Facts read from nccwebsite.org · last checked Nov 7, 2026
The job analysis gives blood disorders 6 of the scored questions, and jaundice questions come on top of that across the exam. Here the work is reading a bilirubin against the right curve and choosing blood products by current trial evidence, not by habit.
Practice questions
60 questions written to the NNP-BC outline; each choice is explained once you pick.
Red cells: anemia, polycythemia, Rh and ABO disease.
Platelets, clotting and white cells: platelet disorders, vitamin K deficiency, DIC, factor deficiencies, neutropenia and neutrophilia.
Blood component therapy.
Jaundice and the liver: direct and indirect hyperbilirubinemia, breast milk jaundice, kernicterus, phototherapy, exchange transfusion, biliary atresia.
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15 blood and jaundice questions
0 / 15 answered15 questions
Tap an option: why each one is right or wrong appears under it.
Neonatal hematology and bilirubin · 6 items
A 5-week-old breastfed infant is admitted for persistent jaundice with pale stools and dark urine. Total bilirubin is 9.2 mg/dL with direct 5.8 mg/dL, and ultrasound shows a triangular cord sign. The next step is
Interrupting breastfeeding tests for breast milk jaundice, which is unconjugated; it delays the diagnosis of a direct hyperbilirubinemia.
Waiting a month on ursodiol pushes the Kasai past the age when it works best.
Conjugated jaundice with acholic stools and a triangular cord sign means biliary atresia until proven otherwise; intraoperative cholangiography confirms it so a Kasai can be done, ideally before 60 days.
Within hours of birth, a term infant develops expanding purpuric skin lesions with necrosis. Platelets and fibrinogen are low, D-dimer is high, protein C activity is undetectable, and both parents have low protein C levels. The most appropriate immediate therapy is
Vitamin K cannot raise protein C when the gene defect blocks its production.
Heparin does not replace the missing natural anticoagulant, and with DIC and low platelets it adds bleeding risk.
Severe congenital protein C deficiency causes purpura fulminans with DIC soon after birth; the missing protein C is replaced at once with fresh frozen plasma or protein C concentrate.
A 28-week infant is now 7 weeks old and clinically stable, with hemoglobin 7.8 g/dL and a reticulocyte count of 1%. The primary mechanism of this anemia is
Folate deficiency is uncommon with routine supplementation and would produce large red cells.
Anemia of prematurity is hypoproliferative: erythropoietin, still made mostly in the liver, rises little with anemia, so the reticulocyte count stays low.
Hemolysis would drive a high reticulocyte count and jaundice, not the low count seen here.
A 4-day-old with DAT-negative jaundice and spherocytes on the smear has a father who had a splenectomy. The BEST test to confirm the likely diagnosis in the newborn is
Hereditary spherocytosis is best confirmed in newborns by eosin-5-maleimide flow cytometry, which detects loss of band-3-related membrane protein.
G6PD deficiency also causes DAT-negative hemolysis, but spherocytes and a splenectomized father point to a membrane defect.
Osmotic fragility is the classic test, but neonatal red cells give unreliable results without special reference ranges.
A 4-day-old 38-week infant has TSB 26 mg/dL with hypertonia, retrocollis, and a high-pitched cry. The most appropriate action is
Enzyme induction takes days and has no place in an encephalopathic infant.
Phototherapy alone works too slowly once neurotoxicity is visible, and waiting 4 hours risks permanent kernicterus.
Hypertonia, retrocollis and a high-pitched cry are signs of intermediate or advanced acute bilirubin encephalopathy, which require an immediate exchange regardless of the TSB, with intensive phototherapy meanwhile.
A term infant is admitted to the NICU on day 6 with persistent oozing from the umbilical stump and is otherwise well. PT, PTT, platelet count and fibrinogen are normal. Which deficiency is most likely?
Factor XIII cross-links fibrin, and its deficiency leaves PT and PTT normal; delayed umbilical stump bleeding is the classic sign and intracranial bleeding the main risk.
von Willebrand levels are high at birth, so von Willebrand disease rarely bleeds in the newborn period.
Vitamin K deficiency prolongs the PT, so a normal PT argues against it.
Each infant has a TSB 1 mg/dL above the phototherapy threshold, is feeding well and has never had phototherapy. Under the 2022 AAP guideline, which infant may receive home phototherapy?
A positive DAT means isoimmune hemolysis, a neurotoxicity risk factor that rules out home treatment.
Home phototherapy is an option for an infant of at least 38 weeks and 48 hours, feeding well, without neurotoxicity risk factors, and with a TSB no more than 1 mg/dL above threshold.
Gestational age under 38 weeks is itself a neurotoxicity risk factor, so this infant needs hospital phototherapy despite being older.
A 900 g infant needs a large-volume transfusion. Choosing red cells collected within the last 5–7 days, especially if irradiated, MAINLY reduces the risk of
Irradiation is what prevents transfusion-associated GVHD; unit freshness addresses potassium, not GVHD.
Hypoglycemia can follow an exchange because of the glucose in the anticoagulant, but it does not depend on the age of the unit.
Potassium leaks from stored red cells, and irradiation speeds the leak, so fresh units limit the potassium load of a large-volume or exchange transfusion in a small infant.
A 60-hour-old male of Mediterranean ancestry has TSB 21 mg/dL rising 0.3 mg/dL/h; the DAT is negative. Which test is MOST useful next?
Hypothyroidism prolongs jaundice over weeks; it does not cause a fast early rise to 21 mg/dL.
A rapid rise with a negative DAT in a male of Mediterranean ancestry suggests G6PD deficiency, a neurotoxicity risk factor that lowers the treatment threshold.
Reducing substances screen for galactosemia, which causes later jaundice, often direct, with liver dysfunction and E. coli sepsis.
Which neonate is at HIGHEST risk for polycythemia?
Rh disease destroys red cells and causes anemia, sometimes severe enough for hydrops.
In twin-twin transfusion the recipient receives excess blood volume and becomes polycythemic; chronic fetal hypoxia and delayed clamping are other causes.
Abruption causes fetal blood loss and anemia, the opposite problem.
A 39-week, 60-hour-old infant without neurotoxicity risk factors started phototherapy at a TSB of 19 mg/dL, the threshold for his age. Twelve hours later the TSB is 16.5 mg/dL. Under the 2022 AAP guideline, the best action is to
A 50% fall is an invented target that prolongs treatment well past the guideline's stopping point.
The 2022 AAP guideline allows phototherapy to stop once the TSB is at least 2 mg/dL below the hour-specific threshold at which it started (16.5 is 2.5 below 19); a follow-up bilirubin is then timed by rebound risk.
There is no minimum duration; a fixed 24-hour course keeps the infant away from feeding and the parent without benefit.
A term infant is born with a fully formed 4-cm violaceous tumor on the thigh with coarse telangiectasias and a pale rim. The platelet count is normal. The most appropriate management is
Propranolol treats infantile hemangiomas, which appear after birth and grow; congenital hemangiomas respond poorly.
Excision is kept for lesions that fail to involute, ulcerate or leave residual tissue, not for a new tumor likely to shrink.
A vascular tumor fully formed at birth with coarse telangiectasias and a pale rim is a congenital hemangioma, most often the rapidly involuting type, so it is observed.
Parents decline IM vitamin K and request oral dosing for their breastfed term newborn. Counseling should include that oral vitamin K
Oral vitamin K protects less well than a single 1 mg IM dose against late vitamin K deficiency bleeding at 2 to 12 weeks, which often presents as intracranial hemorrhage in breastfed infants.
Equivalence is the common misconception; a single oral dose leaves breastfed infants exposed to late bleeding.
Formula contains vitamin K, while breast milk is low in it, so breastfed infants are the ones at higher risk.
A 20-hour-old with ABO isoimmune hemolysis (positive DAT) has a TSB within 2 mg/dL of the exchange threshold despite intensive phototherapy. Which additional therapy is indicated?
In isoimmune hemolysis, IVIG blocks Fc receptors and slows red cell destruction; the AAP advises it once the TSB reaches the escalation-of-care level despite intensive phototherapy.
Extra water or dextrose does not lower bilirubin and is not recommended; it can also reduce milk intake.
Phenobarbital induces conjugation over days and does not stop antibody-mediated hemolysis in time.
A running total sits here; it fills in after your last pick.
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Jaundice and transfusion traps
Plotting on the 2004 nomogram. The AAP's 2022 guideline for infants at 35 weeks or more raised the phototherapy and exchange thresholds and replaced the old risk zones with curves chosen by gestational age, hour of life and neurotoxicity risk. A key built on the risk zones is out of date.
Trusting a high transcutaneous reading. The same guideline asks for a serum bilirubin when the transcutaneous value reaches 15 mg/dL or comes within 3 mg/dL of the phototherapy threshold.
Extra water for jaundice. Supplementing a breastfed infant with water or dextrose water is not recommended.
One vitamin K dose for every weight. AAP's 2022 policy statement gives 1 mg IM to infants over 1,500 g and 0.3 to 0.5 mg/kg IM at 1,500 g or less.
Transfusing at higher thresholds “to be safe.” In extremely low birth weight infants, the TOP (NEJM, 2020) and ETTNO (JAMA, 2020) trials found no benefit to death or neurodevelopment from liberal red cell thresholds, and PlaNeT-2 (NEJM, 2019) found more death or major bleeding with a platelet threshold of 50,000 than with 25,000.
Missing alloimmune thrombocytopenia. A severely thrombocytopenic, otherwise well newborn whose mother has a normal platelet count suggests fetal and neonatal alloimmune thrombocytopenia; in maternal ITP the mother's count is low.