General Assessment
9%of exam
Gestational AgeAntepartum RiskGrowth CurvesFHR Patterns
General Management
39%of exam
ResuscitationFluids & GlucoseVentilationThermoregulationPharmacology
Pathophysiologic States
44%of exam
RespiratoryCardiacGI/GUHematologyInfection
Psychosocial Support
5%of exam
Discharge PlanningGrief & BereavementAttachmentPalliative Care
Professional Issues
3%of exam
EthicsEvidence-Based PracticeLegal IssuesPatient Safety
Quick Facts
- Exam
- RNC-NIC
- Credential
- Neonatal Intensive Care Nursing
- Body
- NCC
- Questions
- 175 (150 scored)
- Time
- 3 hours
- Pass Model
- Criterion-referenced pass/fail
- Format
- 3-option MCQ, computer-based
- Fee
- $325
- Validity
- 3 years
- Level
- Advanced, 24 mo NICU RN
- Blueprint
- 2026 Candidate Guide
APGAR Components
Appearance, Pulse, Grimace, Activity, Respiration
ColorHeart rateReflex irritabilityMuscle toneBreathing effort
Gestational Age Assessment
- AGA
- 10th-90th percentile
- SGA
- Below 10th percentile
- LGA
- Above 90th percentile
- New Ballard Score
- GA estimation tool
- Preterm
- <37 weeks
- Post-term
- ≥42 weeks
- SGA/IUGR risk
- Hypoglycemia, polycythemia
- LGA risk
- Birth trauma, hypoglycemia
Antepartum Risk & FHR Patterns
- Early deceleration
- Head compression
- Variable deceleration
- Cord compression
- Late deceleration
- Uteroplacental insufficiency
- Oligohydramnios
- Renal agenesis risk
- Polyhydramnios
- GI/esophageal atresia risk
- PROM
- Infection, chorioamnionitis risk
- Meconium fluid
- Fetal distress marker
- Amniotic bands
- Limb constriction risk
Heat Loss Mechanisms
ECCR: Evaporation, Conduction, Convection, Radiation
Evaporation: wet skinConduction: cold contactConvection: cold airRadiation: cold objects
Respiratory Support Escalation
- Mild WOB, stable→Nasal cannula/HFNC
- Increasing WOB, FiO2 rising→CPAP/NIV
- Apnea, poor respiratory effort→Intubate, PPV
- RDS, surfactant deficient→Surfactant via ETT
- Refractory hypoxemia, PPHN→iNO therapy
- iNO/conventional vent failing→HFOV or ECMO
NRP Resuscitation Steps
- Initial steps
- Warm, dry, stimulate
- PPV indicated
- HR <100 bpm
- Compressions indicated
- HR <60 bpm
- Compression:ventilation ratio
- 3:1
- Epinephrine IV/UVC
- 0.01-0.03 mg/kg
- Epinephrine ETT
- 0.05-0.1 mg/kg
- Volume expander
- NS 10 mL/kg
- MR SOPA
- Fix ventilation problems
MR SOPA Ventilation Corrections
Mask, Reposition, Suction, Open mouth, Pressure, Airway
Mask sealReposition headSuction secretionsIncrease pressure
NRP Heart Rate Decisions
- HR <100 bpm→Start PPV
- HR <60 after 30s PPV→Chest compressions
- HR <60 after compressions→Give epinephrine
- No response, hypovolemia suspected→Volume expander
- Chest not moving with PPV→MR SOPA steps(Fix ventilation)
Fluids, Electrolytes & Glucose
- Hypoglycemia (0-4h)
- Treat below 40 mg/dL
- Hypoglycemia (4-24h)
- Treat below 45 mg/dL
- IDM
- Hypoglycemia risk, first hours
- Insensible water loss
- Preterm skin, phototherapy
- Third spacing
- Capillary leak, edema
- Hyponatremia, early
- Usually fluid overload
- Urine output
- 1-3 mL/kg/hr
Ventilation & Blood Gas
- Respiratory acidosis
- High CO2, low pH
- Respiratory alkalosis
- Low CO2, high pH
- Metabolic acidosis
- Low HCO3, low pH
- Metabolic alkalosis
- High HCO3, high pH
- Compensated
- Near-normal pH
- HFNC
- Humidified high-flow support
- ECMO
- Cardiopulmonary bypass rescue
- Serum lactate
- Hypoperfusion marker
Thermoregulation Mechanisms
- Evaporation
- Wet skin heat loss
- Conduction
- Cold surface contact
- Convection
- Cold air currents
- Radiation
- Nearby cold objects
- Neutral thermal environment
- Goal, minimal O2 use
- Cold stress
- Increased O2 consumption
- Radiant warmer
- Open, visible access
- Incubator
- Humidity-controlled enclosed warmth
Neonatal Pharmacology & NAS
- Immature liver
- Slower drug clearance
- Immature kidneys
- Prolonged drug half-life
- NAS
- Neonatal opioid withdrawal syndrome
- Finnegan score
- NAS severity tool
- Caffeine citrate
- Apnea of prematurity
- Surfactant
- Given via endotracheal tube
- Therapeutic drug monitoring
- Narrow-margin drugs
- Fetal alcohol syndrome
- Growth, facial, CNS effects
Cyanotic Heart Lesions
5 Ts: Tetralogy, Transposition, Truncus, Tricuspid, TAPVR
Tetralogy of FallotTransposition great vesselsTruncus arteriosusTAPVR
RDS vs TTN
RDS
- Surfactant deficiency
- Worsens over hours
- Ground-glass X-ray
TTN
- Retained lung fluid
- Resolves in 24-72h
- Benign, self-limited
Progressive vs transient
Ductal-Dependent Lesion Management
- Cyanotic, ductal-dependent lesion→Start PGE1
- Acyanotic PDA, symptomatic→Indomethacin or ibuprofen
- NSAID contraindicated→Acetaminophen
- Medical closure fails→Surgical/catheter closure
Cardiac Lesions
- PDA
- Fetal shunt, aorta-pulmonary
- Ductal-dependent lesions
- Need patent ductus
- PGE1
- Keeps ductus arteriosus open
- Indomethacin/ibuprofen
- Close ductus arteriosus
- Acetaminophen
- Alternative PDA closure agent
- Cyanotic CHD
- 5 T's
- TOF
- 4 defects, boot heart
- Coarctation
- Differential upper/lower pulses
- TGA
- Parallel, not mixing circuits
- HLHS
- Underdeveloped left ventricle
TORCH Congenital Infections
TORCH: Toxo, Other, Rubella, CMV, Herpes
ToxoplasmosisSyphilis, varicella (other)CMVHerpes simplex
Central vs Peripheral Cyanosis
Central
- Lips, tongue blue
- Cardiac or pulmonary
- Always abnormal
Peripheral
- Hands, feet blue
- Acrocyanosis, normal
- Often transient
Core vs extremities
Hyperbilirubinemia Management Path
- High-risk zone, rising TSB→Start phototherapy
- Bilirubin near exchange threshold→Intensive phototherapy
- Phototherapy fails, rising rapidly→Exchange transfusion
- Direct/conjugated bilirubin elevated→Evaluate biliary cause(Not phototherapy)
Respiratory Disorders
- RDS
- Surfactant deficiency, preterm
- Surfactant
- Reduces alveolar surface tension
- TTN
- Retained fetal lung fluid
- Meconium aspiration
- Air trapping, chemical pneumonitis
- PPHN
- Elevated pulmonary vascular resistance
- iNO starting dose
- 20 ppm
- BPD
- Chronic lung, O2 need ≥28 days
- Pneumothorax
- Sudden desaturation, asymmetry
- Apnea of prematurity
- Pause ≥20 sec
Direct vs Indirect Bilirubin
Indirect
- Unconjugated
- Lipid-soluble
- Crosses blood-brain barrier
Direct
- Conjugated
- Water-soluble
- Suggests liver/biliary disease
Physiologic vs pathologic cause
Sepsis Evaluation Pathway
- Maternal risk factors present→CBC, blood culture
- Clinical signs of sepsis→Start empiric antibiotics
- CNS signs present→Add lumbar puncture
- Culture negative, well infant→Stop antibiotics 36-48h
GI & GU Disorders
- NEC
- Bowel wall inflammation/necrosis
- NEC sign
- Pneumatosis intestinalis
- Gastroschisis
- No membrane, right-sided
- Omphalocele
- Membrane-covered, midline defect
- Hirschsprung
- Absent ganglion cells
- Duodenal atresia
- Double-bubble sign
- Meconium ileus
- Cystic fibrosis marker
- Renal vein thrombosis
- Hematuria, flank mass
Gastroschisis vs Omphalocele
Gastroschisis
- No sac
- Right of cord
- Isolated defect
Omphalocele
- Sac covers bowel
- At umbilical cord
- Other anomalies common
Sac absent vs present
Hematology & Bilirubin
- Physiologic jaundice
- After 24 hours
- Pathologic jaundice
- Within first 24h
- Indirect bilirubin
- Unconjugated, lipid-soluble
- Direct bilirubin
- Conjugated, water-soluble
- Bhutani nomogram
- Hour-specific risk zones
- Kernicterus
- Bilirubin CNS toxicity
- Coombs test
- Antibody-coated RBCs
- Rh/ABO incompatibility
- Hemolysis, hydrops risk
- Polycythemia
- Hematocrit above 65%
PGE1 vs Indomethacin/Ibuprofen
PGE1
- Keeps ductus open
- Ductal-dependent lesions
- Apnea side effect
NSAIDs
- Closes ductus
- Symptomatic PDA
- GI, renal risks
Open vs close ductus
Neuro & Genetic Disorders
- IVH
- Fragile germinal matrix bleed
- PVL
- White matter ischemic injury
- HIE
- Perinatal asphyxia brain injury
- Trisomy 21
- Down syndrome
- Trisomy 18
- Edwards syndrome
- Trisomy 13
- Patau syndrome
- CAH
- Cortisol synthesis defect
- Galactosemia
- Galactose metabolism defect
Early- vs Late-Onset Sepsis
Early-onset
- Within 72 hours
- Maternal/vertical transmission
- GBS, E. coli
Late-onset
- After 7 days
- Nosocomial, environmental
- Coag-negative staph
Birth-acquired vs NICU-acquired
Neonatal Infection
- Early-onset GBS
- Within 72 hours
- Late-onset GBS
- After 7 days
- TORCH infections
- Congenital transmission group
- Immature host defenses
- Poor IgM response
- Sepsis signs
- Temp instability, lethargy
- CRP/CBC
- Sepsis workup markers
Physiologic vs Pathologic Jaundice
Physiologic
- Appears after 24h
- Peaks day 3-5
- Resolves spontaneously
Pathologic
- Appears before 24h
- Rapid rise rate
- Needs urgent workup
Timing of onset
Ethics & Professional Practice
- Autonomy
- Respect patient/parent choice
- Beneficence
- Act in patient's benefit
- Nonmaleficence
- Avoid causing harm
- Justice
- Fair resource distribution
- Levels of evidence
- Hierarchy of rigor
- Informed consent
- Parent/guardian authorization
Common Traps
Physiologic vs pathologic jaundice
Physiologic starts after 24h ≠ Pathologic starts before 24h
PPHN vs simple hypoxemia
PPHN needs echo confirmation ≠ Not just low saturations
Central vs peripheral cyanosis
Central is always abnormal ≠ Peripheral often benign, transient
Gastroschisis vs omphalocele
Gastroschisis has no sac ≠ Omphalocele covered by membrane
Pretest items vs scored items
25 pretest items unscored ≠ 150 items count toward pass
NRP compressions vs epinephrine timing
Compressions start at HR<60 ≠ Epinephrine after compressions fail
IUGR vs prematurity
IUGR is growth restriction ≠ Prematurity is gestational age
Last Minute
- 1.Weights: 9/39/44/5/3
- 2.175 questions, 150 scored
- 3.3-hour time limit
- 4.Criterion-referenced pass/fail scoring
- 5.PPV starts at HR<100
- 6.Compressions start at HR<60
- 7.Epinephrine IV: 0.01-0.03 mg/kg
- 8.iNO starting dose: 20 ppm
- 9.Hypoglycemia: <40 mg/dL (0-4h)
- 10.Physiologic jaundice appears after 24h
- 11.PGE1 opens; NSAIDs close ductus
- 12.Gastroschisis: no sac, right-sided
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