#2 A mother well known to your practice has just presented to the hospital with premature rupture of the membranes at 24 weeks’ gestation. The medical student shadowing you in the office asks you if there is a clinical variable that is associated with improved survival and outcome at this very early gestational age.

Of the following, the BEST response to the student’s question is:

# 3 During morning rounds, the nurse informs you that a 3.8-kg neonate has just been delivered by

caesarean section due to breech presentation. The pregnancy was notable for well-controlled maternal type I diabetes. The maternal glycated hemoglobin A1c values ranged between 5% to 6% before conception and during pregnancy. Level II screening ultrasonography done at 18 weeks of gestation was normal. Your assessment at 40 minutes after birth reveals a pink, well-perfused neonate with normal tone, strong suck, and good color. Cardiac examination reveals a grade 1/6 systolic murmur at the left lower sternal border with a preductal oxygen saturation of 97% on room air. The mother is anxious to breastfeed.

Of the following, the MOST appropriate next step in management is to immediately

#4 A neonate is being assessed for increasing work of breathing.

#5 You are called to attend the vaginal delivery of a woman who presented completely dilated at 29

weeks of gestation. The newborn emerges limp without any respiratory effort. After gently suctioning

and drying the newborn, you begin bag-mask ventilation with 30% oxygen. A pulse oximetry probe is

placed on the right hand. The heart rate slowly begins to rise over 100 beats/min after 30 seconds of

effective ventilation, and the pulse oximeter reads 90% oxygen saturation. The infant begins to have

weak spontaneous respiratory effort associated with deep retractions. A decision is made to intubate,

and a 3 mm endotracheal tube is placed on the first attempt. At 5 minutes after birth, the newborn

continues to require positive pressure ventilation with 30% oxygen. The newborn is centrally pink with

a heart rate of 140 beats/min and continues with a weak spontaneous respiratory effort while

intubated. The newborn has some flexion and grimaces upon intramuscular injection of vitamin K.

Of the following, the MOST appropriate Apgar score to assign at 5 minutes is

#6 You are assessing a term neonate who was born by vaginal delivery that was complicated by shoulder

dystocia and thick meconium. The neonate emerged limp and apneic. No meconium was found below

the vocal cords after the initial intubation and suctioning were performed. The neonate required

resuscitation with bag-mask ventilation for 2 minutes. Apgar scores assigned were 1 at one minute (1

for heart rate) and 6 at five minutes (2 for heart rate, 2 for respiratory effort, 1 for color, 0 for tone,

and 1 for reflex irritability). Examination reveals an alert newborn with mild retractions and decreased

tone, with a temperature of 36.7°C, heart rate of 110 beats/min, respiratory rate of 80 breaths/min,

blood pressure of 64/40 mm Hg, and oxygen saturation of 95% on room air. An arterial blood gas

obtained 20 minutes after delivery reveals a pH of 7.22, Paco2 of 51 mm Hg, Pao2 of 60 mm Hg,

bicarbonate of 19 mEq/L (19 mmol/L), and base deficit of -7.

7. You are called in to see a female neonate born at term to a 34-year-old gravida 2, para 2 woman following a reportedly uneventful pregnancy, although the mother had only 2 prenatal visits at 30 and 36 weeks’ gestation. The neonate’s birth weight is 2.3 kg (below the 5th percentile), and her Apgar scores were 7 and 9 at one and five minutes, respectively. On examination, her head circumference is at the fifth percentile. Facial features are seen in Item Q138. Examination is also remarkable for bilateral radioulnar synostosis, small distal phalanges, fifth-fingernail hypoplasia, and a soft systolic cardiac murmur. Echocardiogram demonstrates a small muscular ventricular septal defect.

Of the following, the MOST likely diagnosis for this infant is

8. You are called by a family who has just learned that an infant will become available for adoption. The

mother is a late entrant into prenatal care. Results of maternal screening studies, including hepatitis

B, human immunodeficiency virus, and rapid plasma reagin, are negative. Urine toxicology result is

positive for marijuana and cocaine at the most recent prenatal visit at 30 weeks of gestation. The

family is delighted about the upcoming adoption but asks if the illicit substances used by the mother

during pregnancy may affect the infant.

Of the following, the MOST appropriate response is that the infant is at increased risk of

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