pharmacology
A 4,300 g term infant born after a shoulder dystocia has a right Erb palsy and persistent tachypnea. The chest film shows an elevated right hemidiaphragm, and ultrasound shows paradoxical upward motion of the right hemidiaphragm during inspiration. What is the MOST likely diagnosis?
- A.Congenital eventration
- B.Right phrenic nerve palsy
- C.Right Bochdalek hernia
Show answer and explanation
Answer: B. Right phrenic nerve palsy
Traction injury to the C3 to C5 roots during a difficult delivery can injure the phrenic nerve along with the upper brachial plexus, producing an elevated, paradoxically moving hemidiaphragm on the same side as the Erb palsy. A Bochdalek hernia shows bowel segments in the chest, not just an elevated diaphragm. Eventration is a congenital thinning of the muscle without the birth-injury history and associated plexus palsy.
Question 10 · Hematopoietic and Hyperbilirubinemia
A 3-day-old term male is still oozing blood from his circumcision site 10 hours after the procedure despite pressure dressings. He is otherwise well, and a maternal uncle has a bleeding disorder. The coagulation results are listed in the following lines.
PT 13.1 seconds (normal for age)
PTT 96 seconds (prolonged)
Platelets 258,000/mm3
Fibrinogen 245 mg/dL
What is the MOST appropriate next step in evaluation?
- A.Factor VIII and IX activity levels and a head ultrasound
- B.Von Willebrand panel only, as it is the most common cause
- C.IV vitamin K and a repeat PT in 4 hours as the evaluation
Show answer and explanation
Answer: A. Factor VIII and IX activity levels and a head ultrasound
An isolated prolonged PTT with normal PT, platelets, and fibrinogen in a bleeding male with an affected maternal relative suggests X-linked hemophilia A or B, so factor VIII and IX activity should be measured, with a head ultrasound because of the risk of intracranial hemorrhage. Factor VIII is reliable at birth, while mildly low factor IX may need repeat testing. Vitamin K deficiency prolongs the PT first, and von Willebrand factor is physiologically elevated in newborns, making that diagnosis less likely and harder to confirm now.

PT	13.1 seconds (normal for age)
PTT	96 seconds (prolonged)
Platelets	258,000/mm3
Fibrinogen	245 mg/dL

Keep practicing for the Neonatal NP

TTP Prep has 200 Neonatal NP practice questions with explanations, timed and mock-exam modes, 591 flashcards, interactive lessons, a printable cheat sheet and a readiness score. Start free, no card needed.

Take a free Quick 10 See everything in the Neonatal NP prep