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Barkley Neonatal Nurse Practitioner (NNP-BC)
Certification Exam | 175 Actual Questions and Answers
Domain I: General Assessment — Maternal History & Fetal Evaluation (17% of
Exam)
Question 1
A 32-year-old G2P1 at 39 weeks gestation has a history of systemic lupus
erythematosus (SLE). Which fetal complication is of GREATEST concern in the
immediate newborn period?
A. Polycythemia
B. Complete congenital heart block
C. Hypoglycemia
D. Meconium aspiration syndrome
Correct Answer: B
Explanation:
Maternal SLE with positive anti-Ro/SSA or anti-La/SSB antibodies is strongly
associated with neonatal lupus erythematosus, the most serious manifestation of
which is complete congenital heart block (CCHB). These autoantibodies cross the
placenta and cause inflammation and fibrosis of the fetal conduction system,
typically developing between 18 and 24 weeks gestation. CCHB is irreversible and
often requires permanent pacemaker placement. Polycythemia is associated with
maternal diabetes or intrauterine growth restriction. Hypoglycemia is primarily
seen in infants of diabetic mothers. Meconium aspiration is related to fetal
distress and post-term gestation, not maternal SLE.
Question 2
A mother at 28 weeks gestation is admitted with preterm premature rupture of
membranes (PPROM). Which laboratory test provides the MOST specific
confirmation of ruptured membranes?
pg. 1
,2
A. Nitrazine pH test
B. Ferning pattern on microscopic examination
C. Detection of placental alpha microglobulin-1 (PAMG-1) in vaginal secretions
D. Leopold maneuvers
Correct Answer: C
Explanation:
Detection of placental alpha microglobulin-1 (PAMG-1), commercially available as
the AmniSure test, is highly specific (approximately 99%) for confirming rupture of
membranes. It detects a protein present in high concentrations in amniotic fluid
but not in maternal blood or urine. The nitrazine test has high false-positive rates
due to contamination with blood, semen, or bacterial vaginosis. Ferning is also
subject to false positives. Leopold maneuvers assess fetal presentation, not
membrane integrity.
Question 3
A G1P0 at 26 weeks gestation presents with hypertension, proteinuria, and
epigastric pain. Laboratory results show thrombocytopenia and elevated liver
enzymes. What is the MOST likely diagnosis?
A. Gestational hypertension
B. Chronic hypertension
C. HELLP syndrome
D. Acute fatty liver of pregnancy
Correct Answer: C
Explanation:
HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe
variant of preeclampsia characterized by microangiopathic hemolytic anemia,
hepatic dysfunction, and thrombocytopenia. Epigastric pain results from hepatic
capsular distention. It carries high maternal and fetal morbidity, including preterm
delivery, fetal growth restriction, and neonatal thrombocytopenia. Acute fatty
liver of pregnancy also presents with liver dysfunction but includes coagulopathy
and hypoglycemia, and is not specifically characterized by hemolysis.
pg. 2
,3
Question 4
A diabetic mother with poor glycemic control in the first trimester delivers at 38
weeks. Which congenital anomaly is MOST specifically associated with this
exposure?
A. Transposition of the great arteries
B. Sacral agenesis (caudal regression syndrome)
C. Duodenal atresia
D. Tracheoesophageal fistula
Correct Answer: B
Explanation:
Caudal regression syndrome (sacral agenesis) is the congenital anomaly most
specifically linked to maternal diabetes, particularly with poor glycemic control
during the critical period of organogenesis (first trimester). It involves agenesis or
hypoplasia of the sacrum and lumbar spine. The risk is 200 to 400 times higher in
infants of diabetic mothers compared to the general population. Transposition of
the great arteries, duodenal atresia, and tracheoesophageal fistula are also part
of the VACTERL association but are not as specifically linked to maternal diabetes
as sacral agenesis.
Question 5
A 35-year-old G3P2 at 16 weeks gestation undergoes amniocentesis. The
karyotype returns as 47,XX,+21. What is the MOST likely finding on prenatal
ultrasound?
A. Omphalocele
B. Duodenal atresia ("double bubble" sign)
C. Increased nuchal translucency
D. Renal agenesis
Correct Answer: B
Explanation:
Trisomy 21 (Down syndrome) is associated with duodenal atresia, which appears
pg. 3
, 4
on prenatal ultrasound as the "double bubble" sign (dilated stomach and proximal
duodenum). Increased nuchal translucency is a first-trimester screening finding,
not a structural anomaly seen on mid-trimester ultrasound. Omphalocele is
associated with trisomy 18. Renal agenesis is associated with Potter sequence.
Question 6
A mother at 32 weeks gestation receives betamethasone for threatened preterm
delivery. What is the PRIMARY mechanism of benefit to the fetus?
A. Stimulation of thyroid hormone production
B. Induction of fetal lung maturity via surfactant protein production
C. Prevention of neonatal hypoglycemia
D. Acceleration of hepatic gluconeogenesis
Correct Answer: B
Explanation:
Antenatal corticosteroids (betamethasone or dexamethasone) induce fetal lung
maturity by stimulating type II pneumocytes to produce surfactant proteins (SP-A,
SP-B, SP-C, SP-D) and phospholipids. This reduces the incidence and severity of
respiratory distress syndrome (RDS) in preterm infants. The effect is maximal
when delivery occurs 24 hours to 7 days after the first dose. Corticosteroids also
accelerate maturation of other organ systems, including the gastrointestinal tract,
central nervous system, and cardiovascular system, but the primary benefit for
neonatal survival is through pulmonary maturation.
Question 7
A fetal biophysical profile (BPP) includes all of the following components EXCEPT:
A. Fetal breathing movements
B. Fetal tone
C. Amniotic fluid volume
D. Fetal heart rate variability via non-stress test
E. Fetal scalp blood sampling
Correct Answer: E
pg. 4
Barkley Neonatal Nurse Practitioner (NNP-BC)
Certification Exam | 175 Actual Questions and Answers
Domain I: General Assessment — Maternal History & Fetal Evaluation (17% of
Exam)
Question 1
A 32-year-old G2P1 at 39 weeks gestation has a history of systemic lupus
erythematosus (SLE). Which fetal complication is of GREATEST concern in the
immediate newborn period?
A. Polycythemia
B. Complete congenital heart block
C. Hypoglycemia
D. Meconium aspiration syndrome
Correct Answer: B
Explanation:
Maternal SLE with positive anti-Ro/SSA or anti-La/SSB antibodies is strongly
associated with neonatal lupus erythematosus, the most serious manifestation of
which is complete congenital heart block (CCHB). These autoantibodies cross the
placenta and cause inflammation and fibrosis of the fetal conduction system,
typically developing between 18 and 24 weeks gestation. CCHB is irreversible and
often requires permanent pacemaker placement. Polycythemia is associated with
maternal diabetes or intrauterine growth restriction. Hypoglycemia is primarily
seen in infants of diabetic mothers. Meconium aspiration is related to fetal
distress and post-term gestation, not maternal SLE.
Question 2
A mother at 28 weeks gestation is admitted with preterm premature rupture of
membranes (PPROM). Which laboratory test provides the MOST specific
confirmation of ruptured membranes?
pg. 1
,2
A. Nitrazine pH test
B. Ferning pattern on microscopic examination
C. Detection of placental alpha microglobulin-1 (PAMG-1) in vaginal secretions
D. Leopold maneuvers
Correct Answer: C
Explanation:
Detection of placental alpha microglobulin-1 (PAMG-1), commercially available as
the AmniSure test, is highly specific (approximately 99%) for confirming rupture of
membranes. It detects a protein present in high concentrations in amniotic fluid
but not in maternal blood or urine. The nitrazine test has high false-positive rates
due to contamination with blood, semen, or bacterial vaginosis. Ferning is also
subject to false positives. Leopold maneuvers assess fetal presentation, not
membrane integrity.
Question 3
A G1P0 at 26 weeks gestation presents with hypertension, proteinuria, and
epigastric pain. Laboratory results show thrombocytopenia and elevated liver
enzymes. What is the MOST likely diagnosis?
A. Gestational hypertension
B. Chronic hypertension
C. HELLP syndrome
D. Acute fatty liver of pregnancy
Correct Answer: C
Explanation:
HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe
variant of preeclampsia characterized by microangiopathic hemolytic anemia,
hepatic dysfunction, and thrombocytopenia. Epigastric pain results from hepatic
capsular distention. It carries high maternal and fetal morbidity, including preterm
delivery, fetal growth restriction, and neonatal thrombocytopenia. Acute fatty
liver of pregnancy also presents with liver dysfunction but includes coagulopathy
and hypoglycemia, and is not specifically characterized by hemolysis.
pg. 2
,3
Question 4
A diabetic mother with poor glycemic control in the first trimester delivers at 38
weeks. Which congenital anomaly is MOST specifically associated with this
exposure?
A. Transposition of the great arteries
B. Sacral agenesis (caudal regression syndrome)
C. Duodenal atresia
D. Tracheoesophageal fistula
Correct Answer: B
Explanation:
Caudal regression syndrome (sacral agenesis) is the congenital anomaly most
specifically linked to maternal diabetes, particularly with poor glycemic control
during the critical period of organogenesis (first trimester). It involves agenesis or
hypoplasia of the sacrum and lumbar spine. The risk is 200 to 400 times higher in
infants of diabetic mothers compared to the general population. Transposition of
the great arteries, duodenal atresia, and tracheoesophageal fistula are also part
of the VACTERL association but are not as specifically linked to maternal diabetes
as sacral agenesis.
Question 5
A 35-year-old G3P2 at 16 weeks gestation undergoes amniocentesis. The
karyotype returns as 47,XX,+21. What is the MOST likely finding on prenatal
ultrasound?
A. Omphalocele
B. Duodenal atresia ("double bubble" sign)
C. Increased nuchal translucency
D. Renal agenesis
Correct Answer: B
Explanation:
Trisomy 21 (Down syndrome) is associated with duodenal atresia, which appears
pg. 3
, 4
on prenatal ultrasound as the "double bubble" sign (dilated stomach and proximal
duodenum). Increased nuchal translucency is a first-trimester screening finding,
not a structural anomaly seen on mid-trimester ultrasound. Omphalocele is
associated with trisomy 18. Renal agenesis is associated with Potter sequence.
Question 6
A mother at 32 weeks gestation receives betamethasone for threatened preterm
delivery. What is the PRIMARY mechanism of benefit to the fetus?
A. Stimulation of thyroid hormone production
B. Induction of fetal lung maturity via surfactant protein production
C. Prevention of neonatal hypoglycemia
D. Acceleration of hepatic gluconeogenesis
Correct Answer: B
Explanation:
Antenatal corticosteroids (betamethasone or dexamethasone) induce fetal lung
maturity by stimulating type II pneumocytes to produce surfactant proteins (SP-A,
SP-B, SP-C, SP-D) and phospholipids. This reduces the incidence and severity of
respiratory distress syndrome (RDS) in preterm infants. The effect is maximal
when delivery occurs 24 hours to 7 days after the first dose. Corticosteroids also
accelerate maturation of other organ systems, including the gastrointestinal tract,
central nervous system, and cardiovascular system, but the primary benefit for
neonatal survival is through pulmonary maturation.
Question 7
A fetal biophysical profile (BPP) includes all of the following components EXCEPT:
A. Fetal breathing movements
B. Fetal tone
C. Amniotic fluid volume
D. Fetal heart rate variability via non-stress test
E. Fetal scalp blood sampling
Correct Answer: E
pg. 4
