Facts read from nccwebsite.org · last checked Nov 7, 2026
The lungs carry more questions than any other system, 14 of the 150 scored. Expect a newborn in distress, a gas, a film or a ventilator setting, and a choice about what it means or what comes next.
Practice questions
60 questions written to the NNP-BC outline; each choice is explained once you pick.
Common distress: RDS, transient tachypnea, meconium aspiration, pneumonia, apnea of prematurity.
Air and fluid: pneumothorax and other air leaks, chylothorax, pulmonary hemorrhage.
Structure: CPAM and cystic lesions, diaphragmatic hernia and eventration, pulmonary hypoplasia, laryngomalacia, tracheomalacia and stenosis.
Circulation and chronic disease: persistent pulmonary hypertension, chronic lung disease.
Support: oxygen delivery, the oxyhemoglobin curve, CPAP, NIPPV, NAVA, conventional and high-frequency ventilation, nitric oxide, ECMO.
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Oxygenation index, worked
A term infant on conventional ventilation: mean airway pressure 14 cm H2O, FiO2 0.80, PaO2 50 mm Hg.
Mean airway pressure × FiO2 × 1001,120
14 × 0.80 × 100
→
Divide by PaO222.4
1,120 ÷ 50
→
Oxygenation indexabout 22
A higher index means sicker lungs. ELSO's neonatal guideline treats an index of 40 or more that persists as a usual threshold for considering ECMO.
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15 neonatal respiratory questions
0 / 15 answered15 questions
Tap an option: why each one is right or wrong appears under it.
Neonatal respiratory care · 14 items
A ventilated 25-week infant develops pulmonary interstitial emphysema confined to the left lung, with rising FiO2. The most helpful strategy is
A longer inspiratory time raises mean airway pressure and air trapping, worsening interstitial emphysema.
Raising PEEP adds distending pressure and drives more air into the interstitium of the injured lung.
Placing the affected lung dependent reduces its ventilation and lets trapped interstitial air resolve; lowering mean airway pressure or high-frequency ventilation are further options.
Extrauterine survival at 22–24 weeks is possible because the lung has entered which stage of development?
The pseudoglandular stage forms conducting airways only, with no gas-exchange surface, so survival is impossible at that point.
In the canalicular stage, about 16 to 26 weeks, respiratory bronchioles form and capillaries meet the airway epithelium, making gas exchange just possible and setting the limit of viability.
True alveoli form from about 36 weeks onward, well after the threshold of viability.
A prenatally detected lung lesion is found to receive its blood supply from a vessel arising from the descending aorta. The lesion is most likely a
A systemic arterial supply from the aorta defines bronchopulmonary sequestration, nonfunctioning lung tissue usually without a normal bronchial connection.
A bronchogenic cyst is a foregut cyst, usually in the mediastinum, supplied by normal vessels.
Lobar emphysema is overinflation of a normally supplied lobe, often the left upper, with no aberrant artery.
A 30-week infant already on caffeine still has frequent apneic events. The recording shows airway obstruction at the start of most episodes. The BEST added therapy is
Low-flow oxygen raises the baseline saturation but gives no distending pressure, so it does not prevent the airway collapse that starts these events.
Most apnea of prematurity is mixed and begins with pharyngeal collapse; nasal CPAP splints the upper airway and raises lung volume, treating the obstructive part caffeine misses.
Doxapram is a second-line central stimulant with more side effects, and like caffeine it does not address obstruction.
A term newborn born after polyhydramnios has severe hypotonia, bilateral clubfeet, facial weakness with a tented upper lip, and needs ventilation. The mother cannot release her grip quickly after a handshake. The most likely diagnosis is
Transient myasthenia needs a mother with myasthenia gravis; a mother who cannot release her grip has myotonia instead.
SMA type 1 causes profound weakness but spares the face, so the infant looks alert, with tongue fasciculations and absent reflexes.
Congenital myotonic dystrophy follows maternal transmission of a large CTG expansion; the mother's grip myotonia, the infant's facial diplegia with a tented lip, clubfeet and respiratory failure are classic.
For which infant is inhaled nitric oxide LEAST supported by current evidence?
Sepsis-associated pulmonary hypertension in a term infant with this OI also falls within the established indication for iNO.
A term infant with meconium aspiration and an OI around 25 or higher is exactly the hypoxemic respiratory failure in which iNO reduces the need for ECMO.
Routine iNO in infants under 34 weeks has not improved survival or BPD, so it is not recommended outside rescue settings such as pulmonary hypoplasia after membrane rupture.
Which factor is most strongly associated with pulmonary hemorrhage in extremely low birth weight infants?
As surfactant lowers pulmonary resistance, a large left-to-right PDA floods the lungs, producing the hemorrhagic pulmonary edema typical of ELBW infants.
Maternal diabetes delays surfactant maturation and raises RDS risk, but it is not a recognized cause of pulmonary hemorrhage.
Antenatal steroids mature the lungs and are protective, so naming them as a cause reverses their effect.
A newborn with respiratory distress and persistent rhinorrhea has situs inversus totalis with dextrocardia. The most likely underlying diagnosis is
Motile cilia at the embryonic node set left–right asymmetry, so in primary ciliary dyskinesia about half of infants have situs inversus, often with neonatal respiratory distress and persistent rhinorrhea.
Cystic fibrosis causes sinopulmonary disease and meconium ileus but does not affect organ laterality.
22q11.2 deletion brings conotruncal heart defects and hypocalcemia, not situs inversus.
A term neonate with respiratory distress has air-filled bowel loops in the left hemithorax, a rightward mediastinal shift, and an orogastric tube tip in the left chest. The most likely diagnosis is
A tension pneumothorax also shifts the mediastinum, but it shows free air without bowel markings and the tube stays in the abdomen.
Lobar emphysema shows one hyperlucent, overexpanded lobe, not bowel loops with the stomach in the chest.
An orogastric tube ending in the chest proves the stomach lies above the diaphragm, confirming a left posterolateral (Bochdalek) hernia.
A term neonate has recurrent hypoventilation during sleep (PaCO2 75 mmHg) with normal breathing awake, normal lungs, and later Hirschsprung disease. The test that confirms the diagnosis is
Hypoventilation during sleep with normal lungs and Hirschsprung disease points to congenital central hypoventilation syndrome, confirmed by PHOX2B testing.
SMN1 deletion causes spinal muscular atrophy, with weakness and hypoventilation while awake as well as asleep.
RET variants cause Hirschsprung disease, which tempts the choice, but they do not explain failure of automatic breathing during sleep.
The initial dose of poractant alfa with the best evidence for treating RDS is
Fifty milligrams per kilogram is well below any studied effective dose and would leave much of the lung untreated.
A first poractant dose of 200 mg/kg (2.5 mL/kg) improves oxygenation and reduces retreatment and mortality compared with 100 mg/kg, so it is the recommended starting dose.
Doubling the dose adds volume and airway obstruction during instillation without extra benefit.
A term infant with clear amniotic fluid has progressive respiratory failure from birth, diffuse ground-glass opacities and only a brief response to repeated poractant doses. A sibling died similarly. The MOST likely diagnosis is:
An RDS picture in a term infant that responds only briefly to surfactant, with a sibling who died the same way, suggests inherited SP-B deficiency, which is usually lethal without transplant.
Meconium aspiration requires meconium-stained fluid; this infant was born through clear fluid.
TTN improves within 24 to 72 hours, while this infant worsens steadily despite treatment.
After several difficult intubation attempts, a 700-g infant has copious oral secretions and an orogastric tube that meets resistance. The radiograph shows the tube tip in the right lower chest, off the normal midline course, with normal bowel gas. The MOST likely diagnosis is
Traumatic intubation in an ELBW infant can puncture the pharynx or esophagus and create a false passage that mimics atresia, with drooling and a tube tip off the midline course.
Stenosis can resist the tube but keeps it in the midline esophagus; a tube that leaves the normal track in the chest suggests perforation.
An H-type fistula lets the tube pass normally and presents later with coughing or choking on feeds.
A 30-week infant with RDS worsens over the first 2 days. On day 3, urine output rises sharply and weight falls. The respiratory course is now MOST likely to
Worsening after the diuresis is not the natural course and should prompt a search for a PDA, air leak or infection.
In RDS the spontaneous diuresis on about days 2 to 4 coincides with rising surfactant production and lung fluid clearance, and it usually heralds better compliance and a falling oxygen need.
RDS typically peaks at 48 to 72 hours and then improves; a two-week plateau describes evolving chronic lung disease, not the diuretic phase.
A running total sits here; it fills in after your last pick.
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Reading lungs: common traps
TTN called RDS. Transient tachypnea follows a term or late-preterm birth, often by cesarean without labor; the film shows streaky perihilar markings and fluid in the fissures, and it clears within a few days. RDS is a preterm, surfactant-deficient lung with low volumes and a diffuse ground-glass pattern.
Chest rise as tube confirmation. The NRP textbook uses exhaled CO2 with a rising heart rate. A detector can stay negative with a correct tube when cardiac output is very low, so read it with the heart rate.
A normal pH read as a normal gas. In established chronic lung disease, a pH in range with a high PaCO2 and a high bicarbonate is compensated respiratory acidosis, not a normal result.
Pulmonary hypertension without the two probes. A pre-ductal (right hand) saturation clearly above the post-ductal one points to right-to-left ductal shunting; echocardiography confirms the diagnosis.