Certified Registered Nurse Anesthetist (CRNA) Practice Exam

A neonate has Apgar scores of 8 and 8. He is pink when actively crying, but cyanosis and retractions appear when he is quiet. What is the most likely diagnosis?

1. Choanal atresia

2. Tracheoesophageal fistula

3. Pneumothorax

4. Congenital diaphragmatic hernia

The correct answer is: Choanal atresia

The scenario describes a neonate who has normal Apgar scores, indicating that the immediate transition to life after birth is satisfactory. However, the presence of cyanosis and retractions when the baby is quiet suggests a respiratory issue that manifests under specific circumstances, such as when the infant is not actively crying. Choanal atresia is a condition where the back of the nasal passage is blocked, usually by abnormal tissue, which can lead to respiratory distress, particularly when the infant is at rest or feeding. When the baby is crying, there is increased airflow that can temporarily relieve cyanosis, but once the baby becomes quiet, the obstruction can result in difficulty with breathing, leading to cyanosis and retractions. In contrast, the other conditions listed would likely present with different symptoms or patterns. For example, a tracheoesophageal fistula generally presents with feeding difficulties and significant respiratory distress. Pneumothorax would present with acute respiratory distress and often unilateral findings, while congenital diaphragmatic hernia typically leads to severe respiratory distress at birth, characterized by scaphoid abdomen and may not stabilize with crying. Thus, the clinical picture of cyanosis that resolves when the infant is active aligns well with choanal atresia, which is characterized