NRP 8th Edition Test Answers
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| Questions | Answers |
| Your team has provided face-mask PPV with chest movement for 30 seconds. When is placement of an endotracheal tube strongly recommended? | The baby’s heart rate remains less than 100 bpm and is not increasing. |
| During a delivery, when and where should a person with intubation skills be available? | In the hospital and immediately available |
| What are the primary methods of confirming endotracheal tube placement within the trachea? | Demonstration of exhaled carbon dioxide (CO2) and a rapidly increasing heart rate |
| You are resuscitating a critically ill newborn whose heart rate is 20 bpm. The baby has been intubated and the endotracheal tube insertion depth is correct. You can see chest movement with PPV and hear bilateral breath sounds, but the colorimetric CO2 detector does not turn yellow. What is the likely reason for this? | Low cardiac output. |
| According to the Textbook of Neonatal Resuscitation, 8th edition algorithm, at what point during resuscitation is a cardiac monitor recommended to assess the baby’s heart rate? | When an alternative airway is inserted |
| What size laryngoscope blade is recommended to intubate a preterm newborn with an estimated gestational age of 32 weeks (estimated birth weight of 1.4 kg)? | 0 |
| Even brief interruptions of chest compressions may significantly reduce their effectiveness, but it is also important to assess the need to continue chest compressions. What is the preferred way to assess the heart rate during chest compressions? | Briefly interrupt chest compressions every 60 seconds to assess the heart rate using the cardiac monitor. |
| Your team is resuscitating a newborn at birth. The heart rate is low and the baby has poor perfusion. Which is the preferred method to assess the heart rate? | Cardiac monitor |
| When are chest compressions indicated? | When the heart rate remains less than 60 bpm after at least 30 seconds of PPV that moves the chest, preferably through an alternative airway |
| After 60 seconds of PPV coordinated with chest compressions, the cardiac monitor indicates a heart rate of 70 beats per minute. What is your next action? | Stop chest compressions and continue PPV. |
| What is the recommended depth of chest compressions? | One-third of the anterior-posterior diameter of the chest |
| During chest compressions, which of the following is correct? | To coordinate compressions and ventilations, the compressor calls out one-and-two-and-three-and-breathe-and… |
| Your team is resuscitating a newborn whose heart rate remains less than 60 bpm despite effective PPV and 60 seconds of chest compressions. You have administered epinephrine intravenously. According to the Textbook of Neonatal Resuscitation, 8th edition, what volume of normal saline flush should you administer? | 3 mL |
| According to the Textbook of Neonatal Resuscitation, 8th edition, what is the suggested initial dose for IV epinephrine (0.1 mg/1 mL=1 mg/10 mL)? | 0.02 mg/kg (equal to 0.2 mL/kg) |
| When is the administration of a volume expander indicated during newborn resuscitation? | The baby’s heart rate is not increasing and there are signs of shock or a history of acute blood loss. |
| Your team is caring for a term newborn whose heart rate is 50 bpm after receiving effective ventilation, chest compressions, and intravenous epinephrine administration. There is a history of acute blood loss around the time of delivery. You administer 10 mL/kg of normal saline (based on the newborn’s estimated weight). At what rate should this be administered? | Over 5 to 10 minutes |
| How soon after administration of intravenous epinephrine should you pause compressions and reassess the baby’s heart rate? | 60 seconds |
| You are called to the birth of a newborn at 30 weeks gestation. As you prepare your equipment, what concentration of oxygen will you use initially if PPV is required? | 21% to 30% |
| A baby is born at 26 weeks gestation. The initial steps of care, including gentle stimulation, have been completed and the baby is nearly 1-minute old. The baby is not breathing. What is the most appropriate next step? | Begin PPV by mask. |
| Choose the appropriate step(s) to prepare for the birth of a newborn <32 weeks gestation. | Prepare the preheated radiant warmer with a thermal mattress, plastic wrap or bag, a hat, and a skin temperature sensor |
| A term newborn was born via emergency cesarean section in the setting of fetal bradycardia. The baby was limp and bradycardic at birth and was intubated at 6 minutes after birth for persistent apnea. The cord blood gas demonstrates a severe metabolic acidosis, and the physical examination is consistent with hypoxic-ischemic encephalopathy (HIE). Which of the following is the most appropriate intervention for this newborn? | Admit the newborn to a center with the capability to perform therapeutic hypothermia. |
| A term baby was vigorous at birth but receives CPAP for 3 minutes after birth for grunting respirations. The baby is now 15 minutes old, breathing comfortably in room air, and bonding with their mother. The team plans for the baby to room-in with their mother. What immediate decision needs to be made regarding post-resuscitation care? | Identify who will continue to monitor the baby in the mother’s room. |
| A baby’s heart rate does not increase after intubation and the breath sounds are louder on the right side than on the left side of the chest. Which of the following is a common cause of asymmetric breath sounds in an intubated baby? | Endotracheal tube inserted into the right mainstem bronchus |
| During resuscitation, a baby initially responds to PPV with a rapidly increasing heart rate. Subsequently, the baby’s heart rate and oxygen saturation suddenly worsen. The baby has decreased breath sounds on the left side and transillumination reveals a bright glow. What is the most likely cause of this distress? | Left-sided pneumothorax |
| You attend the birth of a baby with prenatally diagnosed severe congenital diaphragmatic hernia. What are the most appropriate steps as you begin your resuscitation? | Intubate the trachea and insert an orogastric tube into the stomach. |
| A woman in labor received opioid medication for pain relief 1 hour before delivery. The baby does not breathe spontaneously and remains apneic after stimulation. What is your next intervention? | Start PPV. |
| In most cases, who are the usual and appropriate surrogate decision makers for a newborn? | The newborn’s parents |
| When a newborn has a high risk of mortality and there is a significant burden of morbidity among survivors, what should be included in the discussion with the parents concerning options for resuscitation? | The option of providing comfort care can be considered. |
| You are in the delivery room caring for a preterm newborn at 27 weeks gestation. The baby is 5 minutes old and breathing spontaneously. The baby’s heart rate is 120 bpm and the oxygen saturation is 90% without respiratory support. The baby’s respirations are labored. Which of the following is an appropriate action? | Administer CPAP at 5 cm H2O pressure with 21% oxygen. |
| Ideally, how quickly should the intubation procedure be completed? | 30 seconds |
| Which of the following is an indication for placement of an alternate airway? | The need for PPV is prolonged |
| What size (internal diameter) endotracheal tube should be used to intubate a newborn with an estimated gestational age of 26 weeks (estimated birth weight of 0.8 kg)? | 2.5 mm |
| When coordinating PPV with chest compressions how long does it take to complete a cycle of 3 compressions and 1 breath? | 2 seconds |
| When chest compressions are in progress, how often should the heart rate be assessed? | Every 60 seconds |
| A baby is delivered at 29 weeks gestation. At 5 minutes after birth, the baby is breathing spontaneously while receiving CPAP (at a pressure of 5 cm H2O) and 30% oxygen. A pulse oximeter sensor on the baby’s right hand is reading 95% and oxygen saturation is increasing. What is the most appropriate next step? | Decrease the oxygen concentration. |
| When is the placement of endotracheal tube recommended? | A- HR<100 |
| Intubation skills be available? | A- In hospital and immediately available |
| Confirming endotracheal tube | C- exhaled Co2 and inc HR |
| Co2 detector not yellow | D- Low cardiac output |
| 8th edition cardiac monitor recommended | B- When alternative airway is inserted |
| Laryngoscope blade sizes | D- single 0 not 00 |
| HR during chest compression | C- 60 sec and use cardiac monitor |
| HR low and poor perfusion | A-cardiac monitor |
| Chest compression indicated? | B- HR<60 after 30 sec PPV |
| HR 70 bpm after PPV | A- Stop chest compression and continue PPV |
| Depth of chest compressions | A- 1/3rd AP dia of chest |
| chest compressions | D- 1-2-3 and breathe |
| Saline Flush | C- 3ml |
| 8th annual NPR – Epi | A- 0.02 mg/kg |
| Volume expanders | A- Hr not inc and sign of shock and hx of acute blood loss |
| 10ml/kg saline | B- 5 to 10 min |
| After IV check HR after | C- 60 sec |
| Conc of O2 for PPV | A- 21-30% |
| Gentle stimulation and 1 min old. not breathing | A- Begin PPV by mask |
| Birth<32 weeks gestations | C- Preheat radiant warmer |
| Team plan to leave baby with mother | C-who will monitor baby in mother room |
| asymmetric breath sounds immediately after intubation suggest? | C- Rt main bronchus |
| congenital diaphragmatic hernia | B- Intubate and orogastric tube |
| Surrogate | B- Newborn parents |
| morbidity burden and option for resuscitations | A-Comfort care |
| Need for alternative airway | D- need for PPV is prolonged |
| Gestation age of 26 weeks | A- 2.5 mm |
| How often HR during compression | A- Every 60 sec |
| CPAP inc O2 so next step | A- Dec o2 concentration |
NRP 8th Edition Chapter 1-4 Test Answers
- What are the five blocks of the NRP algorithm?
Rapid evaluation: this evaluation determines if the baby can stay wit the mother for routine care or should be moved to the radiant warmer
Airway: The initial steps open the airway and support spontaneous respirations.
Breathing: Assist breathing with PPV if baby apneic, gasping, or bradycardic. CPAP or or O2 may be appropriate for labored breathing or low O2 sat.
circulation: Perform chest compressions coordinated with PPV if severe bradycardia exists despite assisted ventilation
drug: administer epinephrine if severe bradycardia persists despite PPV and coordinated chest compressions. - What skills must be present to comprise a qualified team that must be immediately available for every resuscitation?
Persons skilled in endotracheal intubation, chest compressions, emergency vascular access, and medication administration. (probably requires 4 or more qualified persons) - What is a NRP quick equipment checklist?
List of all supplies and equipment for a complete resuscitation that must be readily available and functional for every birth.
NRP checklist – warming and clear airway supplies
NRP checklist – Ventilate & oxygenate equipment - After completing the rapid evaluation, the next step is completion of the initial steps of newborn care, which include __________ and __________.
After completing the rapid evaluation, the next step is completion of the initial steps of newborn care, which include opening the airway and supporting spontaneous respiration. - What is looked at in determining if baby can stay with Mum?
-Term gestation?
-Good tone?
-breathing or crying?Determine within 1 minute. - What if baby fails rapid evaluation?
Warm, dry, stimulate, position airway, suction if needed. - What if baby is apneic or gasping or heart rate under 100 bpm after stimulation, et al?
PPV, pulse oximetry, consider cardiac monitor.
What if severe bradycardia persists (under 60)
ETT or laryngeal mask, chest compressions. - Heart rate still under 60 bpm?
epinephrine q 3-5 minutes. Consider hypovolemia or pneumothorax - According to the NRP algorithm, what are the indicators for PPV?
_cyanosis
-apnea
-tachycardia
-gasping
-heart rate less than 100 bpm - According to the NRP algorithm, what are the indicators for PPV?
_cyanosis
-apnea
-tachycardia
-gasping
-heart rate less than 100 bpm - What is the single most important and effective step in neonatal resuscitation?
Learning how to provide positive pressure ventilation. - Newborn resuscitation is usually the result of _____________.
Respiratory failure. - What are the four prebirth questions to ask to determine appropriate team and equipment?
-What is the expected gestational age?
-Is the amniotic fluid clear
-Are there any additional risk factors?
-What is our umbilical cord management plan? - How many qualified people should be at the birth if there is meconium stained fluid?
at least two qualified people to only manage the baby, including person with intubation skills, if this is the only risk factor. - How many people should be present at a birth to manage the baby if there is no risk factors?
Every birth should be attended by at least one qualified individual skilled in the initial steps of newborn care and PPV whose only responsibility is management of the baby. - How many people should be present to manage the baby if risk factors are present.
At least 2. - What is required skillset for a resuscitation team?
4 or more qualified providers skilled with ET, chest compressions, emergency vascular access, and medication administration. - What must be done prior to every birth?
Checklist that all essential supplies and equipment are at the radiant warmer for neonatal resuscitations. - What should size of suction catheter and setting?
10f or 12f suction catheter attached to wall suction, set at 80-100 mm Hg - What should the flowmeter be set at?
10L/min - What should oxygen blender be set at?
21% (21-30% if less than 35 weeks GA) - According to the NRP Quick Equipment Checklist, how should the flowmeter be set to prepare for ventilation?
-5 L/min
-10 L/min
15 L/min
18 L/min
10 L/min - How long should cord clamping be delayed in healthy baby?
30-60 seconds - What if baby is not vigorous at birth (re: cord clamp)
-brief delay in cord clamping while provider clears the airway with the bulb syringe and gently stimulates baby to breath. If baby doesn’t breathe after suction and brief stimulation, the cord should be cut and baby brought to radiant warmer. - What are the three rapid evaluation questions that determine if the baby can stay with the mother or should be moved to the radiant warmer?
Term: Does the baby appear to be term? - Tone: Does the baby have good muscle tone?
Breathing: Is the baby breathing or crying? - What if every answer to the rapid evaluation at birth is yes? (Term? Tone? Breathing?)
Then baby can stay with mother; initial steps and care can take place with baby in mother’s arms or on chest. - What if any answer to the rapid evaluation is no (Term? Tone? Breathing?)
Then the baby is moved to radiant warmer to perform initial steps. - What are five initial steps of newborn care?
-Provide warmth
-dry the baby (if greater than 32 weeks GA) and remove wet linen
-Stimulate by gently rubbing baby’s back and extremities
-Position head and neck to open the airway (sniffing position)
-clear secretions from airway if needed. - During initial steps, if the baby is ______ weeks, do not dry the baby.
less than 32 weeks - Care for baby if Term, Tone, Breathing is “yes”
1) a)place baby skin-to-skin with mother, dry the baby, b) then cover with warm dry blanket and c) position the head and neck to facilitate breathing.
2) Clear secretions with bulb syringe only if secretions are obstructing baby’s breathing or if the baby is having difficulty clearing secretions;
3)-monitor breathing, tone, activity, color, and temperature of baby to determine if additional interventions are needed. - What should be done with baby after completing the initial steps? What should heart rate be?
Assess breathing. If baby is breathing, assess and monitor heart rate. It should be at least 100 bpm. - What to do if you assess breathing and baby is apneic, gasping, or bradycardic (less than 100 bpm even if breathing)?
Start PPV immediately; to count heartbeat, count for 6 seconds, and add “0” to count. - When the baby stays with the mother for initial steps after birth, what should be monitored to determine if additional interventions are required?
-breathing
-blood pressure
-temperature
-tone and activity
-color
-breathing
-temperature
-tone and activity
-color - What are the 5 initial steps if baby “fails” rapid evaluation? (Term, Tone, Breathing?)
-Move baby to radiant warmer for initial steps.
1. Place baby uncovered under warmer so radiant heat can reach baby
2. Dry baby (if greater than 32 weeks GA and remove wet linen
3-Gently rub the baby’s back, trunk, or extremities if baby is still not breathing.
4. Position baby’s head and neck in sniffing position to facilitate breathing. (towel can be placed under shoulders to assist position)
5. suction mouth, then nose, in anticipation of PPV. - What if NB not breathing after moved to radiant warmer and 5 steps completed?
Immediately begin PPV (within first 60 seconds after birth). - What if…baby is breathing, but is bradycardic (heart rate less than 100 bpm)
Start PPV immediately. Also if baby apneic, gasping, or bradycardia. - If a baby is apneic, gasping or has a heart rate of less than 100 bpm after the initial steps of resuscitation________ immediately.
Start PPV - Where and how should you auscultate the NB heart rate?
Auscultate with stethescope along let side of chest. Estimate the heart rate by counting the number of beats in 6 seconds and add 0. Heart rate should be at least 100, if less. start PPV. Can also connect a pulse ox or a cardiac monitor. - What are the time goal of starting PPV in an infant who has heart rate less than 100, is gasping or apneic?
Within 1 minute of birth - What are oxygen saturation goals at 10 minutes?
85-95% - PPV terminology: Peak Inspiratory Pressure (PIP)
Highest pressure delivered with each breath - PPV terminology: Positive End Expiratory Pressure (PEEP)
Pressure maintained in the lungs between breaths when baby receiving assisted ventilation. - What would it mean if baby receiving breaths at 25/5
PIP is 25 cm/ and PEEP is 5 cm - CPAP (continuous positive airway pressure)
Gas pressure maintained in lungs b/n breath when baby breathing on its own. Keeps lungs slightly inflated so baby doesn’t have to work as hard to reinflate lungs with each breath. - What is “inspiratory” or “I” time
Durations in second of the inspiratory phase of each breath. - Ventilation rate
# of assisted BPM - What is the single most important and most effective step in neonatal resuscitation?
ventilation of lungs - Does self inflating bag require oxygen plug-in?
No - How is a T piece used?
Breath is delivered by alternating b/n covering and releasing the covering on the cap; length of breath is how long finger is covering opening - How to position PPV mask on baby?
Place baby in “sniffing” position;small towel under shoulders may be helpful. Cup chin in mask; bring mask up and over mouth and nose (covering both but not eyes). Circle rim with thumb and index finger. Other fingers are under bony angle of the jaw. Lift the jaw up towards mask. Don’t rest hand on baby’s eye or compress neck. - How often are breaths given?
40-60 BPM (Waltzing rhythm: “breath – 2 – 3”. See gentle rise and fall of breath. - Starting value suggestions for T piece PPV?
PEEP – 5
21% O2 (use pulse ox).
40-60 BPM.
PIP: 20-25 cm H20 (first few for term may be as high as 40)
After 15 seconds, do first heart check while ventilation continues and announce BPM. - What if heart rate is increasing after first 15 seconds.
Carry on with ventilations for another 15 seconds, then listen again. - What if heart rate is not increasing after 15 seconds?
-if chest is moving, continue PPV and check after 15 seconds.
-if chest is NOT moving and heart rate is NOT increasing, “MR SOPA” ventilation steps “immediately”. - What does MR SOPA stand for?
M–mask adjustment
R–reposition head and neck
Give 5 breaths and assess chest movement. If no chest movement…
S–suction mouth and nose
O–open mouth
Give 5 breaths and assess chest movement, if no chest movement….
P–pressure increase (increments of 5 until 40 max (term)
Assess chest movement after several seconds
A–airway alternative (laryngeal) - What are the first 2 steps of MR. SOPA ventilation corrective steps that often solve the problem?
-Mask adjustment and reposition head
-Monitor and reassess the heart rate
-suction mouth and reassess heart rate
-chest movement and repeat stimulation
-Mask adjustment and reposition head - You are performing the Mr. SOPA ventilation correction steps on a term baby. You have adjusted the mask and repositioned the head. You have suctioned the mouth and nose and opened the mouth. There is still no chest movement. What is the next step?
-Increase PEEP from 5 to 10
-Increase pressure in 5 to 10 increments up to 40
-Increase pressure in 5 to 10 increments up to 50
-Increase pressure in 5 to 10 increments up to 30
-Increase pressure in 5 to 10 increments up to 40 - When might an OG tube be placed?
If CPAP or PPV has been used longer than several minutes. Leave uncapped to act as a vent for the stomach - How to measure for OG tube?
Measure from bridge of the nose to earlobe; from earlobe to point 1/2way b/n xyphoid process and umbilicus. (during ventilation) Note cm mark at that place. Insert tube, then use syringe to remove some gastric content. Remove syringe. - What are alternative airways?
laryngeal mask (use size 1 for NB over 1500-2000g) and ET - Do you have to visualize the baby’s vocal cords to insert a laryngeal mask?
No - What are indications for inserting a laryngeal mask? (SATA)
-NB has congenital anomalies involving mouth, lip, tongue, palate or neck
-a self inflating bag is not available
-you cannot intubate
-NB has large tongue
-you cannot ventilate
-NP has small mandible
-NB has congenital anomalies involving mouth, lip, tongue, palate or neck
-you cannot intubate
-NB has large tongue
-you cannot ventilate
-NP has small mandible - When to d/c PPV?
As HR increases over 100 bpm and baby begins to breathe, slow rate of PPV and gently stimulate the baby. - When baby is breathing well enough to sustain HR over 100 bpm, discontinue PPV
-Continue to monitor heart rate and O2 sat with pulse ox. - Left off at “when to call for help”
… - What if you are alone with baby who needs PPV?
1. Start PPV and mobilize additional help. - Ask 2 people to help you by
a. auscultate heart rate and attach pulse oximeter to right hand or wrist
b. document vital signs and interventions about every 30-60 seconds. Include Respiratory effort, heart rate, O2 sat, O2 concentration in use, and chest movement with PPV - When should you “consider” using a cardiac monitor?
When
-PPV is required
-baby is not vigorous and heart rate is difficult to auscultate
-when pulse ox does not work
-you are using alternative airway - What should you do prior to cardiac compressions or medications?
-baby should have received 30 seconds of PPV that moves the chest, preferably thru alt airway (use pulse ox) - When should PPV be d/c?
when baby’s heart rate is more than 100 bpm and baby has sustained spontaneous respirations - What is the most important indicator of successful PPV?
rising heart rate - When should you consider using a cardiac monitor?
-when an alt airway is required, a cardiac monitor is recommended.
-Pulse ox does not work
-PPV is required
-baby arrives at radiant warmer for initial steps of resuscitation
-heart rate is difficult to auscultate
-baby is not vigorous
-when an alt airway is required, a cardiac monitor is recommended.
-Pulse ox does not work
-PPV is required
-heart rate is difficult to auscultate
-baby is not vigorous - When performing PPV, you may not proceed to chest compressions or medications until the NB has received at least ______ seconds of PPV that moves the chest, preferably through an ET or laryngeal mask.
30 seconds - Is visual assessment of cyanosis a reliable indicator of O2 saturation?
No – healthy babies may have central cyanosis for several minutes after birth, and may take more than 10 minutes to achieve O2 sat greater than 90%. Use pulse ox to evaluate oxygen saturation. - When should you use pulse ox? (4)
-when resuscitation is anticipated (apply after completing initial steps of care)
-to confirm perception of central cyanosis persisting several minutes after birth and to assess need for supplement o2
-to guide o2 concentration when oxygen is administered
-when PPV is required - Where to place the pulse ox?
on right wrist or hand (pre-ductal). Might take few minutes to get good read. - What are the laryngeal mask supplies? Where should it be located?
-size 1 laryngeal mask
-CO2 detector
-8F feeding tube and syringe for use as an orogastric tube
-5 ml syringe – if needed for mask inflation. - What are indications for the use of pulse ox?
-all babies should have pulse ox applied.
-When delayed cord clamping is in progress
-To guide O2 concentration
-To assess the need for supplemental oxygen
-To confirm your perception of central cyanosis
-When PPV is required
-To guide O2 concentration
-To assess the need for supplemental oxygen
-To confirm your perception of central cyanosis
-When PPV is required - How do you know when a newborn needs supplemental O2?
Compare baby’s O2 saturation with target values in the O2 sat table. If reading is below target range, supplemental o2 is appropriate for breathing baby whose heart rate is at least 100 bpm - What is a reasonable supplemental oxygen level?
30%; can adjust upward. - How to administer supplemental O2?
-adjust flowmeter to 10L/min
-set Oxygen blender to 30%
-Administer free-flow O2
-Monitor baby’s o2 sat
-adjust concentration as needed to maintain O2 sat w/in target range - How to administer free-flow o2?
Hold mask or tubing close to (but not on) nose. - What is a reasonable Oxygen concentration with which to begin free flow oxygen?
-60%
-30%
-40%
-20%
30% - You are providing face mask PPV to a newborn who was bradycardic at birth. The heart rate has increased to more than 100 bpm and the baby is beginning to breathe spontaneously. What is your next action?
-Slow the rate of PPV and stimulate the baby
-D/C PPV immediately
-Increase the ventilation rate and pressure
-Continue PPV for 3 minutes
Slow the rate of PPV and stimulate the baby - How long should cord clamping be delayed in vigorous babies?
30-60 seconds - What to do about cord clamping if baby is not vigorous at birth?
-may be reasonable to delay cord clamping while provider clears airway with bulb syringe and gently stimulates baby to breathe. If baby does not breathe at this point, cord should be clamped and cut and baby brought to radiant warmer. - What should PPV oxygen be started at?
-21% oxygen for over 35 weeks
-21-30% oxygen for less than 35 weeks
Benefits of delayed cord clamping for term and preterm babies - According to the NRP algorithm, what are the indicators for PPV?
-heart rate less than 100 bpm
-cyanosis
-tachycardia
-apnea
-gasping - Heart rate less than 100 bpm
apnea
gasping