RNC NIC ACTUAL 2026 TEST PAPER QUESTIONS AND
SOLUTIONS RATED A+
✔✔transillumination - ✔✔- tool used for newborn physical exam that is a fiberoptic light
source attached to the end of a long, flexible tube
- fluid- or air-filled structures will transmit the light (light up), e.g. hydroceles, severe
hydrocephalus, pneumothorax
-**solid masses will NOT light up/transmit light, e.g. tumors, testicular torsion**
✔✔red reflex - ✔✔- **reflex due to light reflecting off the interior lining of the eye
(fundus)**
- shows as a bright orange-red or pale/gray in darker skinned newborns
- absent or disrupted reflex could be congenital cataracts, glaucoma, or retinoblastoma
✔✔acrocyanosis - ✔✔- **blue/pale discoloration of hands and feet, normal in the first 48
hours of life**
✔✔general pallor/cyanosis - ✔✔- blue/pale discoloration outside of the first 48 hours of
life or outside of just the hands/feet that may be due to anemia, hypoxemia, or shock
✔✔how to differentiate between cyanosis and ecchymosis (bruising) - ✔✔- **assess the
ability of the skin to blanch**
- **ecchymosis (bruising) will NOT blanch**
✔✔jaundice/icterus - ✔✔- **yellow discoloration of the skin d/t hyperbilirubinemia**
- **ALWAYS an abnormal finding in the FIRST 24 HOURS OF LIFE**
✔✔general safe temperature range - ✔✔36 to 37.5 degrees C (96.8 to 99.5 degrees F)
✔✔craniotabes - ✔✔- **aka congenital cranial osteoporosis, defined as a softening of
the skull bones**
- can occur in up to 1/3 of all newborns and can be a normal finding, especially in
preemies
- **soft areas of the skull (especially along the suture line) can pop in and out like a ping
pong ball
- **mostly found along the occipital and parietal bones
✔✔caput succedanenum - ✔✔- hemorrhagic edema that **crosses suture line**
- evident at birth; looks like soft swelling with discoloration (usually looks like a
bruise/red, blue, purple)
- does not grow in size
- may develop hyperbilirubinemia (bleeding/bruising --> jaundice)
✔✔preauricular sinuses/pit - ✔✔- **often associated with renal abnormalities and 2-
vessel cord**
,- could also be skin tags (more common)
✔✔cystic hygroma - ✔✔- fluid-filled sacs that results from a blockage in the lymphatic
system
- **may require immediate intubation or emergent tracheotomy in the delivery room**
- ENT typically present at delivery
- some cases resolve, leading to webbed neck, edema, and lymphangioma
✔✔murmurs - ✔✔- abnormal heart sound **due to turbulent blood flow**
- e.g. turbulence due to blood flowing in the wrong direction, at the wrong velocity, in the
wrong vessel, etc.
✔✔hymenal tag - ✔✔- a *normal* urogenital finding in some female newborns that *will
recede on its own*
✔✔cysts along spinal column - ✔✔- any of these soft tissue masses or findings *could
indicate spinal defects, such as spina bifida occulta*
- **if present, assess for other signs, such as muscle tone and movement of LEs, anal
wink, distended bladder, etc.**
✔✔erythema toxicum neonatorum - ✔✔- **benign newborn rash**
- looks like small white or yellow pinpoint papules with an erythematous base, usually
appearing in the 2nd or 3rd DOL
- **contains Eosinophils**
✔✔hyperpigmented macule, aka "Mongolian spot" - ✔✔- **large gray or blue-green
patches of skin, usually found on the buttocks, flanks, or shoulders**
- often seen in darker skinned newborns
✔✔transient neonatal pustular melanosis - ✔✔- lesions similar to milia but present at
birth and will rupture within 48 hours after birth, leaving small, hyperpigmented macules
- **contains neutrophils**
✔✔strawberry hemangioma - ✔✔- benign bright red, raised tumor consisting of dilated
blood vessels
- can appear on head, neck, trunk, or extremities
- often recede spontaneously within 6-12 months
- if very large, may lead to airway obstruction when located on the neck
- **typically get larger over ~first 6 months, then get smaller**
✔✔neonatal eye drainage - ✔✔- **does not always mean infection, especially in cases
where the drainage is either clear or cloudy white**
- **consider other causes, such as a blocked lacrimal (tear) duct**
- may benefit from warm compresses/lacrimal massage
,✔✔cephalohematoma - ✔✔- a subperiosteal collection of blood that overlies a cranial
bone that **does NOT extend across the suture line**
- usually unilateral, but may be bilateral
- overlying scalp is not discolored; swelling may not be apparent for several hours to
days after birth
- does not transilluminate
✔✔choanal atresia - ✔✔- membranous or bony complete nasal obstruction in the
neonate
- may be associated with Apert, Treacher Collins, Down, or Crouzon Syndromes or with
CHARGE association
- **classic presentation: cyanotic when at rest or when eating (when mouth is
closed/occluded), but pink when crying (mouth is open)**
- **check nasal patency with a small-bore NG tube passed on one side, then the other**
- oral airway, may need intubation until surgical repair
✔✔most important risk factor for ROP - ✔✔- **immaturity/prematurity**
- oxygen exposure is less important
✔✔ROP stage I - ✔✔- mildest stage of ROP, feature is a demarcation line: border
between optic (posterior) vascular and peripheral avascular retina
✔✔ROP stage II - ✔✔- second mildest stage of ROP, feature is a ridge: lifting of
demarcation margin above the retinal plane with penetrating new vessels
✔✔ROP stage III - ✔✔- middle stage of ROP in terms of severity, feature is extraretinal
fibrovascular proliferation: invasion of vitreous humor by vessels perforating near the
demarcation line (vessels in the ridge)
✔✔ROP stage IV - ✔✔- second severest stage of ROP, feature is partial retinal
detachment: lifting of the peripheral retina by traction of thick vessels
✔✔ROP stage V - ✔✔- most severe stage of ROP with complete retinal detachment:
lifting of the entire retina
✔✔zones of ROP - ✔✔- describes the location of ROP
- the lower the number, the worse it is (I is the most posterior)
✔✔plus disease - ✔✔- can occur with any stage of ROP
- implies increased severity and that progression may be rapid
- characterized by vascular dilation and tortuosity near the optic pole
- presence mandates weekly exams
✔✔congenital infections known or suspected to be associated with sensorineural
hearing loss or impairment - ✔✔-*toxoplasmosis*
, - *syphilis*
- *rubella*
- *CMV*
- *herpes*
- *bacterial meningitis*
- at additional risk due to ototoxic antibiotic treatment
✔✔frequent tracheostomy plugging - ✔✔- *may indicate more humidity is needed in the
system*
✔✔neutral thermal environment - ✔✔- *the environmental temperature at which the
individual infant utilizes the least amount of energy and consumes the least amount of
oxygen while maintaining a normal core body temperature that is needed for optimal
growth and development*
- *results in minimal heat production and oxygen consumption while still maintaining a
core temperature that is within normal limits*
✔✔why newborns are at greater risk of hypothermia - ✔✔- *newborns have an
increased surface area: body weight ratio --> a MAJOR cause of heat loss for babies*
- also poorly developed autonomic thermoregulatory response
- inability to shiver to produce heat
- increased percentage of body weight as water and increased permeability of the skin
result in greater evaporative heat loss
✔✔infants most at risk for hypothermia - ✔✔- **any infant that is stressed!**
- apnea, hypothermia, hypoglycemia are the first 3 presenting signs of many issues in
neonates
✔✔ways infants produce heat - ✔✔- *non-shivering (chemical) thermogenesis (primary
mode)
- voluntary muscle tone
- shivering (very limited ability in newborns, absent in preemies)
✔✔chemical thermogenesis - ✔✔- cold stress --> stimulation of skin receptors --> cold
stress stimulus send to the hypothalamus --> *release of norepinephrine from the
sympathetic nervous system* --> brown fat metabolism --> chemical breakdown of TG
in brown fat --> glycerol and non-esterified fatty acids
- Non-esterified fatty acids --> circulation, oxidized, re-esterified into TG
✔✔what happens once the brown fat is used up in infant thermogenesis? - ✔✔- infants
must rely on *gluconeogenesis*
- gluconeogenesis plays a major role in energy stabilization
- turns proteins and fats into glucose
- this process if mediated by the anterior pituitary gland and cortisol
SOLUTIONS RATED A+
✔✔transillumination - ✔✔- tool used for newborn physical exam that is a fiberoptic light
source attached to the end of a long, flexible tube
- fluid- or air-filled structures will transmit the light (light up), e.g. hydroceles, severe
hydrocephalus, pneumothorax
-**solid masses will NOT light up/transmit light, e.g. tumors, testicular torsion**
✔✔red reflex - ✔✔- **reflex due to light reflecting off the interior lining of the eye
(fundus)**
- shows as a bright orange-red or pale/gray in darker skinned newborns
- absent or disrupted reflex could be congenital cataracts, glaucoma, or retinoblastoma
✔✔acrocyanosis - ✔✔- **blue/pale discoloration of hands and feet, normal in the first 48
hours of life**
✔✔general pallor/cyanosis - ✔✔- blue/pale discoloration outside of the first 48 hours of
life or outside of just the hands/feet that may be due to anemia, hypoxemia, or shock
✔✔how to differentiate between cyanosis and ecchymosis (bruising) - ✔✔- **assess the
ability of the skin to blanch**
- **ecchymosis (bruising) will NOT blanch**
✔✔jaundice/icterus - ✔✔- **yellow discoloration of the skin d/t hyperbilirubinemia**
- **ALWAYS an abnormal finding in the FIRST 24 HOURS OF LIFE**
✔✔general safe temperature range - ✔✔36 to 37.5 degrees C (96.8 to 99.5 degrees F)
✔✔craniotabes - ✔✔- **aka congenital cranial osteoporosis, defined as a softening of
the skull bones**
- can occur in up to 1/3 of all newborns and can be a normal finding, especially in
preemies
- **soft areas of the skull (especially along the suture line) can pop in and out like a ping
pong ball
- **mostly found along the occipital and parietal bones
✔✔caput succedanenum - ✔✔- hemorrhagic edema that **crosses suture line**
- evident at birth; looks like soft swelling with discoloration (usually looks like a
bruise/red, blue, purple)
- does not grow in size
- may develop hyperbilirubinemia (bleeding/bruising --> jaundice)
✔✔preauricular sinuses/pit - ✔✔- **often associated with renal abnormalities and 2-
vessel cord**
,- could also be skin tags (more common)
✔✔cystic hygroma - ✔✔- fluid-filled sacs that results from a blockage in the lymphatic
system
- **may require immediate intubation or emergent tracheotomy in the delivery room**
- ENT typically present at delivery
- some cases resolve, leading to webbed neck, edema, and lymphangioma
✔✔murmurs - ✔✔- abnormal heart sound **due to turbulent blood flow**
- e.g. turbulence due to blood flowing in the wrong direction, at the wrong velocity, in the
wrong vessel, etc.
✔✔hymenal tag - ✔✔- a *normal* urogenital finding in some female newborns that *will
recede on its own*
✔✔cysts along spinal column - ✔✔- any of these soft tissue masses or findings *could
indicate spinal defects, such as spina bifida occulta*
- **if present, assess for other signs, such as muscle tone and movement of LEs, anal
wink, distended bladder, etc.**
✔✔erythema toxicum neonatorum - ✔✔- **benign newborn rash**
- looks like small white or yellow pinpoint papules with an erythematous base, usually
appearing in the 2nd or 3rd DOL
- **contains Eosinophils**
✔✔hyperpigmented macule, aka "Mongolian spot" - ✔✔- **large gray or blue-green
patches of skin, usually found on the buttocks, flanks, or shoulders**
- often seen in darker skinned newborns
✔✔transient neonatal pustular melanosis - ✔✔- lesions similar to milia but present at
birth and will rupture within 48 hours after birth, leaving small, hyperpigmented macules
- **contains neutrophils**
✔✔strawberry hemangioma - ✔✔- benign bright red, raised tumor consisting of dilated
blood vessels
- can appear on head, neck, trunk, or extremities
- often recede spontaneously within 6-12 months
- if very large, may lead to airway obstruction when located on the neck
- **typically get larger over ~first 6 months, then get smaller**
✔✔neonatal eye drainage - ✔✔- **does not always mean infection, especially in cases
where the drainage is either clear or cloudy white**
- **consider other causes, such as a blocked lacrimal (tear) duct**
- may benefit from warm compresses/lacrimal massage
,✔✔cephalohematoma - ✔✔- a subperiosteal collection of blood that overlies a cranial
bone that **does NOT extend across the suture line**
- usually unilateral, but may be bilateral
- overlying scalp is not discolored; swelling may not be apparent for several hours to
days after birth
- does not transilluminate
✔✔choanal atresia - ✔✔- membranous or bony complete nasal obstruction in the
neonate
- may be associated with Apert, Treacher Collins, Down, or Crouzon Syndromes or with
CHARGE association
- **classic presentation: cyanotic when at rest or when eating (when mouth is
closed/occluded), but pink when crying (mouth is open)**
- **check nasal patency with a small-bore NG tube passed on one side, then the other**
- oral airway, may need intubation until surgical repair
✔✔most important risk factor for ROP - ✔✔- **immaturity/prematurity**
- oxygen exposure is less important
✔✔ROP stage I - ✔✔- mildest stage of ROP, feature is a demarcation line: border
between optic (posterior) vascular and peripheral avascular retina
✔✔ROP stage II - ✔✔- second mildest stage of ROP, feature is a ridge: lifting of
demarcation margin above the retinal plane with penetrating new vessels
✔✔ROP stage III - ✔✔- middle stage of ROP in terms of severity, feature is extraretinal
fibrovascular proliferation: invasion of vitreous humor by vessels perforating near the
demarcation line (vessels in the ridge)
✔✔ROP stage IV - ✔✔- second severest stage of ROP, feature is partial retinal
detachment: lifting of the peripheral retina by traction of thick vessels
✔✔ROP stage V - ✔✔- most severe stage of ROP with complete retinal detachment:
lifting of the entire retina
✔✔zones of ROP - ✔✔- describes the location of ROP
- the lower the number, the worse it is (I is the most posterior)
✔✔plus disease - ✔✔- can occur with any stage of ROP
- implies increased severity and that progression may be rapid
- characterized by vascular dilation and tortuosity near the optic pole
- presence mandates weekly exams
✔✔congenital infections known or suspected to be associated with sensorineural
hearing loss or impairment - ✔✔-*toxoplasmosis*
, - *syphilis*
- *rubella*
- *CMV*
- *herpes*
- *bacterial meningitis*
- at additional risk due to ototoxic antibiotic treatment
✔✔frequent tracheostomy plugging - ✔✔- *may indicate more humidity is needed in the
system*
✔✔neutral thermal environment - ✔✔- *the environmental temperature at which the
individual infant utilizes the least amount of energy and consumes the least amount of
oxygen while maintaining a normal core body temperature that is needed for optimal
growth and development*
- *results in minimal heat production and oxygen consumption while still maintaining a
core temperature that is within normal limits*
✔✔why newborns are at greater risk of hypothermia - ✔✔- *newborns have an
increased surface area: body weight ratio --> a MAJOR cause of heat loss for babies*
- also poorly developed autonomic thermoregulatory response
- inability to shiver to produce heat
- increased percentage of body weight as water and increased permeability of the skin
result in greater evaporative heat loss
✔✔infants most at risk for hypothermia - ✔✔- **any infant that is stressed!**
- apnea, hypothermia, hypoglycemia are the first 3 presenting signs of many issues in
neonates
✔✔ways infants produce heat - ✔✔- *non-shivering (chemical) thermogenesis (primary
mode)
- voluntary muscle tone
- shivering (very limited ability in newborns, absent in preemies)
✔✔chemical thermogenesis - ✔✔- cold stress --> stimulation of skin receptors --> cold
stress stimulus send to the hypothalamus --> *release of norepinephrine from the
sympathetic nervous system* --> brown fat metabolism --> chemical breakdown of TG
in brown fat --> glycerol and non-esterified fatty acids
- Non-esterified fatty acids --> circulation, oxidized, re-esterified into TG
✔✔what happens once the brown fat is used up in infant thermogenesis? - ✔✔- infants
must rely on *gluconeogenesis*
- gluconeogenesis plays a major role in energy stabilization
- turns proteins and fats into glucose
- this process if mediated by the anterior pituitary gland and cortisol
