NNP-BCPractice test · NNP-BC · three options a question
NCC NNP practice test, every option explained
Facts read from nccwebsite.org · last checked Nov 7, 2026
60 questions in the NCC format: one answer, two near misses. General Management and General Assessment take the largest share, as on the outline. Respiratory, which has its own page of questions, gets only two here, and the small systems (kidney, bone, skin, eyes and ears) one or two each.
Figure 1.Test content outline: 150 scored questions, one mark each
The 60 items here are kept apart from the quizzes on the NNP-BC area pages, which makes this set a clean baseline. In each item two choices are near misses, and each option has a one- or two-line reason beside it. Items ask you to interpret a gas or a film, choose the next study, calculate a rate, link the mother's history to what the baby shows.
Test day allows 3 h for 175 questions, roughly a minute apiece. Do a first pass untimed, then a second against that pace.
60 questions across the outline
0 / 60 answered60 questions
Tap an option: why each one is right or wrong appears under it.
Neonatal hematology and bilirubin · 6 items
Hydrops fetalis in alpha-thalassemia major (deletion of all four alpha-globin genes) results mainly from
Low albumin can add to edema, but the primary driver in Bart's hydrops is the useless oxygen carrier.
Without alpha chains the fetus makes hemoglobin Bart's, which holds oxygen so tightly that tissues receive almost none; hypoxia with anemia leads to heart failure and hydrops.
Iron overload is a late complication of transfused beta-thalassemia, not the cause of fetal hydrops.
A 7-week-old former 27-week infant with parenteral-nutrition-associated cholestasis has steatorrhea and poor growth. Which formula property BEST improves fat absorption?
DHA and arachidonic acid are long-chain fats that themselves need bile to be absorbed.
Medium-chain triglycerides are absorbed without bile-acid micelles and go straight to the portal circulation, so they are still absorbed when bile flow is poor.
Lowering lactose helps carbohydrate intolerance, not fat malabsorption from cholestasis.
Parents of an infant with trisomy 18 and complex heart disease agree to a do-not-attempt-resuscitation order. Which statement about the order is correct?
Parents decide with the team; an ethics consultation helps when there is conflict but is not a routine requirement for a DNAR order.
Withdrawing nutrition is a separate decision; reading a DNAR order as 'stop everything' is a common and harmful misunderstanding.
A do-not-attempt-resuscitation order limits only CPR and related resuscitation; feeding, comfort care and other indicated treatments continue unless separately addressed.
Parents of an infant born at 23 weeks who now has bilateral grade IV intraventricular hemorrhage ask to redirect care to comfort measures. Which decision-making standard should guide the team?
A neonate has never had capacity or expressed wishes, so parents and the team weigh the benefits and burdens of treatment for the infant: the best interest standard.
Substituted judgment asks what the patient would have chosen, which is impossible for an infant who never expressed values.
The reasonable person standard defines how much information to disclose for informed consent, not how surrogates decide.
A well-appearing 1-day-old breastfed term infant has blood-tinged gastric aspirate. The Apt test stays pink after alkali is added. The NEXT step is to
Fetal hemoglobin resists alkali, so a pink Apt test means the blood is the infant's own; that calls for a coagulation evaluation, including whether vitamin K was given.
Swallowed maternal blood would turn yellow-brown with alkali; reassuring here misreads the test.
Changing formula treats protein allergy, which does not cause fresh bleeding on day 1 in a breastfed infant.
A 26-week infant is stabilized in a plastic bag on an exothermic mattress under a radiant warmer at full output. At 10 minutes, the axillary temperature is 38.1 °C. The NEXT step is to
A temperature of 38.1 °C at 10 minutes under stacked heat sources is iatrogenic, not a sign of infection.
Stacking a bag, a chemical heat pad and a warmer at full output overheats small infants; removing the extra heat source and switching to servo control brings the temperature back to 36.5–37.5 °C.
Taking off the bag exposes the thin skin to evaporative loss and swings the infant from hyperthermia to cold stress.
A 4-hour-old term infant has blue hands and feet and a bluish tinge around the lips. The tongue is pink and SpO2 is 98% in the right hand. The best interpretation is
Polycythemia can give plethora or cyanosis, but with a pink tongue and normal saturation there is no reason to suspect it.
Methemoglobinemia causes central cyanosis, including the tongue, with a low pulse-oximetry reading.
Blue hands, feet and lips with a pink tongue and normal saturation are benign vasomotor findings in the first days of life.
A newborn has a midline defect at the umbilicus with bowel and liver inside a membranous sac into which the cord inserts. Compared with gastroschisis, this defect is more often associated with
A covered midline defect with the cord inserting into the sac is an omphalocele, which carries frequent trisomy 13 or 18, cardiac defects and Beckwith-Wiedemann syndrome.
Atresia and thickened, inflamed bowel from amniotic fluid exposure are features of gastroschisis, where the bowel has no sac.
Young maternal age and smoking are risk factors for gastroschisis, not omphalocele.
A 26-week infant is expected to need parenteral nutrition for several weeks. Which lipid emulsion is preferred to reduce the risk of PN-associated liver disease?
Soybean oil is rich in phytosterols and omega-6 fatty acids, the profile linked to PN-associated liver disease.
Withholding lipids for weeks causes essential fatty acid deficiency and poor growth in an extremely preterm infant.
Mixed-oil emulsions containing fish oil have fewer phytosterols and more omega-3 fatty acids and are associated with less cholestasis than pure soybean oil.
A term infant becomes cyanotic when calm or feeding and turns pink when crying. A catheter cannot be passed through either nostril. The most likely diagnosis is
Robin sequence obstructs the airway through micrognathia and glossoptosis; the nasal passages are open.
Newborns are obligate nasal breathers, so blocked choanae cause cyanosis at rest that clears when the infant cries through the mouth; an oral airway is the immediate fix.
Laryngomalacia causes inspiratory stridor that worsens supine and with feeding, and a nasal catheter passes normally.
An infant has Hirschsprung disease, a white forelock, and congenital sensorineural hearing loss. These defects share an origin from
Enteric ganglia, skin melanocytes and inner-ear melanocytes all come from the neural crest, so one migration defect explains all three findings (Waardenburg-Shah syndrome).
Surface ectoderm forms the epidermis, hair and lens, but not pigment cells or enteric neurons.
Endoderm tempts because the gut is involved, but it forms only the lining, not the ganglion cells that are missing in Hirschsprung disease.
The MOST effective analgesia for a heel lance in a term neonate is
Topical anesthetic does not reduce heel-lance pain, because most of the pain comes from squeezing the heel.
Swaddling helps, but alone it gives less relief than sucrose with sucking.
Oral sucrose given about 2 minutes before, with nonnutritive sucking, reliably lowers heel-lance pain scores; breastfeeding or skin-to-skin work similarly.
A mother has active genital lesions from a first-episode primary HSV infection and delivers vaginally. The infant is asymptomatic. At about 24 hours the recommended approach is to
With maternal first-episode primary infection the transmission risk is high, so at about 24 hours the infant has surface and blood PCR, CSF studies and ALT, and starts empiric IV acyclovir.
Observation alone fits low-risk exposures; after primary maternal infection it leaves a likely infected infant untreated until disease appears.
Oral suppression follows IV treatment of proven disease; it is not a substitute for evaluation and IV therapy.
After a difficult breech extraction, an infant with a right upper brachial plexus injury has tachypnea and decreased right breath sounds. Chest radiograph shows an elevated right hemidiaphragm. The most likely diagnosis is
Traction on C3–C5 often accompanies an upper brachial plexus injury and paralyzes the hemidiaphragm, which then sits high and moves paradoxically on ultrasound or fluoroscopy.
A diaphragmatic hernia shows bowel or liver in the chest, not a smooth, elevated dome, and right-sided hernias are uncommon.
A pneumothorax also lowers breath sounds after a hard delivery, but the film would show free pleural air, not a raised hemidiaphragm.
A jaundiced 32-week infant with suspected late-onset sepsis needs gram-negative coverage. Which antibiotic should be avoided because it displaces bilirubin from albumin?
Ampicillin does not displace bilirubin; sulfonamides and ceftriaxone are the classic displacing drugs.
Ceftriaxone displaces bilirubin from albumin, raising free bilirubin that can enter the brain, and in neonates it must not be given with IV calcium.
Cefepime gives gram-negative coverage without meaningful bilirubin displacement and is a usual alternative when a cephalosporin is needed.
Before a double-volume exchange, an infant's TSB was 26 mg/dL. Immediately after, it is 12 mg/dL, and 2 hours later it is 16 mg/dL. The BEST interpretation is
A rebound to 16 mg/dL is the predicted pattern and far below the exchange range; repeating the procedure exposes the infant to its risks for no gain.
Compatible donor cells do not hemolyze; the rise reflects redistribution of bilirubin already in the body.
An exchange clears intravascular bilirubin, but bilirubin from tissues and extravascular albumin moves back into plasma, so TSB typically rebounds to about 60% of the pre-exchange level within hours.
A newborn with trisomy 21 has bilious vomiting and a double-bubble sign with a little distal gas. At surgery, a ring of pancreatic tissue encircles the duodenum. This results from abnormal
The ventral bud normally rotates behind the duodenum to fuse with the dorsal bud; if it splits or migrates abnormally, a ring of pancreas encircles the duodenum.
Dorsal bud agenesis leaves a short pancreas and does not create a ring around the duodenum.
Midgut malrotation causes Ladd bands and volvulus, not a ring of pancreatic tissue.
Before a hepatobiliary (HIDA) scan for suspected biliary atresia, an infant is given phenobarbital for several days to
The scan needs a still infant, but the days of pretreatment are for bile flow, not sedation.
Phenobarbital induces hepatic enzymes and increases bile flow, so tracer reaches the bowel if the ducts are open, and absent excretion points more firmly to biliary atresia.
Pruritus is not a problem at this age; the drug is given to make the scan more specific.
A 900-g infant is fluid-restricted to 100 mL/kg/day, all given as PN through a PICC. To provide a GIR of 8 mg/kg/min, the dextrose concentration must be about
Rearranging GIR = %D × mL/kg/day ÷ 144 gives %D = 8 × 144 ÷ 100 ≈ 11.5%, a concentration a PICC can deliver.
Setting the dextrose percentage equal to the GIR skips the calculation entirely and underdoses glucose.
Using the total 90 mL/day instead of the per-kilogram rate of 100 mL/kg/day mixes units and overshoots the dextrose.
A term infant with no dysmorphic features fails the newborn hearing screen, and diagnostic ABR confirms bilateral severe sensorineural loss. Congenital CMV testing is negative. The most likely genetic cause is
Waardenburg syndrome brings pigmentary signs such as a white forelock or different-colored irises, which this infant lacks.
Pendred syndrome is a recognizable cause of inherited deafness with enlarged vestibular aqueducts and later goiter, but it is far less common than GJB2.
Biallelic GJB2 variants are the most common cause of congenital nonsyndromic sensorineural hearing loss; inheritance is recessive, so hearing parents often have an affected child.
A term infant born through meconium-stained fluid is vigorous, with good respiratory effort, heart rate above 100/min and good tone. The MOST appropriate initial management is
Deep suctioning of a vigorous infant can cause bradycardia and airway trauma and does not prevent meconium aspiration.
A vigorous infant born through meconium stays with the parent for routine care; the mouth and nose are cleared only if secretions obstruct the airway.
Suctioning on the perineum was abandoned after a large trial showed no reduction in meconium aspiration syndrome.
Metabolic, endocrine and genetic disorders · 11 items
A 5-day-old has poor feeding, lethargy, alternating hypertonia and opisthotonus, and a sweet odor to the cerumen; ammonia is normal. Elevation of which plasma amino acid is chiefly responsible for the neurotoxicity?
Glycine is raised in nonketotic hyperglycinemia, which causes apnea, hiccups and myoclonus without a sweet odor.
Citrulline rises in some urea cycle defects, which present with high ammonia, not the normal ammonia here.
In maple syrup urine disease, leucine and its ketoacid drive cerebral edema and encephalopathy, and leucine levels guide treatment.
Which congenital anomaly is most specifically associated with poorly controlled pregestational diabetes?
Gastroschisis is linked to young maternal age, smoking and early vascular disruption of the abdominal wall, not to maternal diabetes.
Caudal regression (sacral agenesis) is rare but the anomaly most specifically linked to first-trimester maternal hyperglycemia; heart and neural tube defects are more common but less specific.
Ebstein anomaly is the classic association with first-trimester lithium, not with maternal diabetes.
A NICU wants a validated procedural pain scale for preterm infants that adjusts for gestational age and behavioral state. The best choice is
FLACC is a behavioral scale validated in older infants and children, without adjustment for prematurity.
FACES needs self-report from a child old enough to point to a face.
The Premature Infant Pain Profile adds points for lower gestational age and a quiet behavioral state, because preterm infants show blunted pain responses.
A term newborn has a 3-cm tan-brown, slightly raised plaque on the forearm, present at birth, that turns red, swells and sometimes blisters when rubbed. The MOST likely diagnosis is
Bullous impetigo forms flaccid, crusting bullae that spread after the first days, not a fixed tan plaque present at birth that swells only when rubbed.
Juvenile xanthogranuloma is a firm yellow-orange papule or nodule that does not urticate or blister with friction.
Redness and swelling of a lesion when it is rubbed (Darier sign) mark cutaneous mastocytosis; in infants the lesion may blister, and a solitary mastocytoma usually regresses in childhood.
A former 25-week infant who was intubated for 7 weeks has persistent biphasic stridor 3 weeks after extubation. It is worse with agitation and unaffected by position. The most likely cause is
Prolonged intubation injures the mucosa at the cricoid ring, and scarring produces a fixed obstruction with biphasic stridor that persists weeks after extubation.
Tracheomalacia gives expiratory noise from collapse of the intrathoracic airway, not fixed biphasic stridor.
Laryngomalacia causes inspiratory stridor that changes with position and is usually congenital rather than acquired after intubation.
A 25-week infant is apneic at birth. A team member suggests a 15-second sustained inflation to open the lungs. The best response is to
In the SAIL trial, sustained inflations at 23–26 weeks increased early death without reducing BPD, so standard PPV at 40–60 breaths/min with PEEP is used.
Moving the sustained inflation to the endotracheal tube does not remove its risk; the problem is the maneuver, not the interface.
Repeating long inflations multiplies the harm seen in the trial rather than correcting it.
A term boy has a right testis palpable in the inguinal canal that cannot be brought into the scrotum. The left testis is descended, and the penis and meatus are normal. The most appropriate plan is
Newborn surgery is unnecessary because spontaneous descent is still possible in the first months.
Karyotype and 17-OHP are needed when both gonads are nonpalpable or an undescended testis comes with hypospadias, which raises concern for a disorder of sex development.
Many undescended testes in term boys descend in the first months, so a palpable unilateral one is rechecked and referred to urology if still undescended at 6 months, with orchiopexy ideally by 18 months.
After primary fascial closure of a gastroschisis, an infant needs rising ventilator pressures, becomes oliguric, and has mottled, edematous legs. Bladder pressure is 22 mmHg. The most appropriate management is to
Diuretics do not relieve compression of the kidneys and vena cava, so urine output stays low.
Closure under tension raises abdominal pressure above about 20 mmHg with organ dysfunction; decompression by reopening the fascia and using a silo is the treatment.
Higher pressures only fight the elevated diaphragm while renal and bowel perfusion keep falling.
A neonate with pulmonary atresia on alprostadil 0.05 mcg/kg/min develops apnea. The most appropriate action is to
A bolus treats hypotension and does nothing for drug-induced apnea.
Stopping alprostadil lets the duct constrict, causing profound hypoxemia in a duct-dependent lesion.
Apnea is a common dose-related effect of alprostadil, but lung blood flow in pulmonary atresia depends on the ductus, so the infusion continues while breathing is supported.
Metabolic, endocrine and genetic disorders · 11 items
Healthy parents have an infant with an autosomal recessive metabolic disorder confirmed by two pathogenic variants, one inherited from each parent. The chance that their next child will be affected is
A very low recurrence risk applies to a de novo variant, not to an infant who inherited one variant from each parent.
When both parents carry one pathogenic variant, each pregnancy has a 1 in 4 chance of an affected child, regardless of earlier outcomes.
Two-thirds is the chance that an unaffected sibling is a carrier, a different question from the recurrence risk.
Metabolic, endocrine and genetic disorders · 11 items
A 6-week-old has glucose 350 mg/dL with low C-peptide. Genetic testing shows an activating KCNJ11 (KATP channel) mutation. The preferred long-term therapy is
Diazoxide opens KATP channels, the treatment for hyperinsulinism, and would worsen this form of diabetes.
Activating KATP mutations keep the channel open so beta cells cannot release insulin; sulfonylureas close the channel and let most infants come off insulin.
Metformin treats insulin resistance; this infant cannot secrete insulin at all.
Metabolic, endocrine and genetic disorders · 11 items
A 2-day-old with hypoketotic hypoglycemia, cardiomyopathy and raised long-chain hydroxyacylcarnitines on the newborn screen is suspected to have LCHAD deficiency. PN is being ordered. Which component should be withheld?
Standard IV lipid is long-chain fat that cannot be oxidized in LCHAD deficiency and can worsen cardiomyopathy and arrhythmia; a generous GIR suppresses lipolysis instead.
Protein is restricted in urea cycle defects and some organic acidemias, not in fatty acid oxidation disorders.
Minerals are unaffected by the metabolic block and are needed for growth.
A newborn of a healthy mother has an expressionless face with incomplete eye closure on both sides, a weak suck, and cannot abduct either eye. The MOST likely diagnosis is
Transient myasthenia requires a mother with myasthenia gravis, and this mother is healthy.
Myotonic dystrophy also gives facial diplegia, but eye abduction is preserved and the mother usually has myotonia.
Bilateral facial weakness combined with bilateral abducens palsy is Möbius syndrome, from hypoplastic brainstem cranial nerve nuclei.
A unit proposes twice-daily petrolatum ointment over the whole body of every infant under 1,000 g for the first 2 weeks. The main concern with this practice is
Petrolatum reduces evaporative water loss, which tends to help temperature rather than cool the infant.
Routine prophylactic ointment in very preterm infants in high-income settings has not improved outcomes and has been linked to more nosocomial infection, especially coagulase-negative staphylococci.
The preterm barrier matures quickly after birth whatever is applied; the documented harm is infection, not delayed maturation.
A neonate with bilious emesis and multiple dilated loops is found to have jejunal atresia. Unlike duodenal atresia, this lesion MOST often results from:
Jejunoileal atresia follows an in-utero vascular accident, such as volvulus or intussusception, that infarcts a segment of bowel, so associated anomalies are uncommon.
Absent ganglion cells define Hirschsprung disease, a functional obstruction without a gap in the bowel.
Thick meconium in cystic fibrosis causes meconium ileus, though it can occasionally lead to secondary atresia.
Metabolic, endocrine and genetic disorders · 11 items
A hypotonic newborn has inverted nipples, abnormal fat pads over the buttocks, cerebellar hypoplasia and raised liver enzymes. The BEST screening test is
Organic acids detect organic acidemias, which present with acidosis and encephalopathy, not this pattern of fat and nipple changes.
Inverted nipples, abnormal fat pads and cerebellar hypoplasia are the hallmark of PMM2 congenital disorder of glycosylation, screened by transferrin isoelectric focusing.
A microarray finds copy-number changes but cannot detect a glycosylation defect caused by single-gene variants.
A 5-day-old with a TSB of 32 mg/dL develops hypertonia, retrocollis and a high-pitched cry. A brain MRI is MOST likely to show bilateral signal change in the
Bilirubin preferentially injures the globus pallidus, subthalamic nuclei and auditory brainstem nuclei, and bilateral pallidal signal change is the MRI signature of kernicterus.
Thalamic and putaminal injury is the pattern of acute profound hypoxia-ischemia, a different cause of neonatal encephalopathy.
Periventricular white-matter injury is the preterm pattern of hypoxic-ischemic damage, not a sign of bilirubin toxicity.
A 10-day-old term infant develops bloody stools, abdominal distention and pneumatosis intestinalis. Which underlying condition is most commonly associated with NEC in term infants?
Breast milk protects against NEC, so naming it as the association reverses its effect.
Fast advancement is a debated contributor in preterm infants, not the main association in term infants.
Most term infants with NEC have a predisposing condition, and congenital heart disease with low diastolic or ductal-steal flow, such as hypoplastic left heart, is the most common.
A mother was diagnosed with smear-positive, drug-susceptible pulmonary tuberculosis 3 weeks before delivery and has taken four-drug therapy since; she is adherent and improving. Her term infant is well, and evaluation for congenital TB is negative. The BEST plan is
Once the mother is on effective therapy, adherent and improving, and the infant has no congenital TB, the infant starts isoniazid and stays with the mother.
Separation is needed only for nonadherence, drug resistance or illness requiring hospitalization; waiting for culture conversion separates the pair without benefit.
Observation without isoniazid leaves the infant unprotected when the risk of disseminated TB is highest.
Before discharge from the newborn nursery, a 3-day-old has a tight lingual frenulum, a poor latch and maternal nipple trauma that persist despite lactation support. The BEST next step is:
Nystatin treats thrush, which is not the cause of a tight frenulum with nipple trauma.
When ankyloglossia causes breastfeeding problems that persist after skilled lactation support, frenotomy is a simple, low-risk procedure that can improve latch and nipple pain.
Switching to bottles abandons breastfeeding rather than fixing a correctable cause of the poor latch.
A 26-week infant of a CMV-seronegative mother needs a red cell transfusion. Which product modification MOST reduces the risk of transfusion-transmitted CMV?
Washing mainly removes plasma and potassium and leaves enough leukocytes to transmit CMV.
Irradiation disables donor lymphocytes to prevent transfusion-associated GVHD, but it does not remove the virus.
CMV stays latent in donor white cells, and filtering out more than 99.9% of leukocytes brings the risk close to that of CMV-seronegative units.
Echocardiography in a newborn with several hypopigmented macules shows multiple echogenic ventricular masses without outflow obstruction or arrhythmia. The expected course of these masses is
Multiple cardiac rhabdomyomas with ash-leaf macules point to tuberous sclerosis; the tumors grow most before birth and then regress in most infants.
Assuming the masses stay unchanged misses their typical involution over the first years.
Postnatal growth of rhabdomyomas is unusual; growth is a fetal phenomenon.
A term infant born by uneventful cesarean has a painless, mobile bump over the middle of the right clavicle. There is no crepitus, tenderness or callus, and the arm moves normally. The most likely diagnosis is
A birth fracture follows a difficult delivery, is tender with crepitus and forms a palpable callus within 1 to 2 weeks, none of which fits a painless bump after an easy cesarean.
Congenital pseudarthrosis of the clavicle is almost always right-sided, present without birth trauma, painless and without crepitus or callus; it is observed and repaired later only if symptomatic.
A sternocleidomastoid tumor is a firm mass in the muscle of the neck with head tilt, not a mobile bump over the middle of the clavicle.
In anti-Kell alloimmunization, the fetus may become severely anemic while amniotic fluid bilirubin stays low. This is because anti-Kell antibodies MAINLY
Anti-Kell is IgG and crosses the placenta readily, which is why it can cause hydrops well before birth.
Anti-Kell harms the fetus in utero; MCA Doppler is used to monitor fetal anemia for that reason.
The Kell antigen appears early on erythroid precursors, so anti-Kell suppresses red cell production as well as destroying cells, giving severe anemia with little bilirubin.
Which set of findings indicates MODERATE (Sarnat stage 2) encephalopathy?
Jitteriness with a strong suck describes mild, sympathetic-dominant encephalopathy, not stage 2.
Hyperalertness with normal tone and dilated pupils is stage 1, mild encephalopathy, which is not an indication for cooling.
Sarnat stage 2 features lethargy, low tone, a weak suck and parasympathetic signs such as miosis and bradycardia, the threshold for therapeutic hypothermia.
No. This page counts correct answers; the board equates its forms and judges each candidate on an ability scale, so read a percentage here as a pointer to weak areas, not as a forecast.
Why do the questions have only three answer choices?
Because NCC's form does. Writing practice items the same way keeps the habit you need on test day: weighing one answer against two plausible near misses.
Which neonatal topics appear here but not on the area pages?
Renal and genitourinary, musculoskeletal, skin, eyes, ears and throat, professional issues, and for now neurology, GI and metabolic and genetic disorders.