Neonatal Pediatric Specialist (NPS)
Exam Study Guide – Practice
Exam – Questions and Correct
Answer
Question 1:
A 34-week gestation neonate, born 6 hours ago, develops
worsening respiratory distress. Blood gas: pH 7.20, PaCO2 68
mmHg, PaO2 55 mmHg, HCO3 22. Chest X-ray shows diffuse
ground-glass opacities and air bronchograms. What is the MOST
appropriate next step?
A) Administer prophylactic surfactant via endotracheal tube
B) Increase nasal CPAP to 8 cm H2O
C) Intubate and administer surfactant replacement therapy
D) Trial of high-flow nasal cannula at 4 L/min
Correct Answer: C – Intubate and administer surfactant
replacement therapy
*Rationale: The blood gas shows hypercapnia, hypoxemia, and
acidosis (respiratory acidosis) despite being on some support
(likely CPAP or oxygen). The CXR is classic for RDS. Current
NRP/neonatal guidelines recommend intubation and surfactant
administration for infants with RDS and evidence of respiratory
failure (PaO2 <50-60, PaCO2 >60, or severe work of breathing).
CPAP alone is insufficient here.*
,Question 2:
A 2-day-old term infant is post-op from repair of a
tracheoesophageal fistula. The infant is intubated and receiving
volume-controlled ventilation. Suddenly, the peak inspiratory
pressure (PIP) drops from 22 to 12 cm H2O, tidal volume drops
from 5.5 to 1.5 mL/kg, and there is no breath sound on the left.
The MOST likely cause is:
A) Mainstem intubation into the right bronchus
B) Pneumothorax on the left
C) Mucus plug in the endotracheal tube
D) Disconnection of the ventilator circuit
Correct Answer: A – Mainstem intubation into the right
bronchus
Rationale: A sudden drop in PIP and tidal volume with absent left
breath sounds points to the ET tube migrating into the right main
bronchus. This causes left lung collapse and low exhaled volumes.
Pneumothorax would likely increase PIP and cause hypotension.
Mucus plug would increase PIP. Disconnection would show no
exhaled tidal volume at all and low pressure alarm.
Question 3:
A 3.5 kg neonate with persistent pulmonary hypertension (PPHN)
is on inhaled nitric oxide (iNO) at 20 ppm and high frequency
oscillatory ventilation (HFOV). The PaO2 increases from 45 to 88
,mmHg. Which of the following reflects the CORRECT weaning
strategy for iNO?
A) Weep iNO by 5-10 ppm every 30 minutes until 5 ppm, then
stop
B) Decrease FiO2 first, then wean iNO to 10 ppm, then 5 ppm,
then 1 ppm before discontinuation
C) Discontinue iNO abruptly once PaO2 >80 mmHg to avoid
methemoglobinemia
D) Maintain iNO at 20 ppm for at least 7 days to prevent rebound
Correct Answer: B – Decrease FiO2 first, then wean iNO to 10
ppm, then 5 ppm, then 1 ppm before discontinuation
Rationale: iNO should be weaned gradually in small decrements
(e.g., 5 ppm steps) with close monitoring of oxygenation and FiO2.
The patient should be stable on FiO2 <60% before weaning iNO
below 5 ppm. Abrupt discontinuation can cause rebound
hypoxemia and severe pulmonary hypertension.
Question 4:
A 6-month-old with bronchiolitis is on high-flow nasal cannula
(HFNC) at 12 L/min. The respiratory rate is 72, heart rate 190, and
SpO2 88%. The infant is retracting and grunting. The MOST
appropriate next action is:
A) Increase HFNC to 15 L/min
B) Obtain a chest X-ray
C) Escalate to non-invasive positive pressure ventilation (NIPPV) or
, intubation
D) Administer a nebulized albuterol treatment
Correct Answer: C – Escalate to non-invasive positive pressure
ventilation (NIPPV) or intubation
Rationale: This infant has failed HFNC (persistent hypoxemia,
tachypnea, retractions, grunting). Increasing HFNC further is
unlikely to help. NIPPV (bilevel) or intubation is required. Albuterol
is not first-line for RSV bronchiolitis per AAP guidelines.
Question 5:
Which of the following is the BEST indicator of successful
extubation in a preterm infant recovering from RDS?
A) Minimal oxygen requirement of 35%
B) Tidal volume of 4 mL/kg on spontaneous breaths
C) Negative inspiratory force (NIF) > -40 cm H2O
D) Rapid shallow breathing index (RSBI) < 100
Correct Answer: C – Negative inspiratory force (NIF) > -40 cm
H2O
*Rationale: A NIF (also called maximal inspiratory pressure) more
negative than -30 to -40 cm H2O indicates adequate respiratory
muscle strength and is the best single predictor of extubation
success in neonates. RSBI is used in adults, not validated in
neonates. Tidal volume and FiO2 alone are not sufficient.*
Exam Study Guide – Practice
Exam – Questions and Correct
Answer
Question 1:
A 34-week gestation neonate, born 6 hours ago, develops
worsening respiratory distress. Blood gas: pH 7.20, PaCO2 68
mmHg, PaO2 55 mmHg, HCO3 22. Chest X-ray shows diffuse
ground-glass opacities and air bronchograms. What is the MOST
appropriate next step?
A) Administer prophylactic surfactant via endotracheal tube
B) Increase nasal CPAP to 8 cm H2O
C) Intubate and administer surfactant replacement therapy
D) Trial of high-flow nasal cannula at 4 L/min
Correct Answer: C – Intubate and administer surfactant
replacement therapy
*Rationale: The blood gas shows hypercapnia, hypoxemia, and
acidosis (respiratory acidosis) despite being on some support
(likely CPAP or oxygen). The CXR is classic for RDS. Current
NRP/neonatal guidelines recommend intubation and surfactant
administration for infants with RDS and evidence of respiratory
failure (PaO2 <50-60, PaCO2 >60, or severe work of breathing).
CPAP alone is insufficient here.*
,Question 2:
A 2-day-old term infant is post-op from repair of a
tracheoesophageal fistula. The infant is intubated and receiving
volume-controlled ventilation. Suddenly, the peak inspiratory
pressure (PIP) drops from 22 to 12 cm H2O, tidal volume drops
from 5.5 to 1.5 mL/kg, and there is no breath sound on the left.
The MOST likely cause is:
A) Mainstem intubation into the right bronchus
B) Pneumothorax on the left
C) Mucus plug in the endotracheal tube
D) Disconnection of the ventilator circuit
Correct Answer: A – Mainstem intubation into the right
bronchus
Rationale: A sudden drop in PIP and tidal volume with absent left
breath sounds points to the ET tube migrating into the right main
bronchus. This causes left lung collapse and low exhaled volumes.
Pneumothorax would likely increase PIP and cause hypotension.
Mucus plug would increase PIP. Disconnection would show no
exhaled tidal volume at all and low pressure alarm.
Question 3:
A 3.5 kg neonate with persistent pulmonary hypertension (PPHN)
is on inhaled nitric oxide (iNO) at 20 ppm and high frequency
oscillatory ventilation (HFOV). The PaO2 increases from 45 to 88
,mmHg. Which of the following reflects the CORRECT weaning
strategy for iNO?
A) Weep iNO by 5-10 ppm every 30 minutes until 5 ppm, then
stop
B) Decrease FiO2 first, then wean iNO to 10 ppm, then 5 ppm,
then 1 ppm before discontinuation
C) Discontinue iNO abruptly once PaO2 >80 mmHg to avoid
methemoglobinemia
D) Maintain iNO at 20 ppm for at least 7 days to prevent rebound
Correct Answer: B – Decrease FiO2 first, then wean iNO to 10
ppm, then 5 ppm, then 1 ppm before discontinuation
Rationale: iNO should be weaned gradually in small decrements
(e.g., 5 ppm steps) with close monitoring of oxygenation and FiO2.
The patient should be stable on FiO2 <60% before weaning iNO
below 5 ppm. Abrupt discontinuation can cause rebound
hypoxemia and severe pulmonary hypertension.
Question 4:
A 6-month-old with bronchiolitis is on high-flow nasal cannula
(HFNC) at 12 L/min. The respiratory rate is 72, heart rate 190, and
SpO2 88%. The infant is retracting and grunting. The MOST
appropriate next action is:
A) Increase HFNC to 15 L/min
B) Obtain a chest X-ray
C) Escalate to non-invasive positive pressure ventilation (NIPPV) or
, intubation
D) Administer a nebulized albuterol treatment
Correct Answer: C – Escalate to non-invasive positive pressure
ventilation (NIPPV) or intubation
Rationale: This infant has failed HFNC (persistent hypoxemia,
tachypnea, retractions, grunting). Increasing HFNC further is
unlikely to help. NIPPV (bilevel) or intubation is required. Albuterol
is not first-line for RSV bronchiolitis per AAP guidelines.
Question 5:
Which of the following is the BEST indicator of successful
extubation in a preterm infant recovering from RDS?
A) Minimal oxygen requirement of 35%
B) Tidal volume of 4 mL/kg on spontaneous breaths
C) Negative inspiratory force (NIF) > -40 cm H2O
D) Rapid shallow breathing index (RSBI) < 100
Correct Answer: C – Negative inspiratory force (NIF) > -40 cm
H2O
*Rationale: A NIF (also called maximal inspiratory pressure) more
negative than -30 to -40 cm H2O indicates adequate respiratory
muscle strength and is the best single predictor of extubation
success in neonates. RSBI is used in adults, not validated in
neonates. Tidal volume and FiO2 alone are not sufficient.*
