RNC NIC ACTUAL 2026 STUDY GUIDE QUESTIONS AND
SOLUTIONS RATED A+
✔✔postdiuretic phase - ✔✔- DOL 4-5, when UOP begins to respond appropriately to
changes in fluid intake
- infant more readily able to vary urine and sodium output in response to fluid and
sodium intake and body fluid status
- when recovery from RDS begins to occur
✔✔weight loss after birth - ✔✔- 5-10% in term infants
- 10-20% in preterm infants (more premature, higher insensible water losses
✔✔potassium excretion - ✔✔- excreted in UOP, serum levels will decrease as renal
excretion occurs
- serum levels rise in first 24-72 hours of life in moderately to extremely premature
infants
✔✔normal urine output - ✔✔2-4 mL/kg/hour
✔✔urine specific gravity - ✔✔- *normal: 1.008-1.012*
- *early indication of hydration status*
- *we often see low values in newborns, especially preemies, because their kidneys are
immature and can't concentrate urine very well*
✔✔urine dipstick results - ✔✔- *proteinuria may be a sign of dehydration*
- *hematuria may be a sign of renal vein thrombosis* (dehydration could cause thick,
viscous blood, which could lead to clots and cause renal vein thrombosis)
✔✔blood urea nitrogen (BUN) - ✔✔- *normal: 7-20 mg/dL*
- unreliable measure of GFR because it is dependent on many factors (urine flow,
medications, diet, catabolism)
- may be elevated in sepsis, excessive catabolism, high protein load, renal failure,
tissue necrosis, hypovolemia, hypotension, CHF, or inborn errors of metabolism
- level of >20 mg/dL or rise of >1-5 mg/dL/day indicates some degree of renal failure
✔✔creatinine (Cr) - ✔✔- *normal 0.8-1.4 mg/dL*
* a more reliable measure of kidney function because it is a good measure of GFR)*
- at birth, levels will mimic maternal levels; need to watch trends
✔✔reasons insensible water loss in more pronounced in extremely premature infants -
✔✔- *increased permeability of skin* --> transepidermal losses
- increased respiratory losses
- increased ratio of body surface area to body weight
- phototherapy
- radiant warmer use
,- can prevent with high-humidity environment, petrolatum-based barriers, double-walled
incubators, humidified O2, maintenance of skin integrity
✔✔renal function in ELBW newborns - ✔✔- renal function is decreased in preemies,
which may affect GFR (*serum Cr*), tubular reabsorption of sodium and bicarb +
secretion of K and hydrogen, and the ability to concentrate or dilute urine
✔✔carbohydrate requirements - ✔✔- carbs provide 4 kcal/g
- IV glucose intake is measured in mg/kg/min (known as the *glucose infusion rate*,
GIR)
- *initial requirements: 4-6 mg/kg/min; can advance to as high as ~12 mg/kg/min to meet
nutritional needs*
✔✔GIR calculation - ✔✔(mL/kg/day * %dextrose) / 1.44
✔✔infants most at risk for hypoglycemia - ✔✔- *those with low hepatic glycogen stores
(SGA, preterm)*
- *hyperinsulinism (IDM)*
- *sepsis*
✔✔consequences of hyperglycemia - ✔✔- *osmotic diuresis in the short term, which
can lead to dehydration* (when glucose gets too high, infant begins spilling glucose in
the urine, which pulls water, thus causing osmotic diuresis)
- compromised nutritional status
- neurologic development in the long term
✔✔zinc - ✔✔- *needed for wound healing* or skin breakdown
✔✔nutrition considerations for preemies born before 33 weeks gestation - ✔✔- miss an
important stage of development and will be low in nutrient stores including glycogen,
protein, fat, fat soluble vitamins, trace minerals, calcium, phosphorus, and magnesium
✔✔goal of minimal enteral nutrition (MEN) - ✔✔- aka gut-stim, gut-priming, or trophic
feeds
- goal: to keep the gut healthy and active o it is prepared for the eventual initiation of
enteral feedings
✔✔considerations for NPO status - ✔✔- "if you don't use it, you lose it" --> can lead to
loss of villi, decreased weight of the stomach/intestines/pancreas, decreased enzyme
activity, increased permeability of the gut to antigens, increased susceptibility to
allergies
- but it is appropriate for conditions that lead to decreased perfusion to the gut (i.e.
acute
,✔✔preterm formulas - ✔✔- contains medium chain triglycerides (MCT) so that it is
easier for preemies to digest
- *MCT improves gastric emptying, does not require bile salts for digestion, does not
require carnitine for metabolism, and improves calcium absorption*
✔✔how much 20 cal MBM would preemies need to meet their needs? - ✔✔- *180
mL/kg to meet caloric needs*
- *290 mL/kg to meet protein needs*
- reasons to fortify human milk
- also: *premature HM is deficient in calcium and phosphorus, so additional need to
fortify*
✔✔weight gain parameters for monitoring growth - ✔✔- *1-2% per day after the initial
weight loss*
✔✔head circumference parameters for monitoring growth - ✔✔- *0.75-1.25 cm/week*
✔✔length parameters for monitoring growth - ✔✔- *0.75-1.5 cm/week*
✔✔self-regulatory state - ✔✔- *the ability to balance these dimensions (of
neurobehavioral organization) using self-consoling measures such as sucking or hand-
to-mouth maneuvers*
✔✔neuroendocrine response to pain - ✔✔- release of catecholamines, *cortisol/plasma
renin*, endorphins, other chemicals
- *suppression of insulin (leads to hyperglycemia)* --> this is why babies are
hyperglycemic when stressed (hypoinsulinemia)
✔✔relationship between pH and hydrogen ion concentration - ✔✔- the pH is the
negative logarithm (inverse relationship) of the hydrogen ion concentration --> thus, the
hydrogen ion concentration determines the pH of the blood
- the higher the hydrogen ion concentration, the lower the pH, and vice versa
- H+ = acid; high H+ = low pH (more acidic), low H+ = high pH (more basic)
✔✔normal range of plasma pH - ✔✔- *normal: 7.35-7.45*
- <7.35 = acidosis
- >7.45 = alkalosis
✔✔how is hydrogen carried? - ✔✔- in the form of carbonic acid (H2CO3) or fixed acids
including sulfuric acid, *lactic acid*, pyruvic acid, phosphoric acid, or ketoacids
✔✔gas exchange - ✔✔- the exchange of O2 and CO2 between air and blood and then
blood and tissue
- the exchange of O2 is reflected in the PaO2 (partial pressure of oxygen) in arterial
blood
, - the exchange of PaCO2 (partial pressure of CO2) is a *direct reflection of the
adequacy of alveolar ventilation*
✔✔why are preemies slightly acidotic? - ✔✔- preemies can't concentrate their urine,
which means they cannot keep bicarb (it is excreted in their urine), so this allows them
to be slightly acidotic
✔✔factors affecting adequate gas exchange - ✔✔- blood flow (i.e. polycythemia or thick
blood affects the pH)
- metabolic rate (hot = high metabolic rate, cold = low metabolic rate)
- shunting (e.g. PDA, ASD, VSD, etc.)
- cardiac output (i.e. low)
- diffusion (i.e. diseased, fluid-filled, or collapsed lungs)
- gas concentration of inspired air (i.e. % FiO2)
✔✔effects of acetate - ✔✔- acetate is a buffer --> it is not bicarb, but it can help buffer
acids, having a similar effect to bicarb
✔✔the role of respiration in acid-base balance - ✔✔- carbon dioxide and water form
carbonic acid (happens in RBCs)
- carbonic acid breaks down to form hydrogen and bicarb
- the amount of hydrogen ions present determines pH
- if you are not breathing effectively, you will build up more CO2 (more carbonic acid =
respiratory acidosis)
- if you are breathing too much, you will blow off too much CO2 (not enough acid =
respiratory alkalosis)
✔✔the role of metabolism in acid-base balance - ✔✔- the kidneys will either excrete or
hold on to bicarbonate to help buffer the pH
- *bicarbonate is the most important buffer of hydrogen ions*
- increased bicarb = less acid/more base = increased pH (metabolic alkalosis)
- decreased bicarb = more acid/less base = decreased pH (metabolic acidosis)
✔✔oxygen diffusion and trasport - ✔✔- through breathing, oxygen is taken from the
atmosphere into the lungs and CO2 is transferred from the lungs out to the atmosphere
- O2 diffuses into the blood in the pulmonary vasculature and is carried throughout the
body and diffuses from systemic capillary blood into the interstitial fluid and cells
- *the affinity of hemoglobin for O2 translates oxygen flow into oxygen availability* (just
because you have oxygen on your blood/being carried around does NOT mean it will be
accepted by the tissues)
✔✔oxygen-hemoglobin dissociation curve - ✔✔- hemoglobin-oxygen affinity is the
continuous relationship between hemoglobin-O2 saturation and oxygen tension under
standard conditions (the perfect situation/ideal condition or pH, PaCO2, and
temperature)
SOLUTIONS RATED A+
✔✔postdiuretic phase - ✔✔- DOL 4-5, when UOP begins to respond appropriately to
changes in fluid intake
- infant more readily able to vary urine and sodium output in response to fluid and
sodium intake and body fluid status
- when recovery from RDS begins to occur
✔✔weight loss after birth - ✔✔- 5-10% in term infants
- 10-20% in preterm infants (more premature, higher insensible water losses
✔✔potassium excretion - ✔✔- excreted in UOP, serum levels will decrease as renal
excretion occurs
- serum levels rise in first 24-72 hours of life in moderately to extremely premature
infants
✔✔normal urine output - ✔✔2-4 mL/kg/hour
✔✔urine specific gravity - ✔✔- *normal: 1.008-1.012*
- *early indication of hydration status*
- *we often see low values in newborns, especially preemies, because their kidneys are
immature and can't concentrate urine very well*
✔✔urine dipstick results - ✔✔- *proteinuria may be a sign of dehydration*
- *hematuria may be a sign of renal vein thrombosis* (dehydration could cause thick,
viscous blood, which could lead to clots and cause renal vein thrombosis)
✔✔blood urea nitrogen (BUN) - ✔✔- *normal: 7-20 mg/dL*
- unreliable measure of GFR because it is dependent on many factors (urine flow,
medications, diet, catabolism)
- may be elevated in sepsis, excessive catabolism, high protein load, renal failure,
tissue necrosis, hypovolemia, hypotension, CHF, or inborn errors of metabolism
- level of >20 mg/dL or rise of >1-5 mg/dL/day indicates some degree of renal failure
✔✔creatinine (Cr) - ✔✔- *normal 0.8-1.4 mg/dL*
* a more reliable measure of kidney function because it is a good measure of GFR)*
- at birth, levels will mimic maternal levels; need to watch trends
✔✔reasons insensible water loss in more pronounced in extremely premature infants -
✔✔- *increased permeability of skin* --> transepidermal losses
- increased respiratory losses
- increased ratio of body surface area to body weight
- phototherapy
- radiant warmer use
,- can prevent with high-humidity environment, petrolatum-based barriers, double-walled
incubators, humidified O2, maintenance of skin integrity
✔✔renal function in ELBW newborns - ✔✔- renal function is decreased in preemies,
which may affect GFR (*serum Cr*), tubular reabsorption of sodium and bicarb +
secretion of K and hydrogen, and the ability to concentrate or dilute urine
✔✔carbohydrate requirements - ✔✔- carbs provide 4 kcal/g
- IV glucose intake is measured in mg/kg/min (known as the *glucose infusion rate*,
GIR)
- *initial requirements: 4-6 mg/kg/min; can advance to as high as ~12 mg/kg/min to meet
nutritional needs*
✔✔GIR calculation - ✔✔(mL/kg/day * %dextrose) / 1.44
✔✔infants most at risk for hypoglycemia - ✔✔- *those with low hepatic glycogen stores
(SGA, preterm)*
- *hyperinsulinism (IDM)*
- *sepsis*
✔✔consequences of hyperglycemia - ✔✔- *osmotic diuresis in the short term, which
can lead to dehydration* (when glucose gets too high, infant begins spilling glucose in
the urine, which pulls water, thus causing osmotic diuresis)
- compromised nutritional status
- neurologic development in the long term
✔✔zinc - ✔✔- *needed for wound healing* or skin breakdown
✔✔nutrition considerations for preemies born before 33 weeks gestation - ✔✔- miss an
important stage of development and will be low in nutrient stores including glycogen,
protein, fat, fat soluble vitamins, trace minerals, calcium, phosphorus, and magnesium
✔✔goal of minimal enteral nutrition (MEN) - ✔✔- aka gut-stim, gut-priming, or trophic
feeds
- goal: to keep the gut healthy and active o it is prepared for the eventual initiation of
enteral feedings
✔✔considerations for NPO status - ✔✔- "if you don't use it, you lose it" --> can lead to
loss of villi, decreased weight of the stomach/intestines/pancreas, decreased enzyme
activity, increased permeability of the gut to antigens, increased susceptibility to
allergies
- but it is appropriate for conditions that lead to decreased perfusion to the gut (i.e.
acute
,✔✔preterm formulas - ✔✔- contains medium chain triglycerides (MCT) so that it is
easier for preemies to digest
- *MCT improves gastric emptying, does not require bile salts for digestion, does not
require carnitine for metabolism, and improves calcium absorption*
✔✔how much 20 cal MBM would preemies need to meet their needs? - ✔✔- *180
mL/kg to meet caloric needs*
- *290 mL/kg to meet protein needs*
- reasons to fortify human milk
- also: *premature HM is deficient in calcium and phosphorus, so additional need to
fortify*
✔✔weight gain parameters for monitoring growth - ✔✔- *1-2% per day after the initial
weight loss*
✔✔head circumference parameters for monitoring growth - ✔✔- *0.75-1.25 cm/week*
✔✔length parameters for monitoring growth - ✔✔- *0.75-1.5 cm/week*
✔✔self-regulatory state - ✔✔- *the ability to balance these dimensions (of
neurobehavioral organization) using self-consoling measures such as sucking or hand-
to-mouth maneuvers*
✔✔neuroendocrine response to pain - ✔✔- release of catecholamines, *cortisol/plasma
renin*, endorphins, other chemicals
- *suppression of insulin (leads to hyperglycemia)* --> this is why babies are
hyperglycemic when stressed (hypoinsulinemia)
✔✔relationship between pH and hydrogen ion concentration - ✔✔- the pH is the
negative logarithm (inverse relationship) of the hydrogen ion concentration --> thus, the
hydrogen ion concentration determines the pH of the blood
- the higher the hydrogen ion concentration, the lower the pH, and vice versa
- H+ = acid; high H+ = low pH (more acidic), low H+ = high pH (more basic)
✔✔normal range of plasma pH - ✔✔- *normal: 7.35-7.45*
- <7.35 = acidosis
- >7.45 = alkalosis
✔✔how is hydrogen carried? - ✔✔- in the form of carbonic acid (H2CO3) or fixed acids
including sulfuric acid, *lactic acid*, pyruvic acid, phosphoric acid, or ketoacids
✔✔gas exchange - ✔✔- the exchange of O2 and CO2 between air and blood and then
blood and tissue
- the exchange of O2 is reflected in the PaO2 (partial pressure of oxygen) in arterial
blood
, - the exchange of PaCO2 (partial pressure of CO2) is a *direct reflection of the
adequacy of alveolar ventilation*
✔✔why are preemies slightly acidotic? - ✔✔- preemies can't concentrate their urine,
which means they cannot keep bicarb (it is excreted in their urine), so this allows them
to be slightly acidotic
✔✔factors affecting adequate gas exchange - ✔✔- blood flow (i.e. polycythemia or thick
blood affects the pH)
- metabolic rate (hot = high metabolic rate, cold = low metabolic rate)
- shunting (e.g. PDA, ASD, VSD, etc.)
- cardiac output (i.e. low)
- diffusion (i.e. diseased, fluid-filled, or collapsed lungs)
- gas concentration of inspired air (i.e. % FiO2)
✔✔effects of acetate - ✔✔- acetate is a buffer --> it is not bicarb, but it can help buffer
acids, having a similar effect to bicarb
✔✔the role of respiration in acid-base balance - ✔✔- carbon dioxide and water form
carbonic acid (happens in RBCs)
- carbonic acid breaks down to form hydrogen and bicarb
- the amount of hydrogen ions present determines pH
- if you are not breathing effectively, you will build up more CO2 (more carbonic acid =
respiratory acidosis)
- if you are breathing too much, you will blow off too much CO2 (not enough acid =
respiratory alkalosis)
✔✔the role of metabolism in acid-base balance - ✔✔- the kidneys will either excrete or
hold on to bicarbonate to help buffer the pH
- *bicarbonate is the most important buffer of hydrogen ions*
- increased bicarb = less acid/more base = increased pH (metabolic alkalosis)
- decreased bicarb = more acid/less base = decreased pH (metabolic acidosis)
✔✔oxygen diffusion and trasport - ✔✔- through breathing, oxygen is taken from the
atmosphere into the lungs and CO2 is transferred from the lungs out to the atmosphere
- O2 diffuses into the blood in the pulmonary vasculature and is carried throughout the
body and diffuses from systemic capillary blood into the interstitial fluid and cells
- *the affinity of hemoglobin for O2 translates oxygen flow into oxygen availability* (just
because you have oxygen on your blood/being carried around does NOT mean it will be
accepted by the tissues)
✔✔oxygen-hemoglobin dissociation curve - ✔✔- hemoglobin-oxygen affinity is the
continuous relationship between hemoglobin-O2 saturation and oxygen tension under
standard conditions (the perfect situation/ideal condition or pH, PaCO2, and
temperature)
