NICU Exam Questions and Answers: Neonatal Care and Medications, Exams of Nursing

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NICU Basics Exam Questions with Answers Latest Update Term infant - Correct answer 38-42 weeks gestation Moderate to late preterm - Correct answer 32-37 weeks Very preterm - Correct answer 28-32 weeks Extremely preterm - Correct answer <28 weeks Threshold of viability - Correct answer 22-23 weeks Low birth weight - Correct answer <2.5 kg Very low birth weight - Correct answer <1.5 kg Extremely low birth weight - Correct answer <1 kg NICU Classifications: Level I - Correct answer Basic -Well-born nursery -Provide neonatal resuscitation at delivery -Physiologically-stable neonates 35-37 week’s gestation NICU Classifications: Level II - Correct answer Specialty IIA: Resuscitate and stabilize ill infants for transport -Neonates >32 weeks, >/=1.5 kg IIB: Mechanical ventilation <24h OR CPAP NICU Classifications: Level III - Correct answer Subspecialty IIIA: Neonates >28w, >1 kg -Sustained mechanical ventilation -Minor surgical procedures IIIB: Neonates <28w, <1 kg -High frequency ventilation in -Full range of pediatric sub-specialties IIIC: ECMO, surgical repair of complex cardiac malformations that require bypass NICU Clinical Pharmacist Role - Correct answer Centers on being a pharmacotherapy expert -Determining safe and effective medication dosing regimens -Appropriate preparation, storage, and administration of medications -Assuring necessary monitoring parameters followed to ensure efficacy and prevent toxicity -Expert on appropriate indication and patient selections for pharmacotherapeutic interventions Differences in dosing needs throughout spectrum of NICU stay is due to - Correct answer Maturation of the organ systems Maternal factors affecting medications in breast milk - Correct answer Dose and duration of therapy -Low dose, infrequent dosing, short duration -If drug contraindicated, consider "pump and dump" to keep up milk supply Route of Administration -Drugs given IV due to poor PO bioavailability are usually poorly absorbed by infant through milk Drug PK -Drugs with long half-life may result in cumulative exposure to infant Infant factors effecting medications and breast milk - Correct answer Total amount of drug exposure to infant -Concentration in breast milk and volume ingested per day Gestational age and postnatal age determine infant’s ability to absorb, metabolize and excrete drug -Preterm infants are less able to metabolize and excrete drugs due to less mature liver/kidney --> may lead to more drug accumulation Respiratory Distress Syndrome - Correct answer Occurs secondary to pulmonary surfactant deficiency -Alveoli close and fail to reopen -Atelectasis, inflammation, pulmonary edema and eventual pulmonary hemorrhage RDS presentation - Correct answer Difficulty breathing, grunting, tachypnea, retractions, hypoxemia Surfactant is secreted by - Correct answer Type II Alveolar cells Surfactant role - Correct answer Reduces surface tension of alveoli -In deficiency, larger alveoli over-expand to correct for collapse of smaller alveoli Adult brain (GABA) - Correct answer -GABA A receptor binding causes influx of Cal --> decreased excitability Goals of therapy for neonatal seizures - Correct answer -Cessation or minimization of seizure activity -Minimal to no risk of long-term neurotoxicity AED efficacy definition - Correct answer 80% reduction in seizure severity or complete seizure cessation First-line AED in neonatal seizures - Correct answer Phenobarbital Phenobarbital MOA - Correct answer Increases Gambia-mediated inhibition (limited efficacy since Gambia is more likely excitatory in neonates) Phenobarbital monitoring - Correct answer Serum concentrations Phenobarbital concerns - Correct answer -Increased neuronal apoptosis, impaired neurodevelopment -Electro clinical uncoupling -Clinically-relevant DDIs Second line for neonatal seizures - Correct answer Phenytoin Midazolam (2/3) Levetiracetam (2/3) Lidocaine (2/3) Phenytoin MOA - Correct answer Reduces excitatory neurotransmission by blocking voltage-gated NA channels Efficacy of Phenytoin - Correct answer 50% when used in combination with phenobarbital Phenytoin monitoring - Correct answer serum concentrations (free and total) Phenytoin concerns - Correct answer Potential detrimental effect on developing neurons Phenytoin in Hypothermia - Correct answer Clearance is significantly decreased- warrants close monitoring of serum concentrations Midazolam MOA - Correct answer Increase inhibitor neurotransmission via Gambia receptor Midazolam efficacy - Correct answer 50% as second line 73-100% as third line Midazolam concerns - Correct answer -Higher doses can cause cardiac depression -Serum concentrations can build up with decreased hepatic function -BZDs may cause neurodevelopmental impairment, smaller hippocampus region in brain Levetiracetam MOA - Correct answer Thought to work via stabilization of synaptic vesicles to prevent release of neuroexcitatory toxicity Levetiracetam Efficacy - Correct answer 35-64% in first 24 hours 52-100% within 72 hours Third line seizure treatment - Correct answer Topiramate Topiramate MOA - Correct answer Reduces frequency of action potential firing by altering GABA neurotransmission, blocking voltage-gated sodium channels, weakly blocking glutamate receptors Topiramate efficacy - Correct answer 67% Topiramate dosing - Correct answer PO only Topiramate concerns - Correct answer -Well tolerated -Potentially neuroprotective, reduces brain injury in HIE models -Potentially additive neuronal apoptosis when co-administered with phenobarbital Lidocaine MOA - Correct answer Inhibits voltage-gated NA channels preventing depolarization Lidocaine dosing - Correct answer IV only Lidocaine efficacy - Correct answer 78% Lidocaine monitoring - Correct answer Serum concentrations (>9 mg/L= toxic) Neonatal Abstinence Syndrome - Correct answer maternal intake of medications with close proximity to delivery can result in a wide variety of symptoms -Acute, reversible neonatal effects attributed to withdrawal Non-opioids that cause withdrawal behavior - Correct answer Alcohol, barbiturates, caffeine, chlordiazepoxide, clomipramine, diazepam, ethchlorvynol, glutethimide, hydroxyzine, meprobamate Classes that cause withdrawal behavior - Correct answer Opioids, antidepressants, AEDs, barbiturates, benzodiazepines, antipsychotics NAS clinical symptoms - Correct answer -Complex disorder involving GI, central and autonomic nervous system -Great variability in timing, symptoms, severity and duration Clinical features of neurologic excitability - Correct answer Tremors, irritability, increased wakefulness, high-pitched crying, increased muscle tone, hyperactive deep tendon reflexes, exaggerated moor reflex, seizures, frequent yawning and sneezing Clinical features of GI dysfunction - Correct answer poor feeding, uncoordinated and constant sucking, vomiting, diarrhea, dehydration, poor weight gain Clinical features of autonomic nervous system dysfunction - Correct answer Increased sweating, nasal stuffiness, fever, mottling, temperature instability Timing of NAS presentation - Correct answer Heroin: 24-48h Methadone: 72h Buprenorphine: >72h Factors that exacerbate NAS - Correct answer Use of prescriptions opioids during pregnancy in the absence of other risk factors is associated with low absolute risk of NAS Risk factors: -Use >30 d -Alcohol or other drug misuse -Late pregnancy exposure to other psychotropic medications -Smoking Substances that exacerbate NAS - Correct answer SSRIs, BZDs, nicotine Finnegan - Correct answer Assessment tool for NAS (determines severity) Highly subjective, based on clinical judgment NAS in prematurity - Correct answer Apparent decreased severity Non-pharm approaches for NAS - Correct answer -Swaddling, pacifier use, quiet/dim- lit environments -Treating the baby and mother as interactional dyad -Breastfeeding Pharmacologic options for NAS - Correct answer Opioids considered first line -Morphine -Methadone -Buprenorphine (superior to methadone)