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Barkley Neonatal Nurse Practitioner (NNP-BC)
Certification Exam – 175 Board-Style Questions &
Answers
Welcome! This test bank is designed to help you master the most frequently tested topics on the NCC Neonatal
Nurse Practitioner (NNP-BC)® certification exam. The 175 questions that follow are grouped into 14 high-yield
sections, each focusing on a core domain of neonatal practice. They mirror the style, difficulty, and clinical
reasoning required to pass the 3-hour, 175-question computer-based exam (150 scored, 25 pretest).
DOMAINS COVERED & WEIGHT ON EXAM
• General Assessment & Perinatal History – 12 %
• Embryology, Physiology, & Systems Management – 26 %
• Pharmacology & Common Drug Therapies – 14 %
• Growth, Nutrition, Fluids & Electrolytes – 12 %
• Thermoregulation & Resuscitation – 8 %
• Clinical Genetics & Congenital Anomalies – 8 %
• Infectious Diseases – 6 %
• Professional Considerations, Ethics & Discharge Planning – 14 %
(Weights approximate based on the NCC exam blueprint and Barkley
review course materials.)
SECTION 1 – GENERAL ASSESSMENT & PERINATAL HISTORY (Questions
1–20)
1. A 32-week-gestation infant is born to a mother with
chorioamnionitis. The infant is tachypneic, hypotonic, and has a
pg. 1
,2
purpuric rash. Initial labs show neutropenia and thrombocytopenia.
Which organism is most likely?
A) Group B Streptococcus
B) Escherichia coli
C) Listeria monocytogenes
D) Herpes simplex virus
: Correct Answer : C
Rationale: Listeria monocytogenes causes early-onset sepsis with a
characteristic purpuric rash (“granulomatosis infantiseptica”) and
multisystem involvement. Unlike GBS (A), which classically presents
with respiratory distress, Listeria is associated with maternal flu-like
symptoms and a distinctive rash.
2. A 24-week-gestation infant is noted to have a barely audible cry,
poor suck, and profound generalized hypotonia. Maternal history is
significant for hypertension treated with labetalol and magnesium
sulfate. Which is the most likely cause?
A) Labetalol toxicity
B) Hypermagnesemia
C) Intraventricular hemorrhage
D) Hypoglycemia
: Correct Answer : B
Rationale: Magnesium sulfate crosses the placenta and can cause
neonatal hypermagnesemia, which presents with hypotonia,
respiratory depression, poor suck, and diminished reflexes. The severity
is directly related to the maternal magnesium level and infusion time.
3. A newborn’s CBC shows a nucleated RBC count of 25/100 WBCs.
This finding is most consistent with:
A) Polycythemia
B) Sepsis
pg. 2
,3
C) Chronic intrauterine hypoxia
D) Hemolytic disease
: Correct Answer : C
Rationale: Nucleated red blood cells (NRBCs) are a marker of chronic
intrauterine hypoxia. Elevated NRBCs are seen in conditions such as
placental insufficiency, maternal diabetes, and post-dates pregnancy.
They may also be elevated in Rh disease or sepsis, but the most
common cause is sustained hypoxia.
4. A late-preterm neonate (35 weeks) develops jaundice on day 4 of
life with a total bilirubin of 14 mg/dL (indirect 13.5, direct 0.5). The
infant is breastfeeding well and has gained appropriate weight. Which
type of jaundice is most likely?
A) Physiologic jaundice
B) Pathologic jaundice
C) Breastfeeding jaundice
D) Breast milk jaundice
: Correct Answer : D
Rationale: Breast milk jaundice typically begins after the first week of
life, peaks during the second week, and can persist for several weeks. It
is caused by increased β-glucuronidase activity in breast milk that
deconjugates intestinal bilirubin, leading to increased enterohepatic
circulation. The infant is well, gaining weight, and feeding adequately.
5. A late-preterm infant at day 2 of life has a bilirubin of 12 mg/dL,
poor feeding, weight loss of 8 %, and no stool yet. Which type of
jaundice is most consistent with this presentation?
A) Breastfeeding jaundice
B) Hemolytic disease
C) Crigler-Najjar syndrome
D) Breastfeeding jaundice
pg. 3
, 4
: Correct Answer : D
Rationale: Breastfeeding jaundice (early onset, also called “starvation
jaundice”) occurs in the first days of life due to inadequate milk intake.
The infant becomes dehydrated, does not stool, and reabsorbs
conjugated bilirubin from the gut, increasing enterohepatic circulation.
It resolves when adequate feeding volume is established.
6. A 3-day-old, formula-fed term infant develops vomiting, lethargy,
and abdominal distention. Serum electrolytes show hyponatremia
and hyperkalemia. Which congenital adrenal hyperplasia is most
likely?
A) 11-hydroxylase deficiency
B) 21-hydroxylase deficiency
C) 17-hydroxylase deficiency
D) 3β-hydroxysteroid dehydrogenase deficiency
: Correct Answer : B
Rationale: The classic salt-wasting crisis of 21-hydroxylase deficiency
typically presents on day 3-5 of life with vomiting, dehydration,
hyponatremia, hyperkalemia, and shock. This is the most common
cause of congenital adrenal hyperplasia (CAH).
7. A term infant is noted to have bilateral cryptorchidism and a small
phallus. The parents report that the infant appears otherwise well.
Which of the following should be evaluated first?
A) Renal ultrasound
B) Karyotype
C) LH and FSH levels
D) Testosterone stimulation test
: Correct Answer : B
Rationale: The presence of bilateral cryptorchidism with a small phallus
in a term infant should raise suspicion of a disorder of sexual
pg. 4
Barkley Neonatal Nurse Practitioner (NNP-BC)
Certification Exam – 175 Board-Style Questions &
Answers
Welcome! This test bank is designed to help you master the most frequently tested topics on the NCC Neonatal
Nurse Practitioner (NNP-BC)® certification exam. The 175 questions that follow are grouped into 14 high-yield
sections, each focusing on a core domain of neonatal practice. They mirror the style, difficulty, and clinical
reasoning required to pass the 3-hour, 175-question computer-based exam (150 scored, 25 pretest).
DOMAINS COVERED & WEIGHT ON EXAM
• General Assessment & Perinatal History – 12 %
• Embryology, Physiology, & Systems Management – 26 %
• Pharmacology & Common Drug Therapies – 14 %
• Growth, Nutrition, Fluids & Electrolytes – 12 %
• Thermoregulation & Resuscitation – 8 %
• Clinical Genetics & Congenital Anomalies – 8 %
• Infectious Diseases – 6 %
• Professional Considerations, Ethics & Discharge Planning – 14 %
(Weights approximate based on the NCC exam blueprint and Barkley
review course materials.)
SECTION 1 – GENERAL ASSESSMENT & PERINATAL HISTORY (Questions
1–20)
1. A 32-week-gestation infant is born to a mother with
chorioamnionitis. The infant is tachypneic, hypotonic, and has a
pg. 1
,2
purpuric rash. Initial labs show neutropenia and thrombocytopenia.
Which organism is most likely?
A) Group B Streptococcus
B) Escherichia coli
C) Listeria monocytogenes
D) Herpes simplex virus
: Correct Answer : C
Rationale: Listeria monocytogenes causes early-onset sepsis with a
characteristic purpuric rash (“granulomatosis infantiseptica”) and
multisystem involvement. Unlike GBS (A), which classically presents
with respiratory distress, Listeria is associated with maternal flu-like
symptoms and a distinctive rash.
2. A 24-week-gestation infant is noted to have a barely audible cry,
poor suck, and profound generalized hypotonia. Maternal history is
significant for hypertension treated with labetalol and magnesium
sulfate. Which is the most likely cause?
A) Labetalol toxicity
B) Hypermagnesemia
C) Intraventricular hemorrhage
D) Hypoglycemia
: Correct Answer : B
Rationale: Magnesium sulfate crosses the placenta and can cause
neonatal hypermagnesemia, which presents with hypotonia,
respiratory depression, poor suck, and diminished reflexes. The severity
is directly related to the maternal magnesium level and infusion time.
3. A newborn’s CBC shows a nucleated RBC count of 25/100 WBCs.
This finding is most consistent with:
A) Polycythemia
B) Sepsis
pg. 2
,3
C) Chronic intrauterine hypoxia
D) Hemolytic disease
: Correct Answer : C
Rationale: Nucleated red blood cells (NRBCs) are a marker of chronic
intrauterine hypoxia. Elevated NRBCs are seen in conditions such as
placental insufficiency, maternal diabetes, and post-dates pregnancy.
They may also be elevated in Rh disease or sepsis, but the most
common cause is sustained hypoxia.
4. A late-preterm neonate (35 weeks) develops jaundice on day 4 of
life with a total bilirubin of 14 mg/dL (indirect 13.5, direct 0.5). The
infant is breastfeeding well and has gained appropriate weight. Which
type of jaundice is most likely?
A) Physiologic jaundice
B) Pathologic jaundice
C) Breastfeeding jaundice
D) Breast milk jaundice
: Correct Answer : D
Rationale: Breast milk jaundice typically begins after the first week of
life, peaks during the second week, and can persist for several weeks. It
is caused by increased β-glucuronidase activity in breast milk that
deconjugates intestinal bilirubin, leading to increased enterohepatic
circulation. The infant is well, gaining weight, and feeding adequately.
5. A late-preterm infant at day 2 of life has a bilirubin of 12 mg/dL,
poor feeding, weight loss of 8 %, and no stool yet. Which type of
jaundice is most consistent with this presentation?
A) Breastfeeding jaundice
B) Hemolytic disease
C) Crigler-Najjar syndrome
D) Breastfeeding jaundice
pg. 3
, 4
: Correct Answer : D
Rationale: Breastfeeding jaundice (early onset, also called “starvation
jaundice”) occurs in the first days of life due to inadequate milk intake.
The infant becomes dehydrated, does not stool, and reabsorbs
conjugated bilirubin from the gut, increasing enterohepatic circulation.
It resolves when adequate feeding volume is established.
6. A 3-day-old, formula-fed term infant develops vomiting, lethargy,
and abdominal distention. Serum electrolytes show hyponatremia
and hyperkalemia. Which congenital adrenal hyperplasia is most
likely?
A) 11-hydroxylase deficiency
B) 21-hydroxylase deficiency
C) 17-hydroxylase deficiency
D) 3β-hydroxysteroid dehydrogenase deficiency
: Correct Answer : B
Rationale: The classic salt-wasting crisis of 21-hydroxylase deficiency
typically presents on day 3-5 of life with vomiting, dehydration,
hyponatremia, hyperkalemia, and shock. This is the most common
cause of congenital adrenal hyperplasia (CAH).
7. A term infant is noted to have bilateral cryptorchidism and a small
phallus. The parents report that the infant appears otherwise well.
Which of the following should be evaluated first?
A) Renal ultrasound
B) Karyotype
C) LH and FSH levels
D) Testosterone stimulation test
: Correct Answer : B
Rationale: The presence of bilateral cryptorchidism with a small phallus
in a term infant should raise suspicion of a disorder of sexual
pg. 4
