CCRN Neonatal Certification Exam:
Comprehensive Practice Test 150 Advanced
Multiple-Choice Questions with Correct
Answers and Detailed Rationales
Target Audience: NICU nurses preparing for the AACN CCRN (Neonatal) certification examination
Difficulty Level: Advanced / Hard
References: AACN CCRN Neonatal Test Plan (2025-2026), Certification and Core Review for Neonatal
Intensive Care Nursing (6th Ed.), Merenstein & Gardner's Handbook of Neonatal Intensive Care (10th
Ed.), Core Curriculum for Neonatal Intensive Care Nursing (AWHONN), and AACN sample examination
questions.
TABLE OF CONTENTS
Section Topic Questions
I Cardiovascular 1–20
II Respiratory 21–50
III Endocrine, Hematology, GI, Renal, Integumentary 51–90
IV Musculoskeletal, Neurological, Psychosocial 91–110
V Multisystem 111–130
VI Professional Caring and Ethical Practice 131–150
SECTION I: CARDIOVASCULAR (Questions 1–20)
🟢 1. A 2-day-old, 38-week gestation infant presents with profound cyanosis that does NOT improve
with 100% oxygen. Echocardiography reveals an obstructed total anomalous pulmonary venous return
(TAPVR) below the diaphragm. Which acid-base finding is most consistent with this lesion?
A. Respiratory alkalosis with a normal anion gap
🔴🔴 B. Profound metabolic acidosis with a widened anion gap
,C. Metabolic alkalosis with hyperkalemia
D. Normal pH with elevated PaCO₂
Rationale: Obstructed infradiaphragmatic TAPVR causes severe pulmonary venous obstruction, leading
to low cardiac output, hypoperfusion, and lactic acidosis (widened anion gap metabolic acidosis).
Respiratory alkalosis is not seen, and a normal pH is unlikely in this critical condition.
🟢 2. A neonate with dextro-transposition of the great arteries (d-TGA) and an intact ventricular
septum is receiving prostaglandin E1 (PGE1). Despite adequate ductal patency, SpO₂ remains 65% in
the preductal right hand and 55% in the postductal foot. What is the most appropriate next
intervention?
A. Increase PGE1 infusion to 0.1 mcg/kg/min
🔴🔴 B. Perform an emergency balloon atrial septostomy (BAS)
C. Administer 20 mL/kg normal saline bolus
D. Start inhaled nitric oxide (iNO) at 20 ppm
Rationale: In d-TGA with intact septum, mixing occurs only at the ductal and atrial levels. If BAS is not
performed, severe hypoxemia persists. BAS creates a large atrial communication, improving mixing.
Increasing PGE1 or fluids will not overcome the lack of atrial mixing; iNO is ineffective because no
parenchymal lung disease exists.
🟢 3. A premature infant at 27 weeks gestation (birth weight 750 g) develops hypotension on day 2.
Mean arterial pressure (MAP) is 22 mmHg, heart rate 165 bpm, and lactate 5.2 mmol/L. Which agent
is first-line according to current neonatal resuscitation guidelines for normotensive, adequately filled
infants?
A. Epinephrine infusion
🔴🔴 B. Dopamine (starting at 5 mcg/kg/min)
C. Dobutamine (starting at 10 mcg/kg/min)
D. Hydrocortisone (1 mg/kg IV)
Rationale: For neonatal hypotension with normal left ventricular function and adequate filling,
dopamine is first-line. Dobutamine is preferred for low cardiac output with poor contractility.
Epinephrine is third-line. Hydrocortisone is reserved for refractory hypotension with suspected adrenal
insufficiency.
🟢 4. A term newborn is diagnosed with critical aortic stenosis. Echocardiography shows a hypoplastic
left ventricle (LV) with endocardial fibroelastosis. Which prostaglandin-dependent strategy is correct?
A. PGE1 is contraindicated because it may cause coronary steal
🔴🔴 B. PGE1 should be initiated to maintain ductal patency and systemic perfusion
,C. PGE1 should be withheld until surgical consultation
D. PGE1 should be given only if oxygen saturation falls below 85%
Rationale: In critical aortic stenosis with a hypoplastic LV, systemic perfusion is ductal-dependent. PGE1
maintains ductal patency to ensure systemic blood flow until surgical intervention can be performed.
Withholding PGE1 would result in cardiovascular collapse.
🟢 5. A 3-day-old term infant is diagnosed with a cyanotic congenital heart defect. Which of the
following findings is most consistent with tetralogy of Fallot?
A. Differential cyanosis
🔴🔴 B. Systolic murmur at the left upper sternal border with decreased pulmonary blood flow on chest
x-ray
C. Bounding pulses and a machinery-like murmur
D. Fixed splitting of S2 with a diastolic murmur
Rationale: Tetralogy of Fallot classically presents with a systolic murmur (pulmonary stenosis) at the left
upper sternal border, decreased pulmonary blood flow on chest x-ray (due to right ventricular outflow
tract obstruction), and cyanosis. Differential cyanosis is associated with PDA or PPHN.
🟢 6. A neonate exhibits bounding pulses and a machinery-like heart murmur. Which congenital heart
defect is most likely?
A. Ventricular septal defect (VSD)
🔴🔴 B. Patent ductus arteriosus (PDA)
C. Atrial septal defect (ASD)
D. Tetralogy of Fallot
Rationale: A machinery-like murmur with bounding pulses is the classic presentation of a patent ductus
arteriosus. The continuous murmur is due to turbulent flow from the high-pressure aorta to the lower-
pressure pulmonary artery throughout the cardiac cycle.
🟢 7. A large ventricular septal defect (VSD) in a neonate results in which of the following?
A. Decreased pulmonary circulation
🔴🔴 B. Increased pulmonary blood flow with congestive heart failure
C. Right-to-left shunting with cyanosis
D. Decreased left atrial pressure
Rationale: A large VSD causes left-to-right shunting, leading to increased pulmonary blood flow. This
results in pulmonary overcirculation, congestive heart failure, and increased left atrial pressure.
Cyanosis is not typically seen unless Eisenmenger syndrome develops.
, 🟢 8. Which structure closes functionally within minutes after birth to transition from fetal to neonatal
circulation?
A. Foramen ovale
🔴🔴 B. Ductus arteriosus
C. Ductus venosus
D. Umbilical vein
Rationale: The ductus arteriosus functionally closes within minutes to hours after birth in response to
increased oxygen tension and decreased prostaglandin levels. The foramen ovale functionally closes
immediately after birth due to changes in atrial pressures, but anatomic closure takes months.
🟢 9. A neonate with persistent pulmonary hypertension of the newborn (PPHN) is receiving inhaled
nitric oxide (iNO). Which of the following is the primary mechanism of action of iNO in this condition?
A. Systemic vasodilation
🔴🔴 B. Selective pulmonary vasodilation
C. Increased cardiac contractility
D. Bronchodilation
Rationale: Inhaled nitric oxide is a selective pulmonary vasodilator that reduces pulmonary vascular
resistance without causing systemic hypotension. It improves ventilation-perfusion matching and
oxygenation in PPHN.
🟢 10. A 2-week-old infant presents with poor feeding, tachypnea, and diaphoresis during feeding. On
examination, a systolic murmur is heard at the left lower sternal border. Which congenital heart
defect is most likely?
A. Tetralogy of Fallot
🔴🔴 B. Ventricular septal defect (VSD)
C. Transposition of the great arteries
D. Tricuspid atresia
Rationale: Poor feeding, tachypnea, and diaphoresis during feeding are signs of congestive heart failure
in neonates. A VSD with left-to-right shunting causes increased pulmonary blood flow, leading to CHF.
The systolic murmur at the left lower sternal border is classic for VSD.
🟢 11. A neonate with suspected coarctation of the aorta should be assessed for which of the following
classic findings?
A. Differential cyanosis (upper extremities pink, lower extremities blue)
🔴🔴 B. Blood pressure differential between upper and lower extremities with weak femoral pulses
C. Bounding pulses in all extremities
D. Fixed splitting of S2
Comprehensive Practice Test 150 Advanced
Multiple-Choice Questions with Correct
Answers and Detailed Rationales
Target Audience: NICU nurses preparing for the AACN CCRN (Neonatal) certification examination
Difficulty Level: Advanced / Hard
References: AACN CCRN Neonatal Test Plan (2025-2026), Certification and Core Review for Neonatal
Intensive Care Nursing (6th Ed.), Merenstein & Gardner's Handbook of Neonatal Intensive Care (10th
Ed.), Core Curriculum for Neonatal Intensive Care Nursing (AWHONN), and AACN sample examination
questions.
TABLE OF CONTENTS
Section Topic Questions
I Cardiovascular 1–20
II Respiratory 21–50
III Endocrine, Hematology, GI, Renal, Integumentary 51–90
IV Musculoskeletal, Neurological, Psychosocial 91–110
V Multisystem 111–130
VI Professional Caring and Ethical Practice 131–150
SECTION I: CARDIOVASCULAR (Questions 1–20)
🟢 1. A 2-day-old, 38-week gestation infant presents with profound cyanosis that does NOT improve
with 100% oxygen. Echocardiography reveals an obstructed total anomalous pulmonary venous return
(TAPVR) below the diaphragm. Which acid-base finding is most consistent with this lesion?
A. Respiratory alkalosis with a normal anion gap
🔴🔴 B. Profound metabolic acidosis with a widened anion gap
,C. Metabolic alkalosis with hyperkalemia
D. Normal pH with elevated PaCO₂
Rationale: Obstructed infradiaphragmatic TAPVR causes severe pulmonary venous obstruction, leading
to low cardiac output, hypoperfusion, and lactic acidosis (widened anion gap metabolic acidosis).
Respiratory alkalosis is not seen, and a normal pH is unlikely in this critical condition.
🟢 2. A neonate with dextro-transposition of the great arteries (d-TGA) and an intact ventricular
septum is receiving prostaglandin E1 (PGE1). Despite adequate ductal patency, SpO₂ remains 65% in
the preductal right hand and 55% in the postductal foot. What is the most appropriate next
intervention?
A. Increase PGE1 infusion to 0.1 mcg/kg/min
🔴🔴 B. Perform an emergency balloon atrial septostomy (BAS)
C. Administer 20 mL/kg normal saline bolus
D. Start inhaled nitric oxide (iNO) at 20 ppm
Rationale: In d-TGA with intact septum, mixing occurs only at the ductal and atrial levels. If BAS is not
performed, severe hypoxemia persists. BAS creates a large atrial communication, improving mixing.
Increasing PGE1 or fluids will not overcome the lack of atrial mixing; iNO is ineffective because no
parenchymal lung disease exists.
🟢 3. A premature infant at 27 weeks gestation (birth weight 750 g) develops hypotension on day 2.
Mean arterial pressure (MAP) is 22 mmHg, heart rate 165 bpm, and lactate 5.2 mmol/L. Which agent
is first-line according to current neonatal resuscitation guidelines for normotensive, adequately filled
infants?
A. Epinephrine infusion
🔴🔴 B. Dopamine (starting at 5 mcg/kg/min)
C. Dobutamine (starting at 10 mcg/kg/min)
D. Hydrocortisone (1 mg/kg IV)
Rationale: For neonatal hypotension with normal left ventricular function and adequate filling,
dopamine is first-line. Dobutamine is preferred for low cardiac output with poor contractility.
Epinephrine is third-line. Hydrocortisone is reserved for refractory hypotension with suspected adrenal
insufficiency.
🟢 4. A term newborn is diagnosed with critical aortic stenosis. Echocardiography shows a hypoplastic
left ventricle (LV) with endocardial fibroelastosis. Which prostaglandin-dependent strategy is correct?
A. PGE1 is contraindicated because it may cause coronary steal
🔴🔴 B. PGE1 should be initiated to maintain ductal patency and systemic perfusion
,C. PGE1 should be withheld until surgical consultation
D. PGE1 should be given only if oxygen saturation falls below 85%
Rationale: In critical aortic stenosis with a hypoplastic LV, systemic perfusion is ductal-dependent. PGE1
maintains ductal patency to ensure systemic blood flow until surgical intervention can be performed.
Withholding PGE1 would result in cardiovascular collapse.
🟢 5. A 3-day-old term infant is diagnosed with a cyanotic congenital heart defect. Which of the
following findings is most consistent with tetralogy of Fallot?
A. Differential cyanosis
🔴🔴 B. Systolic murmur at the left upper sternal border with decreased pulmonary blood flow on chest
x-ray
C. Bounding pulses and a machinery-like murmur
D. Fixed splitting of S2 with a diastolic murmur
Rationale: Tetralogy of Fallot classically presents with a systolic murmur (pulmonary stenosis) at the left
upper sternal border, decreased pulmonary blood flow on chest x-ray (due to right ventricular outflow
tract obstruction), and cyanosis. Differential cyanosis is associated with PDA or PPHN.
🟢 6. A neonate exhibits bounding pulses and a machinery-like heart murmur. Which congenital heart
defect is most likely?
A. Ventricular septal defect (VSD)
🔴🔴 B. Patent ductus arteriosus (PDA)
C. Atrial septal defect (ASD)
D. Tetralogy of Fallot
Rationale: A machinery-like murmur with bounding pulses is the classic presentation of a patent ductus
arteriosus. The continuous murmur is due to turbulent flow from the high-pressure aorta to the lower-
pressure pulmonary artery throughout the cardiac cycle.
🟢 7. A large ventricular septal defect (VSD) in a neonate results in which of the following?
A. Decreased pulmonary circulation
🔴🔴 B. Increased pulmonary blood flow with congestive heart failure
C. Right-to-left shunting with cyanosis
D. Decreased left atrial pressure
Rationale: A large VSD causes left-to-right shunting, leading to increased pulmonary blood flow. This
results in pulmonary overcirculation, congestive heart failure, and increased left atrial pressure.
Cyanosis is not typically seen unless Eisenmenger syndrome develops.
, 🟢 8. Which structure closes functionally within minutes after birth to transition from fetal to neonatal
circulation?
A. Foramen ovale
🔴🔴 B. Ductus arteriosus
C. Ductus venosus
D. Umbilical vein
Rationale: The ductus arteriosus functionally closes within minutes to hours after birth in response to
increased oxygen tension and decreased prostaglandin levels. The foramen ovale functionally closes
immediately after birth due to changes in atrial pressures, but anatomic closure takes months.
🟢 9. A neonate with persistent pulmonary hypertension of the newborn (PPHN) is receiving inhaled
nitric oxide (iNO). Which of the following is the primary mechanism of action of iNO in this condition?
A. Systemic vasodilation
🔴🔴 B. Selective pulmonary vasodilation
C. Increased cardiac contractility
D. Bronchodilation
Rationale: Inhaled nitric oxide is a selective pulmonary vasodilator that reduces pulmonary vascular
resistance without causing systemic hypotension. It improves ventilation-perfusion matching and
oxygenation in PPHN.
🟢 10. A 2-week-old infant presents with poor feeding, tachypnea, and diaphoresis during feeding. On
examination, a systolic murmur is heard at the left lower sternal border. Which congenital heart
defect is most likely?
A. Tetralogy of Fallot
🔴🔴 B. Ventricular septal defect (VSD)
C. Transposition of the great arteries
D. Tricuspid atresia
Rationale: Poor feeding, tachypnea, and diaphoresis during feeding are signs of congestive heart failure
in neonates. A VSD with left-to-right shunting causes increased pulmonary blood flow, leading to CHF.
The systolic murmur at the left lower sternal border is classic for VSD.
🟢 11. A neonate with suspected coarctation of the aorta should be assessed for which of the following
classic findings?
A. Differential cyanosis (upper extremities pink, lower extremities blue)
🔴🔴 B. Blood pressure differential between upper and lower extremities with weak femoral pulses
C. Bounding pulses in all extremities
D. Fixed splitting of S2
