Three USMLE Step 2 CK clinical questions on the first steps of newborn care, emergency management of a deteriorating stroke patient, and a newborn with an open neural tube defect. Pick your answer first, then open the explanation.
Question 1: What is the first step after delivery of a healthy newborn?
A term infant is born by normal vaginal delivery. He is crying and has good muscle tone. Which of the following is the most appropriate first step in management?
A. Clamp and cut the umbilical cord immediately B. Gently rub the soles of the feet C. Suction the mouth and nose D. Dry the infant and keep him warm with clean, warm towels
Correct answer: D. Dry the infant and keep him warm
For a vigorous newborn (crying, good tone, term), the first steps are to dry and warm the baby, ideally skin-to-skin with the mother. Newborns lose heat very quickly, and hypothermia increases complications. Drying also stimulates breathing.
Why the other options are wrong:
Immediate cord clamping is no longer recommended for a vigorous infant; delaying clamping for at least 30–60 seconds improves iron stores and blood volume.
Rubbing the feet is tactile stimulation, used if the baby is not breathing well after drying.
Routine suctioning is no longer recommended (even with meconium) unless secretions block the airway; it can cause bradycardia.
High-yield: If the newborn is apneic or the heart rate is below 100/min after initial steps, start positive-pressure ventilation within the first minute (“the golden minute”).
Question 2: Stroke patient with sudden headache and breathing difficulty
A 76-year-old man presents to the emergency department with weakness of the right arm and leg, aphasia and right-sided facial droop. During the examination, he develops a sudden severe headache, becomes drowsy and has increasing respiratory effort. Which of the following is the best next step?
A. Administer aspirin B. Administer thrombolytic therapy C. Secure the airway with endotracheal intubation D. MRI of the head
Correct answer: C. Secure the airway with endotracheal intubation
This patient most likely has an intracerebral hemorrhage (or hemorrhagic transformation of a stroke), with a falling level of consciousness and respiratory compromise. In every emergency, Airway, Breathing and Circulation come first; once the airway is secured, obtain an urgent non-contrast head CT.
Why the other options are wrong:
Aspirin must not be given before hemorrhage is excluded by CT.
Thrombolytics are contraindicated until CT rules out bleeding; they would be dangerous here.
MRI takes too long in an unstable patient; non-contrast CT is the first imaging test.
High-yield: Intubate a stroke patient when GCS ≤ 8, the airway cannot be protected, or breathing is failing.
Question 3: Newborn with myelomeningocele: next step
A newborn is found to have a myelomeningocele over the lumbar spine. Which of the following is the most appropriate management?
A. Antibiotic therapy only B. Lumbar puncture to examine the cerebrospinal fluid C. Manual compression of the sac D. Cover the sac and arrange surgical closure as soon as possible
Correct answer: D. Cover the sac and arrange surgical closure as soon as possible
Myelomeningocele is the most severe form of spina bifida: the meninges and spinal cord herniate through a vertebral defect. Cover the sac with a sterile, moist, non-adherent dressing, keep the baby prone, start antibiotics, and arrange surgical closure within 24–72 hours to prevent infection and further nerve damage.
Why the other options are wrong:
Antibiotics are given to prevent meningitis, but alone they do not treat the defect.
Lumbar puncture is not indicated and risks infection.
Compressing the sac can damage the exposed neural tissue.
High-yield: Myelomeningocele is associated with Arnold-Chiari II malformation and hydrocephalus, lower limb paralysis and neurogenic bladder. Prevention: folic acid before and during early pregnancy; screening with elevated maternal AFP.
Key takeaways
Vigorous newborn → dry and warm first; delay cord clamping; no routine suction.
Deteriorating stroke patient → airway first, then non-contrast CT before any aspirin or thrombolytics.
