Perinatal And Pediatric Respiratory Care 3rd Edition by Brian K. Walsh – Test Bank

Complete Test Bank With Answers

 

 

 

Sample Questions Posted Below

 

 

 

 

Walsh: Perinatal and Pediatric Respiratory Care, 3^rd Edition

 

Chapter 5: Examination and Assessment of the Neonatal Patient

 

Test Bank

 

MULTIPLE CHOICE

 

1. Which of the following factors are taken into consideration when assessing the gestational age of a neonate?
2. Previous maternal pregnancies
3. Prenatal ultrasound evaluations

III. Postnatal findings based on physical and neurologic examinations

1. Gestational duration based on the last menstrual cycle

A.	I and III only
B.	I, II, and III only
C.	I, II, and IV only
D.	II, III, and IV only

 

 

ANS:  D

 

	Feedback
A.	Incorrect response: See explanation D.
B.	Incorrect response: See explanation D.
C.	Incorrect response: See explanation D.
D.	Correct response: Ideally, gestational age assessment is performed before the neonate is 12 hours old, to allow the greatest reliability for infants less than 26 weeks of gestational age. Evaluating gestational age requires consideration of several factors. The three main factors are as follows: • Gestational duration based on the last menstrual cycle • Prenatal ultrasound evaluation • Postnatal findings based on physical and neurologic examinations

 

 

OBJ:   Recall

 

2. The gestational age of a newborn has been evaluated to be 34 weeks. The newborn’s birth weight is greater than the 90th percentile. How should the therapist classify this infant?

A.	Small for gestational age
B.	Average for gestational age
C.	Large for gestational age
D.	Very large for gestational age

 

 

ANS:  C

 

	Feedback
A.	Incorrect response: See explanation C.
B.	Incorrect response: See explanation C.
C.	Correct response: Once gestational age is determined, weight, length, and head circumference are plotted on a standard newborn grid. Any infant whose birth weight is less than the 10th percentile for gestational age is classified as small for gestational age. Similarly, an infant whose birth weight is more than the 90th percentile is large for gestational age. When using intrauterine growth curves, considering specific charts that are race and gender specific may be necessary. Along with prematurity, abnormal gestational age and size for gestational age are associated with many neonatal disease processes.
D.	Incorrect response: See explanation C.

 

 

OBJ:   Application

 

3. An infant arrives in the newborn nursery with an axillary body temperature of 95.6º F. Which of the following events may be responsible for this infant’s temperature?

A.	The neonate was in an infant warmer in the delivery room.
B.	The infant was swaddled in numerous blankets.
C.	The delivery room temperature was low.
D.	The newborn has protracted diarrhea.

 

 

ANS:  C

 

	Feedback
A.	Incorrect response: See explanation C.
B.	Incorrect response: See explanation C.
C.	Correct response: Normal values for temperature are 97.6° F  1° F axillary and 99.6° F  1° F rectally; however, temperature on arrival in the nursery may be lower if the delivery room was cold or may be higher if the radiant warmer was operating at a higher temperature because of incorrect probe position or warmer malfunction.
D.	Incorrect response: See explanation C.

 

 

OBJ:   Application

 

4. A physical examination is being performed on a newborn, and the therapist notices that the infant’s arms do not move symmetrically. Which of the following situations could account for this problem?

A.	An injury to the infant’s brachial plexus may have occurred during birth.
B.	The infant may have been born breach.
C.	The baby was born via cesarean section.
D.	The infant experienced nuchal cords during birth.

 

 

ANS:  A

 

	Feedback
A.	Correct response: Observing the infant’s overall appearance is an important aspect of the physical examination. Ideally, examine the infant lying quietly and unclothed in a neutral thermal environment. Body position and symmetry, both at rest and during muscular activity, provide valuable information regarding possible birth trauma. For example, an infant who does not move the arms symmetrically could have a broken clavicle or an injury to the brachial plexus.
B.	Incorrect response: See explanation A.
C.	Incorrect response: See explanation A.
D.	Incorrect response: See explanation A.

 

 

OBJ:   Application

 

5. The therapist notices that an infant presents with irregular areas of dusky skin alternating with areas of pale skin. On the basis of this observation, which of the following conditions should the therapist anticipate this patient having?

A.	Polycythemia
B.	Hypotension
C.	Situs inversus with dextrocardia
D.	Renal insufficiency

 

 

ANS:  B

 

	Feedback
A.	Incorrect response: See explanation B.
B.	Correct response: Observing skin and color often provides diagnostic clues. Mottling refers to irregular areas of dusky skin alternating with areas of pale skin. An extremely pale or mottled infant suggests hypotension or anemia. Situs inversus, or situs transversus, is a congenital condition in which the major visceral organs are reversed from their normal anatomic positions. The normal arrangement is known as situs solitus. The term situs inversus is a short form of the Latin phrase “situs inversus viscerum,” meaning “inverted position of the internal organs.”
C.	Incorrect response: See explanation B.
D.	Incorrect response: See explanation B.

 

 

OBJ:   Application

 

6. Which of the following neonatal skin presentations at birth is associated with a high hematocrit value or polycythemia and neonatal hyperviscosity syndrome?

A.	Mottling
B.	Lanugo
C.	Reddish blue appearance
D.	Vernix

 

 

ANS:  C

 

	Feedback
A.	Incorrect response: Mottling refers to irregular areas of dusky skin alternating with areas of pale skin. An extremely pale or mottled infant suggests hypotension or anemia.
B.	Incorrect response: The presence of lanugo, the fine hair that covers premature infants mostly over the shoulders, back, forehead, and cheeks, indicates an even younger gestational age than one presenting with vernix.
C.	Correct response: A ruddy, reddish blue appearance is frequently associated with a high hematocrit value, or polycythemia (hematocrit > 65%), and neonatal hyperviscosity syndrome. The yellow color associated with mild to moderate jaundice is common among newborns after the first day of life. Jaundice on the first day of life, however, is always an indication for an immediate evaluation.
D.	Incorrect response: Often a grayish white cheeselike substance, called vernix caseosa, is present in the skin folds of a term infant. However, vernix is even more abundant on a preterm infant and suggests an earlier gestational age.

 

 

OBJ:   Recall

 

7. Why are chest retractions more prominent among neonates than among older children and adults?

A.	Because neonates generate a greater subatmospheric intrapleural pressure.
B.	Because newborns have relatively thin and weak musculature, and a less rigid thorax.
C.	Because neonates have a much higher respiratory rate.
D.	Because airway resistance through the smaller caliber airways is higher.

 

 

ANS:  B

 

	Feedback
A.	Incorrect response: See explanation B.
B.	Correct response: Chest wall retractions are more prominent and easily observed among neonates than in an older children or adults. The newborn musculature is relatively thin and weak, and the thoracic cage is less rigid. The flexible chest wall and thoracic cage of the newborn exhibit noticeable retractions as lung compliance worsens.
C.	Incorrect response: See explanation B.
D.	Incorrect response: See explanation B.

 

 

OBJ:   Recall

 

8. Why is it difficult to localize auscultation findings of the thorax of a newborn?

A.	Because the neonate’s chest is small and sounds are difficult to differentiate.
B.	Because the newborn infant is frequently crying.
C.	Because the neonate’s tidal volume is so small.
D.	Because the newborn’s pulmonary compliance is low.

 

 

ANS:  A

 

	Feedback
A.	Correct response: Auscultation of the newborn can sometimes be difficult. The newborn’s chest wall is small, and sounds easily transmit from one lung region to another. Abdominal sounds may even transmit to the lungs, although bowel sounds heard from the chest in place of absent breath sounds may indicate a diaphragmatic hernia. Localizing auscultation findings in a preterm infant is frequently difficult or impossible with single-head stethoscopes. Auscultation with a double-head stethoscope has proved useful in some situations.
B.	Incorrect response: See explanation A.
C.	Incorrect response: See explanation A.
D.	Incorrect response: See explanation A.

 

 

OBJ:   Recall

 

9. While performing a physical examination on a newborn infant, the therapist notices that the point of maximal cardiac impulse is to the left of the sternal border. Which of the following conditions can cause this situation?

A.	Atelectasis of the right lung
B.	Bilateral pulmonary consolidation
C.	Right-sided pneumothorax
D.	Left mainstem bronchus intubation

 

 

ANS:  C

 

	Feedback
A.	Incorrect response: See explanation C.
B.	Incorrect response: See explanation C.
C.	Correct response: The point of maximal cardiac impulse (PMI) is the position on the chest wall at which the cardiac impulse can be maximally seen. The PMI is usually seen in newborns because of the relatively thin and flexible chest wall. Typically, the PMI is relatively close to the sternal border because of the predominance of the right ventricle in the fetal period. A mediastinal shift due to a pneumothorax will move the PMI away from the affected side (ipsilateral lung) of the chest.
D.	Incorrect response: See explanation C.

 

 

OBJ:   Recall

 

10. Which of the following statements refers to the diagnostic procedure called transillumination?

A.	Place a light source between the surface of the bed and the patient’s back, and orient the patient in a supine position.
B.	Direct a light source toward the ipsilateral surface of the patient’s thorax.
C.	Position a beam of light against a patient’s chest wall in a well-lit room.
D.	Insert a fiberoptic light source down a patient’s endotracheal tube and beyond the tube’s distal tip.

 

 

ANS:  B

 

	Feedback
A.	Incorrect response: See explanation B.
B.	Correct response: With suspected pneumothorax, perform transillumination of the chest wall, using a high-energy flashlight or fiberoptic device in a darkened room. Direct the light source on the chest wall of the suspected (ipsilateral) side. A large pneumothorax will reveal an excessively pink and illuminated, usually irregular area of light, or “glowing” area, through the chest wall when compared with the contralateral side.
C.	Incorrect response: See explanation B.
D.	Incorrect response: See explanation B.

 

 

OBJ:   Recall

 

11. A neonate is found to have a bounding pulse. Which of the following conditions may contribute to this finding?
12. Patent ductus arteriosus
13. Hypoplastic left-sided heart syndrome

III. Coarctation of the aorta

1. Left-to-right shunt

A.	I and II only
B.	I and IV only
C.	II and III only
D.	I, III, and IV only

 

 

ANS:  B

 

	Feedback
A.	Incorrect response: See explanation B.
B.	Correct response: Weak pulses suggest low cardiac output states such as shock and hypoplastic left-sided heart syndrome. Bounding pulses are seen in infants with patent ductus arteriosus and left-to-right shunt. The bounding characteristic of the pulse results from rapid runoff of the blood into the low-resistance pulmonary circulation. This lowers the systolic blood pressure and produces a wider pulse pressure. Brachial and femoral pulses should be equal in intensity and felt simultaneously. A delayed or weak femoral pulse can indicate coarctation of the aorta.
C.	Incorrect response: See explanation B.
D.	Incorrect response: See explanation B.

 

 

OBJ:   Recall

 

12. What condition would be responsible for the therapist observing a pulse oximeter indicating decreased perfusion while central blood pressure remains normal?

A.	Volume depletion with compensatory peripheral vasoconstriction
B.	Hypoplastic left-sided heart syndrome
C.	Hypervolemia with compensatory peripheral vasodilation
D.	Hypoplastic right-sided heart syndrome

 

 

ANS:  A

 

	Feedback
A.	Correct response: A pulse oximeter will display a low pulse rate and perfusion signal as peripheral pulses and perfusion decrease. The cause of this poor perfusion status must be determined. However, if the pulse oximeter suggests decreased perfusion while central blood pressure remains normal, the cause may be volume depletion with compensatory peripheral vasoconstriction.
B.	Incorrect response: See explanation A.
C.	Incorrect response: See explanation A.
D.	Incorrect response: See explanation A.

 

 

OBJ:   Recall

 

13. For the purpose of assessing right-to-left shunting, as in the case of persistent pulmonary hypertension, which of the following sites would render postductal blood?
14. Right arm
15. Left arm

III. Right leg

1. Left leg

A.	I only
B.	II only
C.	I, III, and IV only
D.	II, III, and IV only

 

 

ANS:  D

 

	Feedback
A.	Incorrect response: See explanation D.
B.	Incorrect response: See explanation D.
C.	Incorrect response: See explanation D.
D.	Correct response: When assessing right-to-left shunting, as seen with persistent pulmonary hypertension of the newborn (PPHN), the right arm, or preductal site, will have a higher saturation than the postductal site, or left arm and lower extremities. Postductal blood will have a lower saturation caused by venous admixture. Infants with PPHN have increased pulmonary vascular resistance (PVR) that prevents normal pulmonary blood flow. The increased PVR causes a right-to-left shunting of blood across the patent foramen ovale and patent ductus arteriosus. The diagnosis of PPHN is usually confirmed by echocardiography, along with analysis of blood gas samples from preductal and postductal sites. A simpler method to detect this right-to-left shunting is to use two pulse oximeters and measure preductal and postductal SpO2 (arterial oxygen saturation determined by pulse oximeter). Clinical research has revealed that arterial saturation in the right arm (preductal) of at least 3% above the lower limb (postductal) is evidence of right-to-left ductal shunting.

 

 

OBJ:   Application

 

14. Which of the following conditions can cause abdominal distention?
15. Enterocolitis
16. Ascites

III. Congenital diaphragmatic hernia

1. Omphalocele

A.	I and II only
B.	I, II, and IV only
C.	I, III, and IV only
D.	II, III, and IV only

 

 

ANS:  A

 

	Feedback
A.	Correct response: Distention is a significant finding characterized by tightly drawn skin through which engorged subcutaneous vessels can easily be seen. Distention can suggest a variety of pathologic conditions, including sepsis, obstruction, tumors, ascites, pneumoperitoneum, or necrotizing enterocolitis. Enterocolitis is a bowel infection characterized by sepsis, peritonitis, bowel perforation, and significant mortality. Any of these conditions may cause elevation of the diaphragm and therefore compromise lung expansion.
B.	Incorrect response: See explanation A.
C.	Incorrect response: See explanation A.
D.	Incorrect response: See explanation A.

 

 

OBJ:   Recall

 

15. Which of the following conditions are associated with scaphoid abdomen?
16. Necrotizing enterocolitis
17. Gastroschisis

III. Prune-belly syndrome

1. Sepsis

A.	I and IV only
B.	II and III only
C.	I, II, and III only
D.	II, III, and IV only

 

 

ANS:  B

 

	Feedback
A.	Incorrect response: See explanation B.
B.	Correct response: A scaphoid, hollowed, or unusually flattened abdomen may be associated with congenital diaphragmatic hernia, in which abdominal contents are misplaced into the chest through a defect in the muscular diaphragm. More noticeable abnormalities of the abdomen include prune-belly syndrome, which is a congenital lack of abdominal musculature. Omphalocele is a protrusion of the membranous sac that encloses the abdominal contents through an opening in the abdominal wall into the umbilical cord. Gastroschisis is a defect in the abdominal wall lateral to the midline with protrusion of the intestines.
C.	Incorrect response: See explanation B.
D.	Incorrect response: See explanation B.

 

 

OBJ:   Recall

 

16. While performing an examination of the abdomen of a neonate, the therapist is able to palpate the infant’s liver 1 to 2 cm below the right costal margin. Which of the following conditions can account for this development?

A.	Hepatomegaly
B.	Splenomegaly
C.	Right ventricular failure
D.	Normal liver position

 

 

ANS:  D

 

	Feedback
A.	Incorrect response: See explanation D.
B.	Incorrect response: See explanation D.
C.	Incorrect response: See explanation D.
D.	Correct response: The liver is usually felt as a rounded edge that rolls under the lightly palpating hand. Palpation should begin in the right lower quadrant so that an enlarged liver is not missed. The liver edge is usually easily defined 1 to 2 cm below the right costal margin in newborns. Hepatomegaly may be associated with congenital heart disease, infection, or hemolytic disease.

 

 

OBJ:   Recall

 

17. After the umbilical cord has been cut in the delivery room during the delivery of a large for gestational age infant, the therapist notices that the umbilical cord is large and fat. Which of the following maternal conditions is likely present?

A.	Congestive heart failure
B.	Renal insufficiency
C.	Diabetes mellitus
D.	Hypertension

 

 

ANS:  C

 

	Feedback
A.	Incorrect response: See explanation C.
B.	Incorrect response: See explanation C.
C.	Correct response: The umbilical cord is yellowish white with three blood vessels. The two small and thick-walled arteries and one large and thin-walled vein are easily visible on the end of a freshly cut cord. Wharton’s jelly surrounds the vessels. A single umbilical artery suggests congenital anomalies, especially those of the urinary tract. The presence of meconium in the amniotic fluid causes a greenish yellow staining of the umbilical cord. The umbilical cord of a large for gestational age infant born to a diabetic mother is frequently large and fat.
D.	Incorrect response: See explanation C.

 

 

OBJ:   Recall

 

18. A newborn who presents as pale, mottled, floppy, with little interest in feeding, and slightly irritable most likely has which of the following conditions?

A.	Sepsis
B.	Respiratory distress syndrome
C.	Retinopathy of prematurity
D.	Cri du chat

 

 

ANS:  A

 

	Feedback
A.	Correct response: Sepsis consumes the majority of infants energy. This includes and inability to feeding and even crying in severe cases. Respiratory distress is typically very progressive and can appear the same with the exception of the infant being pale, mottled, and floppy. Without sepsis the infant will have enough energy to breath rapidly, be irritable, and have tone.
B.	Incorrect response: See explanation A.
C.	Incorrect response: See explanation A.
D.	Incorrect response: See explanation A.

 

 

OBJ:   Recall

 

19. The therapist has placed a pulse oximeter probe on a finger of the right hand of a newborn and another pulse oximeter probe on a toe of the infant’s left foot. The pulse oximeter on the right hand reads 80% and the one on the left foot indicates 65%. Which of the following disease conditions does this neonate possibly have?

A.	Diaphragmatic hernia
B.	Persistent pulmonary hypertension of the newborn
C.	Choanal atresia
D.	Suprapubic aspiration

 

 

ANS:  B

 

	Feedback
A.	Incorrect response: See explanation B.
B.	Correct response: The “gold standard” for diagnosing persistent pulmonary hypertension of the newborn (PPHN) involves having the neonate breathe 100% oxygen, and after a certain time to obtain a preductal blood sample from the right radial or temporal artery, and a postductal blood sample from the umbilical artery or lower limbs. If the preductal–postductal pressure of oxygen (PO2) difference is greater than 15 mm Hg, then the infant has ductal shunting. Two pulse oximeters can also be used to measure preductal SpO2 and postductal SpO2. The preductal SpO2 is measured by placing a probe on a finger of the infant’s right hand and the probe from the second oximeter on one of the toes of the newborn’s left foot. A preductal–postductal SpO2 difference greater than 10% indicates ductal shunting. PPHN results when the pulmonary vascular resistance fails to decrease after birth, despite improved alveolar oxygenation and lung expansion. Despite an increase in systemic vascular resistance (with the loss of the placenta), pulmonary vascular resistance remains equal to or greater than systemic vascular resistance. This high pulmonary vascular pressure results in blood continuing to flow through the foramen ovale and ductus arteriosus. Subsequently, with the loss of placental gas exchange and the inability to increase pulmonary blood flow, arterial oxygen tension falls to low levels. If this situation is not reversed, the infant will die of severe hypoxemia.
C.	Incorrect response: See explanation B.
D.	Incorrect response: See explanation B.

 

 

OBJ:   Application

 

20. Which of the following white blood cell counts constitutes the condition leukopenia?

A.	Less than or equal to 3500/mm3
B.	5000 to 10,000/mm3
C.	10,000 to 20,000/mm3
D.	Greater than or equal to 25,000/mm3

 

 

ANS:  A

 

	Feedback
A.	Correct response: Leukopenia refers to white blood cells less than 3500/mm3, and leukocytosis refers to white blood cells greater than 25,000/mm3, which is suggestive of infection.
B.	Incorrect response: See explanation A.
C.	Incorrect response: See explanation A.
D.	Incorrect response: See explanation A.

 

 

OBJ:   Recall

 

 

 

Walsh: Perinatal and Pediatric Respiratory Care, 3^rd Edition

 

Chapter 30: Congenital Cardiac Defects

 

Test Bank

 

MULTIPLE CHOICE

 

1. Which of the following vessels return blood to the right ventricle?
2. Pulmonary vein
3. Inferior vena cava

III. Superior vena cava

1. Coronary sinus

A.	I and IV only
B.	II and III only
C.	I, II, and III only
D.	II, III, and IV only

 

 

ANS:   D

 

	Feedback
A.	Incorrect response: See explanation D.
B.	Incorrect response: See explanation D.
C.	Incorrect response: See explanation D.
D.	Correct response: The right atrium (RA) receives blood from all parts of the body through three veins: (1) the superior vena cava brings blood from parts of the body superior to the heart; (2) the inferior vena cava brings blood from parts of the body inferior to the heart; and (3) the coronary sinus drains blood from most of the vessels supplying the heart.

 

 

Page: Recall

 

2. At birth, what factor causes dilation of the pulmonary vascular bed and a decrease in the pulmonary vascular resistance?

A.	Increased arterial partial pressure of oxygen (PaO2)
B.	Decreased arterial partial pressure of carbon dioxide (PaCO2)
C.	Lung inflation
D.	Circulating indomethacin

 

 

ANS:   A

 

	Feedback
A.	Correct response: Once the umbilical vessels are clamped, the low-pressure system of the placenta is removed from the fetal circulation. Refer to Figure 30-2 in the textbook. As the lungs inflate and gas exchange occurs, the increase in PaO2 causes dilatation of the pulmonary vascular bed, resulting in a reduction in pulmonary vascular resistance.
B.	Incorrect response: See explanation A.
C.	Incorrect response: See explanation A.
D.	Incorrect response: See explanation A.

 

 

Page: Application

 

3. What factor is responsible for closure of the foramen ovale?

A.	Increased PaO2
B.	Increased pressure on the left side of the heart
C.	Blood flowing through the lungs
D.	High pulmonary vascular resistance

 

 

ANS:   B

 

	Feedback
A.	Incorrect response: See explanation B.
B.	Correct response: Because the foramen ovale flap enables blood to flow only from right to left, it closes when the pressures in the left atrium become greater than those in the right atrium. If the foramen ovale lacks a flaplike structure or has a defective one, the opening begins to function as an atrial septal defect (ASD). The pressures in the various chambers of a normal heart and great vessels of the older child can be seen in Figure 30-3 in the textbook.
C.	Incorrect response: See explanation B.
D.	Incorrect response: See explanation B.

 

 

Page: Application

 

4. For which of the following congenital cardiac defects may spontaneous closure of the ductus arteriosus be catastrophic?
5. Tetralogy of Fallot with pulmonary atresia
6. Atrial septal defect

III. Severe coarctation of the aorta

1. Hypoplastic left heart syndrome

A.	I and III only
B.	III and IV only
C.	I, II, and IV only
D.	I, III, and IV only

 

 

ANS:   D

 

	Feedback
A.	Incorrect response: See explanation D.
B.	Incorrect response: See explanation D.
C.	Incorrect response: See explanation D.
D.	Correct response: With both right-to-left shunt (cyanotic cardiac defect) and left-to-right shunt (acyanotic cardiac defect), several lesions depend on a patent ductus arteriosus for adequate pulmonary and systemic blood flow. These anomalies are also called ductal-dependent lesions because spontaneous closure of the ductus arteriosus can prove catastrophic. Anomalies included in this group are severe coarctation of the aorta, hypoplastic left heart syndrome, and tetralogy of Fallot with pulmonary atresia.

 

 

Page: Recall

 

5. How should the therapist interpret a preductal-to-postductal PO₂ difference of 8 mm Hg in a neonate?

A.	Unreliable data
B.	Absence of ductal shunting
C.	Presence of ductal shunting
D.	Inconclusive data

 

 

ANS:   B

 

	Feedback
A.	Incorrect response: See explanation B.
B.	Correct response: If a patent ductus arteriosus (PDA) is suspected, the presence of ductal shunting can be confirmed by evaluating the difference in oxygenation of preductal versus postductal blood. This procedure can be done by obtaining preductal (right radial or temporal artery) and postductal (umbilical artery) blood gases. A PaO2 differential of greater than 15 mm Hg is considered indicative of significant ductal shunting. This assessment can also be done noninvasively with preductal (right hand) and postductal (left hand or lower extremities) pulse oximetry readings. A pulse oximetry difference of greater than 5% is suggestive of ductal shunting.
C.	Incorrect response: See explanation B.
D.	Incorrect response: See explanation B.

 

 

Page: Analysis

 

6. Which of the following methods are involved in the management of a PDA?
7. Increasing the circulating volume
8. Maintaining the hematocrit at the high end of normal

III. Administering indomethacin

1. Administering digoxin

A.	I and IV only
B.	II and III only
C.	III and IV only
D.	I, III, and IV only

 

 

ANS:   B

 

	Feedback
A.	Incorrect response: See explanation B.
B.	Correct response: Management of the PDA includes maintaining euvolemia, a hemoglobin level at the high end of the normal, and indomethacin treatment, which is most effective if given in the first day after birth. A single dose of indomethacin (0.2 mg/kg, intravenous) given in the first 24 hours after delivery can be effective in preventing clinical symptoms associated with PDA. Digoxin does not seem to play an important role in the treatment because the contractility of myocardium is somewhat increased, not reduced, in infants with PDA.
C.	Incorrect response: See explanation B.
D.	Incorrect response: See explanation B.

 

 

Page: Application

 

7. Which of the following clinical manifestations are consistent with an atrial septal defect (ASD)?
8. An ASD often causes congestive heart failure.
9. The right ventricle may become hypertrophic.

III. Most patients with an ASD are symptomatic in the neonatal intensive care unit.

1. Chest radiographs are usually normal.

A.	I and IV only
B.	II and IV only
C.	I, II, and III only
D.	II, III, and IV only

 

 

ANS:   B

 

	Feedback
A.	Incorrect response: See explanation B.
B.	Correct response: Blood flow is usually shunted from left to right through an ASD, with an increase in pulmonary blood flow occurring. This defect rarely produces congestive heart failure in children, although the right ventricle (RV) may become hypertrophic because of the increased blood flow. Although symptoms have been reported in the neonatal period, most of these patients remain asymptomatic until school age, with only approximately 8% having their conditions identified before they are 2 years old. Chest radiographic findings are usually normal, but in extreme cases, when congestive heart failure develops, enlarged pulmonary vascular markings and cardiomegaly may be apparent.
C.	Incorrect response: See explanation B.
D.	Incorrect response: See explanation B.

 

 

Page: Recall

 

8. Which of the following clinical manifestations are consistent with a large ventricular septal defect (VSD)?
9. The majority of the blood flow is shunted from left to right.
10. Shunting typically occurs during ventricular diastole.

III. Chest radiography reveals an enlarged cardiac silhouette and increased pulmonary vascular markings.

1. Thickening and fibrosing of the pulmonary veins develop.

A.	I and III only
B.	I and IV only
C.	I, II, and III only
D.	II, III, and IV only

 

 

ANS:   A

 

	Feedback
A.	Correct response: With a ventricular septal defect (VSD) the majority of the blood flow is shunted from left to right, because the resistance of the pulmonary vascular bed is relatively low compared with systemic vascular resistance. Shunting typically occurs during ventricular systole. The shunt may be large and result in congestive heart failure and pulmonary hypertension. If the VSD is small, the heart may appear normal on the chest radiograph. If the VSD is large, the cardiac silhouette will be enlarged and the pulmonary vascular markings increased, as seen in infants with congestive heart failure. A left-to-right shunt may increase pulmonary blood flow to the point that the increased pressure and volume result in thickening and fibrosis of the pulmonary arterioles.
B.	Incorrect response: See explanation A.
C.	Incorrect response: See explanation A.
D.	Incorrect response: See explanation A.

 

 

Page: Recall

 

9. Why must supplemental oxygen be judiciously administered to patients with an atrioventricular canal defect?

A.	To prevent the development of retinopathy of prematurity
B.	To avoid oxygen-induced hypoventilation
C.	To minimize pulmonary vascular dilation
D.	To reduce oxidative stress

 

 

ANS:   C

 

	Feedback
A.	Incorrect response: See explanation C.
B.	Incorrect response: See explanation C.
C.	Correct response: When oxygen therapy is indicated for patients with an atrioventricular canal defect, supplemental oxygen must be given judiciously to minimize pulmonary vascular dilation, which might increase pulmonary blood flow, causing pulmonary vascular engorgement. The increased oxygen in the blood may have a constricting effect on the ductus arteriosus.
D.	Incorrect response: See explanation C.

 

 

Page: Analysis

 

10. Which of the following clinical features characterize aortic stenosis in a neonate?
11. These patients are generally ductal dependent.
12. The left ventricle demonstrates hypertrophy.

III. Chest radiography reveals a narrowed pulmonary vasculature.

1. These infants are rarely symptomatic during the first month of life.

A.	I and II only
B.	I, II, and III only
C.	I, II, and IV only
D.	II, III, and IV only

 

 

ANS:   C

 

	Feedback
A.	Incorrect response: See explanation C.
B.	Incorrect response: See explanation C.
C.	Correct response: In the presence of aortic stenosis, the myocardium is always hypertrophied, with the left ventricle overdistended to varying degrees. If left ventricular pressures are great enough, congestive heart failure may result. On occasion, left atrial pressures and the resulting distention can cause blood to flow from left to right through the foramen ovale. The chest radiograph reveals findings similar to those of an infant in congestive heart failure. The heart is usually enlarged. The pulmonary vessels appear enlarged on chest X-ray because of pulmonary venous congestion. Infants with aortic stenosis are rarely symptomatic in the first month of life. If they are symptomatic, the indication is that they are critically ill and their cardiac output is extremely low. These infants are likely to die unless surgery is performed rapidly. These patients are often ductal dependent, with systemic circulation depending on blood flow through the ductus arteriosus. Although supplemental oxygen is most likely indicated, it should be given judiciously to limit the vasodilatory effects of oxygen on the pulmonary vasculature and the constricting effect on the ductus arteriosus.
D.	Incorrect response: See explanation C.

 

 

Page: Recall

 

11. Identify the congenital cardiac defect depicted in the following illustration:

A.	Atrial septal defect
B.	Hypoplastic left ventricular syndrome
C.	Hypoplastic right ventricular syndrome
D.	Atrioventricular canal defect

 

 

ANS:   B

 

	Feedback
A.	Incorrect response: See explanation B.
B.	Correct response: The cardiac anomaly depicted in this question is hypoplastic left ventricular syndrome, which can be viewed in the textbook in Figure 30-10.
C.	Incorrect response: See explanation B.
D.	Incorrect response: See explanation B.

 

 

Page: Analysis

 

12. Identify the following congenital cardiac anomaly:

A.	Truncus arteriosus
B.	Hypoplastic left ventricle
C.	Transposition of the great vessels
D.	Ventricular septal defect

 

 

ANS:   A

 

	Feedback
A.	Correct response: The cardiac anomaly depicted in this question is truncus arteriosus, which can be viewed in the textbook in Figure 30-18.
B.	Incorrect response: See explanation A.
C.	Incorrect response: See explanation A.
D.	Incorrect response: See explanation A.

 

 

Page: Analysis

 

16. Name the following congenital cardiac anomaly:

A.	Atrial septal defect
B.	Hypoplastic left ventricular syndrome
C.	Hypoplastic right ventricular syndrome
D.	Atrioventricular canal defect

 

 

ANS:   B

 

	Feedback
A.	Incorrect response: See explanation B.
B.	Correct response: The cardiac anomaly depicted in this question is hypoplastic left ventricular syndrome, which can be viewed in the textbook in Figure 30-10.
C.	Incorrect response: See explanation B.
D.	Incorrect response: See explanation B.

 

 

Page: Analysis

 

17. Which of the following medications are the most common preoperative treatments to minimize preductal constriction until surgical correction of coarctation of the aorta can be achieved?
18. Indomethacin
19. Prostaglandin E₁

III. Negative inotropes

1. Diuretics

A.	I and III only
B.	I and IV only
C.	II and III only
D.	II and IV only

 

 

ANS:   D

 

	Feedback
A.	Incorrect response: See explanation D.
B.	Incorrect response: See explanation D.
C.	Incorrect response: See explanation D.
D.	Correct response: The most important preoperative treatment is the use of prostaglandin E1 to minimize ductal constriction until surgical correction can be achieved. The administration of prostaglandin E1 has drastically improved the outcome for patients with coarctation of the aorta. Presurgical management may also include positive inotropic agents and diuretics for treatment of cardiac failure. Ventilator management is sometimes necessary for patients in shock. Surgery is usually postponed until later in the first year of life if cardiac failure can be controlled medically and an adequate weight gain sustained.

 

 

Page: Application

 

18. Which of the following mechanical ventilation techniques may be necessary during the postoperative period after surgical intervention for hypoplastic left ventricular syndrome?
19. High respiratory rates
20. High positive end-expiratory pressure (PEEP) levels

III. Rule of forties

1. Hypercarbic therapy

A.	III only
B.	II and III only
C.	III and IV only
D.	I, III, and IV only

 

 

ANS:   C

 

	Feedback
A.	Incorrect response: See explanation C.
B.	Incorrect response: See explanation C.
C.	Correct response: Postoperative management focuses on maintaining hemodynamic stability by controlling pulmonary vascular resistance (PVR) and optimizing systemic perfusion. Ventilatory management is an important aspect of care, and inspired fraction of oxygen (FIO2) management is critically important in controlling PVR in patients who have had a classic Norwood procedure. Specific ventilatory techniques may need to be implemented to induce (or maintain) a high PVR (e.g., subambient or hypercarbic therapy). Hyperventilation should be avoided, because it can reduce PVR. A helpful convention is the “rule of forties,” which seeks to keep arterial blood gases in the following ranges: PaO2 approximately 40 mm Hg and PaCO2 approximately 40 mm Hg.
D.	Incorrect response: See explanation C.

 

 

Page: Application

 

19. Which of the following aberrant connections is consistent with anomalous pulmonary venous return?
20. The inferior vena cava connects directly to the left atrium.
21. The pulmonary veins connect directly to the right atrium.

III. The pulmonary artery connects directly to the left atrium.

1. The pulmonary veins connect directly to the superior vena cava.

A.	II only
B.	I and IV only
C.	II and IV only
D.	II, III, and IV only

 

 

ANS:   C

 

	Feedback
A.	Incorrect response: See explanation C.
B.	Incorrect response: See explanation C.
C.	Correct response: Anomalies involving aberrant connections between the pulmonary venous drainage and the systemic circulation can occur in a variety of ways. The common feature is pulmonary veins that have no connection with the left atrium (LA) and drain either directly or indirectly into the RA. Figure 30-16 in the textbook illustrates this congenital cardiac abnormality.
D.	Incorrect response: See explanation C.

 

 

Page: Recall

 

20. Which of the following congenital cardiac anomalies are classified as conotruncal?
21. Tetralogy of Fallot
22. Transposition of the great vessels

III. Coarctation of the aorta

1. Atrioventricular canal defect

A.	I and II only
B.	II and III only
C.	I, III, and IV only
D.	II, III, and IV only

 

 

ANS:   A

 

	Feedback
A.	Correct response: A class of anomalies called conotruncal, a term referring to the site of the developmental derangement that leads to the lesion, includes the tetralogy of Fallot, truncus arteriosus, and transposition of the great vessels. The tetralogy of Fallot consists of four concomitant conditions: (1) overriding aorta, (2) pulmonary stenosis, (3) VSD, and (4) right ventricular hypertrophy. This congenital cardiac defect can be seen in Figure 30-17 in the textbook.
B.	Incorrect response: See explanation A.
C.	Incorrect response: See explanation A.
D.	Incorrect response: See explanation A.

 

Page: Recall

 

21. Which of the following statements describes truncus arteriosus?
22. The pulmonary artery arises from the left ventricle, and the aorta stems from the right ventricle.
23. If PVR increases relative to systemic vascular resistance (SVR), more blood flows to the lungs through the truncus, decreasing systemic cardiac output.

III. If SVR decreases relative to PVR, blood flow will be shunted from right to left, bypassing the lungs.

1. A large VSD allows total mixing of blood from the two ventricles.

A.	I and III only
B.	II and IV only
C.	I, II, and IV only
D.	I, III, and IV only

 

 

ANS:   D

 

	Feedback
A.	Incorrect response: See explanation D.
B.	Incorrect response: See explanation D.
C.	Incorrect response: See explanation D.
D.	Correct response: Truncus arteriosus is a defect in which a single great artery arises from the ventricles of the heart supplying the coronary, pulmonary, and systemic arteries. A large VSD allows total mixing of blood from the two ventricles, making the heart function as a single ventricle. The balance between PVR and SVR affects oxygenation and cardiac output. If PVR decreases relative to SVR, an increase in blood flow to the lungs through the truncus develops, decreasing systemic cardiac output. Pulmonary vascular engorgement may then occur. If SVR decreases, blood flow will be shunted from right to left and bypass the lungs, resulting in severe hypoxemia and acidosis.

 

 

Page: Application

 

22. Which of the following blood flow patterns occurs in complete transposition of the great arteries?

A.	The systemic venous blood passes through the right heart chambers.
B.	The pulmonary venous blood traverses the left side of the heart and then returns to the systemic circulation.
C.	When PVR increases relative to SVR, blood flow increases through the ductus arteriosus.
D.	Systemic venous blood flows to the lungs after leaving the right ventricle.

 

 

ANS:   A

 

	Feedback
A.	Correct response: With complete transposition of the great arteries, the positions of the aorta and the pulmonary artery are reversed. The aorta arises from the RV, and the pulmonary artery arises from the left ventricle (LV). These anomalies can be seen in Figure 30-20 in the textbook. Basically, the two circulations are separate (parallel), instead of in series with each other. The systemic venous blood passes through the right heart chambers and then to the body without flowing through the lungs. The pulmonary venous blood traverses the left side of the heart and then returns to the lungs. Survival depends on mixing between the two separate circuits. In the immediate postnatal period, shunting through a PDA and the foramen ovale is usually sufficient.
B.	Incorrect response: See explanation A.
C.	Incorrect response: See explanation A.
D.	Incorrect response: See explanation A.

 

 

Page: Recall

 

23. Which of the following cardiac defects sometimes requires the use of balloon atrial septostomy?

A.	Complete transposition of the great arteries
B.	Coarctation of the aorta
C.	Truncus arteriosus
D.	Tetralogy of Fallot

 

 

ANS:   A

 

	Feedback
A.	Correct response: Patients with complete transposition of the great arteries usually have a small ASD; however, in some cases it needs to be larger, and balloon atrial septostomy is performed during cardiac catheterization (also called the Rashkind procedure). This procedure includes advancing a balloon-tipped catheter from the RA through the foramen ovale into the LA. The balloon is inflated and rapidly and forcefully withdrawn to create a large ASD. An enlarged ASD ensures adequate mixing between the two atria until corrective surgery can be performed. Balloon atrial septostomy may also be performed preoperatively at the time of cardiac catheterization to enlarge the ASD in total anomalous pulmonary venous return.
B.	Incorrect response: See explanation A.
C.	Incorrect response: See explanation A.
D.	Incorrect response: See explanation A.

 

 

Page: Recall

 

24. When a hypoplastic right ventricle is present, what is the only pathway for blood to leave the right atrium?

A.	Through an ASD
B.	Through a VSD
C.	Through a PDA
D.	Via the left ventricle

 

 

ANS:   A

 

	Feedback
A.	Correct response: A hypoplastic right ventricle is caused by a tricuspid atresia and/or pulmonary atresia. This congenital cardiac defect may be seen in Figure 30-24 in the textbook. With tricuspid atresia, formation of the tricuspid valve is absent. No blood flow occurs between the RA and RV. The only way for blood to leave the RA is through an ASD or patent foramen ovale. The systemic and pulmonary venous blood enter and mix in the LA, and then the blood empties into the LV. A VSD enables blood to flow back into the RV, but only a small amount, if any, is pumped into the pulmonary system. A PDA must be present to facilitate additional pulmonary blood flow.
B.	Incorrect response: See explanation A.
C.	Incorrect response: See explanation A.
D.	Incorrect response: See explanation A.

 

 

Page: Recall

 

25. Identify the letter that indicates the end-tidal carbon dioxide (ETCO₂) along the following capnogram:

A.	A
B.	B
C.	C
D.	D

 

 

ANS:   C

 

	Feedback
A.	Incorrect response: See explanation C.
B.	Incorrect response: See explanation C.
C.	Correct response: The letter A signifies the exhalation of anatomic dead space gas, which is devoid of carbon dioxide. A–B represents the exhalation of the remnants of anatomic dead space gas and the beginning of the emptying of alveoli. B–C reflects the alveolar plateau, where the alveoli are emptying. Label D indicates the end-tidal carbon dioxide. D–C refers to inspiration characterized by a precipitous fall in carbon dioxide as fresh air enters the lungs.
D.	Incorrect response: See explanation C.

 

Page: Analysis