PNP-AC ACTUAL EXAM 2026/2027 | PNCB-Certified Content |
175 Questions | Verified Rationales | Pass Guaranteed - A+
Graded
DOMAIN 1: ASSESSMENT & DIAGNOSIS (50 Questions)
Neonatal/Infant (Questions 1-12)
Q1. A 3-day-old term infant born via emergency cesarean section for fetal bradycardia
presents with respiratory distress, grunting, and oxygen saturation of 82% on room air.
Chest X-ray shows diffuse ground-glass opacities with air bronchograms. The infant
was born through meconium-stained amniotic fluid. Which assessment finding would
most strongly suggest progression to persistent pulmonary hypertension of the
newborn (PPHN)?
A. Presence of a right-to-left shunt at the ductal level detected by preductal/postductal
oxygen saturation differential >10% [CORRECT]
B. Hypercapnia with PaCO₂ of 55 mmHg
C. Respiratory rate of 70 breaths/minute
D. Presence of coarse breath sounds bilaterally
Correct Answer: A
,Rationale: PPHN is characterized by elevated pulmonary vascular resistance causing
right-to-left shunting at the foramen ovale and ductus arteriosus. The preductal (right
hand) versus postductal (lower extremity) oxygen saturation differential >10% is
pathognomonic for PPHN, indicating right-to-left shunting at the ductal level. Option B
(hypercapnia) is common in meconium aspiration syndrome but not specific to PPHN.
Option C (tachypnea) is a nonspecific sign of respiratory distress. Option D (coarse
breaths sounds) suggests meconium obstruction but does not indicate pulmonary
hypertension. Red flag: A saturation differential >10% requires immediate intervention
with iNO or ECMO evaluation.
Q2. [SATA - Select All That Apply] A 6-week-old former 28-week premature infant with
bronchopulmonary dysplasia (BPD) presents to the emergency department with
increased work of breathing. Which of the following findings on assessment would
indicate impending respiratory failure requiring immediate intervention? (Select all that
apply)
A. Respiratory rate of 68 breaths/minute with significant retractions
B. Capillary refill time of 4 seconds with mottled extremities [CORRECT]
C. Silent chest on auscultation with minimal air movement [CORRECT]
D. Periodic breathing with 10-second pauses
E. Grunting with nasal flaring and head bobbing [CORRECT]
Correct Answers: B, C, E
Rationale: Infants with BPD have limited pulmonary reserve. B indicates cardiovascular
compromise and shock, which accompanies respiratory failure. C (silent chest) is a
,critical finding indicating severe airway obstruction or fatigue—this represents pre-arrest
status. E represents the tripod position and accessory muscle use indicating severe
respiratory distress. A is incorrect because while tachypnea with retractions is
concerning, a rate of 68 in a 6-week-old (normal 30-60) with BPD may be compensatory
rather than impending failure. D is incorrect because periodic breathing is normal in
infants, especially former preterms, and 10-second pauses are within normal limits (<20
seconds). Red flags: Silent chest + altered perfusion = immediate intubation.
Q3. A 4-month-old infant presents with a 2-day history of poor feeding, irritability, and
fever to 38.8°C. On assessment, the infant has a bulging fontanelle, neck stiffness, and
a positive Brudzinski sign. Which assessment finding would most strongly suggest the
infant has bacterial meningitis caused by Streptococcus pneumoniae rather than
Neisseria meningitidis?
A. Presence of a generalized petechial rash
B. History of otitis media in the past month [CORRECT]
C. Rapid onset of septic shock within 6 hours
D. Waterhouse-Friderichsen syndrome on imaging
Correct Answer: B
Rationale: S. pneumoniae is the most common cause of bacterial meningitis in infants
1-3 months and is frequently associated with preceding or concurrent otitis media or
sinusitis due to contiguous spread. N. meningitidis typically presents with A
(petechial/purpuric rash), C (rapid shock), and D (adrenal hemorrhage). While N.
meningitidis can cause meningitis in this age group, the presence of preceding otitis
, strongly suggests pneumococcal etiology. Critical error: Do not delay antibiotics for LP
in unstable patients—give ceftriaxone + vancomycin immediately.
Q4. [Bow-tie/NGN Style] A 2-week-old infant presents with projectile, nonbilious
vomiting after every feeding. On assessment, the infant appears dehydrated with
sunken fontanelle and dry mucous membranes.
Actions to Take:
1. Check serum electrolytes [CORRECT]
2. Obtain abdominal ultrasound [CORRECT]
3. Start D10 0.45% NS at maintenance rate
Potential Conditions:
A. Hypertrophic pyloric stenosis [CORRECT]
B. Gastroesophageal reflux disease
Parameters to Monitor:
1. Serum chloride and bicarbonate levels [CORRECT]
2. Weight gain pattern
Rationale: This classic presentation (2-week-old, projectile nonbilious vomiting,
dehydration) indicates hypertrophic pyloric stenosis. Actions: Electrolytes are critical as
these infants develop hypochloremic, hypokalemic metabolic alkalosis from vomiting
gastric acid. Ultrasound is the diagnostic gold standard (target sign). Why not D:
Maintenance fluids without correcting alkalosis first can worsen cerebral
175 Questions | Verified Rationales | Pass Guaranteed - A+
Graded
DOMAIN 1: ASSESSMENT & DIAGNOSIS (50 Questions)
Neonatal/Infant (Questions 1-12)
Q1. A 3-day-old term infant born via emergency cesarean section for fetal bradycardia
presents with respiratory distress, grunting, and oxygen saturation of 82% on room air.
Chest X-ray shows diffuse ground-glass opacities with air bronchograms. The infant
was born through meconium-stained amniotic fluid. Which assessment finding would
most strongly suggest progression to persistent pulmonary hypertension of the
newborn (PPHN)?
A. Presence of a right-to-left shunt at the ductal level detected by preductal/postductal
oxygen saturation differential >10% [CORRECT]
B. Hypercapnia with PaCO₂ of 55 mmHg
C. Respiratory rate of 70 breaths/minute
D. Presence of coarse breath sounds bilaterally
Correct Answer: A
,Rationale: PPHN is characterized by elevated pulmonary vascular resistance causing
right-to-left shunting at the foramen ovale and ductus arteriosus. The preductal (right
hand) versus postductal (lower extremity) oxygen saturation differential >10% is
pathognomonic for PPHN, indicating right-to-left shunting at the ductal level. Option B
(hypercapnia) is common in meconium aspiration syndrome but not specific to PPHN.
Option C (tachypnea) is a nonspecific sign of respiratory distress. Option D (coarse
breaths sounds) suggests meconium obstruction but does not indicate pulmonary
hypertension. Red flag: A saturation differential >10% requires immediate intervention
with iNO or ECMO evaluation.
Q2. [SATA - Select All That Apply] A 6-week-old former 28-week premature infant with
bronchopulmonary dysplasia (BPD) presents to the emergency department with
increased work of breathing. Which of the following findings on assessment would
indicate impending respiratory failure requiring immediate intervention? (Select all that
apply)
A. Respiratory rate of 68 breaths/minute with significant retractions
B. Capillary refill time of 4 seconds with mottled extremities [CORRECT]
C. Silent chest on auscultation with minimal air movement [CORRECT]
D. Periodic breathing with 10-second pauses
E. Grunting with nasal flaring and head bobbing [CORRECT]
Correct Answers: B, C, E
Rationale: Infants with BPD have limited pulmonary reserve. B indicates cardiovascular
compromise and shock, which accompanies respiratory failure. C (silent chest) is a
,critical finding indicating severe airway obstruction or fatigue—this represents pre-arrest
status. E represents the tripod position and accessory muscle use indicating severe
respiratory distress. A is incorrect because while tachypnea with retractions is
concerning, a rate of 68 in a 6-week-old (normal 30-60) with BPD may be compensatory
rather than impending failure. D is incorrect because periodic breathing is normal in
infants, especially former preterms, and 10-second pauses are within normal limits (<20
seconds). Red flags: Silent chest + altered perfusion = immediate intubation.
Q3. A 4-month-old infant presents with a 2-day history of poor feeding, irritability, and
fever to 38.8°C. On assessment, the infant has a bulging fontanelle, neck stiffness, and
a positive Brudzinski sign. Which assessment finding would most strongly suggest the
infant has bacterial meningitis caused by Streptococcus pneumoniae rather than
Neisseria meningitidis?
A. Presence of a generalized petechial rash
B. History of otitis media in the past month [CORRECT]
C. Rapid onset of septic shock within 6 hours
D. Waterhouse-Friderichsen syndrome on imaging
Correct Answer: B
Rationale: S. pneumoniae is the most common cause of bacterial meningitis in infants
1-3 months and is frequently associated with preceding or concurrent otitis media or
sinusitis due to contiguous spread. N. meningitidis typically presents with A
(petechial/purpuric rash), C (rapid shock), and D (adrenal hemorrhage). While N.
meningitidis can cause meningitis in this age group, the presence of preceding otitis
, strongly suggests pneumococcal etiology. Critical error: Do not delay antibiotics for LP
in unstable patients—give ceftriaxone + vancomycin immediately.
Q4. [Bow-tie/NGN Style] A 2-week-old infant presents with projectile, nonbilious
vomiting after every feeding. On assessment, the infant appears dehydrated with
sunken fontanelle and dry mucous membranes.
Actions to Take:
1. Check serum electrolytes [CORRECT]
2. Obtain abdominal ultrasound [CORRECT]
3. Start D10 0.45% NS at maintenance rate
Potential Conditions:
A. Hypertrophic pyloric stenosis [CORRECT]
B. Gastroesophageal reflux disease
Parameters to Monitor:
1. Serum chloride and bicarbonate levels [CORRECT]
2. Weight gain pattern
Rationale: This classic presentation (2-week-old, projectile nonbilious vomiting,
dehydration) indicates hypertrophic pyloric stenosis. Actions: Electrolytes are critical as
these infants develop hypochloremic, hypokalemic metabolic alkalosis from vomiting
gastric acid. Ultrasound is the diagnostic gold standard (target sign). Why not D:
Maintenance fluids without correcting alkalosis first can worsen cerebral
