NMS Q&A Family Medicine

Newborn and Infant Care and Prevention, Birth to Age 1 257Examination Answers1. The answer is E. Koplik spots are associated with anddiagnostic of rubeola. The clinical picture in the vignetteis typical of rubella, and the palatal exanthem consistsof Flourscheimer spots, quite different in number anddistribution from Koplik spots that occur on the buccalmucosae approximately opposite the upper secondmolars, one on each side. The list of neonatal conditions,affecting 50% to 80% of fetuses when maternal rubellaoccurs in the first trimester includes the other choices,cataract, sensorineural hearing loss, hepatitis and smallnessfor gestational age as well as several congenital cardiacanomalies, micophthalmia, glaucoma, retinitis,chronic encephalitis, and blood disorders.2. The answer is C. Group B streptococcus infectionoccurs more often after premature labor and prolongedrupture of membranes. This serious infection with a highcase mortality if untreated must be suspected in any systemicillness occurring within the first week of life.Delayed cases may appear after 1 to 16 weeks. Pneumonitisand apnea are typical and progress rapidly to sepsisand meningitis. Failure to diagnose may have grave medicolegalimplications. Beta strep infection is rare duringthe neonatal period. S. aureus usually is localized andpointing. Rubeola manifests a classic morbilliform rashand otherwise is entirely different in expression. Finally,the mother’s immunity covers the newborn for severalmonths. Erythema infectiosa, “fifth disease” appearsnearly always in the age range of 5 to 15 years.3. The answer is E. Coarctation of the abdominal aorta.This condition of course does not cause cyanosis. Perhapssurprising is that congenital critical pulmonary stenosismay result in cyanosis, on the basis that at birth, the foramenovale and the ductus arteriosis will remain open as amechanical response to the increased right ventricularpressure, to maintain a right to left shunting. Each of theother choices is a condition that results in unoxygenatedblood shunting into the left ventricular outflow circulationby its permanent anatomical nature.4. The answer is C. The incorrect statement is that circumcisionreduces the chances of carcinoma of the cervixin future female partners. However, the presence of theforeskin does appear to be associated with a greater risk ofpenile cancer. It is true that uncircumcised males have agreater risk of urinary tract infections, compared with circumcisedmales; circumcision is contraindicated in newbornswith hypospadias because the foreskin may beinvaluable in plastic repair of the deformity, most specificallyto reconstruct the urethral orifice. Obviously, phimosisis not possible in the absence of a foreskin.5. The answer is D. One wet diaper in the first 24 hoursshould be adequate to ensure normal hydration and kidneyfunction. Normal alimentation is not sensitive enough,whereas all the other signs listed, that is, waiting for drymucosae, poor skin turgor, and sunken eyeballs, which arequite valid for clinical dehydration, are later in developmentthan optimum care dictates. By day 2, there should be a wetdiaper two to three times per 24 hours, and by day 5 thereshould be a wet diaper six to eight times per 24 hours.6. The answer is B. A bilirubin level 10 mg/dL at 12hours of age is an appropriate signal that the indirect-actingbilirubin may reach the level of 20 mg/dL by the third orfourth day, setting the stage for kernicterus. Other cutoffpoints are bilirubin levels of 14 mg/dL between 12 and24 hours and 15 mg/dL at 24 hours of age. Jaundicethat is due to a pathological as opposed to a physiologicalcause appears on the first day of life, and bilirubin levels canrise by more than 5 mg/dL/day. Peak bilirubin levels inphysiologic jaundice rarely exceed 12 mg/dL but pathologicjaundice peaks at a much higher level, as stated. Exchangetransfusion may be necessary if phototherapy does notobviate that need.7. The answer is B, 120 kcal/kg/day is the average caloricrequirement for a newborn infant.8. The answer is E. Family history of atopic disease is notmentioned in the literature as a risk factor for SIDS. Thetwo strongest (and remediable) risk factors are a smokingmother and prone sleeping position. Minority ethnicityand low socioeconomic status are risk factors but are notspecific enough to be helpful.9. The answer is E. Hep B (hepatitis B) is the only routineimmunization recommended for infants in the newbornperiod ( 1 month of age) and should be given atbirth. It may await the first or second month if the motheris negative to hepatitis B surface antigen. DTaP, Hib, IPV,and PCV are each given at 2, 4, and 6 months.10. The answer is D, C. trachomatis. The two most significantcauses of neonatal conjunctivitis (ophthalmianeonatorium) are gonorrhea and C. trachomatis. Gonorrhealconjunctivitis is prevented by routine neonataltreatment with silver nitrate. Presently the approach tochlamydial conjunctivitis is diagnosis by culture or rapid