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Neonatal Resuscitation Program (NRP)
practice
Questions to ask prior to birth - correct answer 1. what is expected Gestational age, (preterm <38 wks, term 38-41 wks or post-term >41 wks)
- what is amniotic fluid color (only clear good),
- what's number of babies expected (twins mebbe more),
- are any additional risk factors (GDM, miscarriages, preeclampsia, etc.) When to clamp umbilical cord - correct answer 30-60 seconds after birth for VIGOROUS newborn Things to look for after birth - correct answer 1. Is the baby term, (if no, bring baby to warmer)
- does the baby have good muscle tone, (flaccid/extended extremities are bad)
- is the baby breathing or crying? (if no crying, observe chest for breathing efforts. if vigorous crying, return to mom) 5 initial steps of care - correct answer 1. Warm,
- position airway,
- clear secretions if needed,
- dry,
- stimulate Flow rate for free-flow O2 administration - correct answer 10lpm O2 level for free-flow O2 administration - correct answer 30% Suction setting for newborn - correct answer 80-100mmHg
Antepartum risk factors - correct answer gestation <36wks or >41wks, pre- eclampsia and eclampsia, maternal HTN, poly and oligohydramnios, fetal hydrops, macrosomia and IGR, fetal malformations or anomalies, no prenatal care. Inpartum - correct answer Emergency c-section, vacuum assisted delivery, breech or abnormal presentation, category II or III, maternal anesthesia, mag, or narcs, prolapse cord, shoulder dystocia, meconium staining, bleeding, placental abruption, chorioamnionitis Abnormal transition signs and symptoms - correct answer Apnea, tachypnea, bradycardia, tachycardia, decreased muscle tone, low SpO2, hypotension Preductal SpO2 at 1 min - correct answer 60-65% Preductal SpO2 at 2 min - correct answer 65-70% Preductal SpO2 at 3 min - correct answer 70-75% Preductal SpO2 at 4 min - correct answer 75-80% Preductal SpO2 at 5 min - correct answer 80-85% Preductal SpO2 at 10 min - correct answer 85-95% Where to put pulse oximeter on newborn - correct answer Right hand or wrist (preductal) Requirements for CPAP on newborn - correct answer HR >100bpm and spontaneous respirations Best way to determine HR - correct answer Listen with stethoscope on left side chest for 6 seconds, multiply by 10
reduced oxygen saturation, resulting in a lower heart rate. Stimulation will usually assist a newborn in the required respiratory transition, however if a newborn does not start breathing immediately following stimulation, he/she is likely experiencing secondary apnea. Further stimulation will not help, and the newborn require positive-pressure ventilation.) Which device should be readily available as a backup wherever resuscitation may be needed, in case a compressed gas source fails? - correct answer Self-inflating bag (Unlike other bag-mask ventilation methods, self-inflating bags reinflate when released due to a pressure-release, or pop-off valve. Valves are typically set by the manufacturer to release at 30 to 40 cm H2O of pressure. This makes them the only method usable when compressed gas sources are not available. It's important to note that for newborns who have not yet taken their first breath, occlusion of the pop-off valve may be necessary to generate sufficient pressure to inflate the nonaerated lungs. However, care must be taken to avoid overinflation and creation of a pulmonary air leak.) Where should pressure be applied when performing compressions on the newborn?
- correct answer Lower third of the sternum (Chest compressions on the newborn should apply pressure to the lower one-third of the sternum, typically in line with the nipples. Downward pressure should be applied perpendicular to the chest wall to depress the sternum about one-third of the anteroposterior diameter of the chest, followed by release of pressure to allow for refilling of the heart. Providers should avoid direct pressure to the xiphoid, which can result in liver injury.) During resuscitation of a newborn, you've establish adequate ventilation with an endotracheal tube and your colleague has begun chest compressions for a heart rate under 60 bpm. Nevertheless, after 60 seconds, the heart rate has not increased. What is the most appropriate next step in management? - correct answer Administer epinephrine. (A persistent heart rate under 60 beats per minute despite chest compressions and adequate ventilation, is indication for epinephrine administration. Epinephrine should only be initiated after establishing adequate ventilation to avoid myocardial injury, as it increases myocardial oxygen consumption and workload. Guidelines
recommend IV epinephrine at a dose of 0.01 to 0.03 mg/kg at a dilution of 1:10,000. Epinephrine can be given every 3 to 5 minutes with the heart rate below 60 bpm.) Air that leaks from inside the lung and collects in the pleural space is called a ________. - correct answer Pneumothorax (A pneumothorax is air present between the parietal and visceral pleura. Pneumothorax in infants may be asymptomatic, however respiratory distress can manifest as tachypnea, pallor and cyanosis. Early indication of pneumothorax can often be a rapid reduction in QRS voltage on EKG. Physical exam findings can include an asymmetric chest larger on the side of pathology, decreased breath sounds on that side, and a point of maximal impulse shift away from that side.) True or False: If a pneumothorax causes significant respiratory distress, it should be relieved by placing a percutaneous catheter or needle into the pleural space and evacuating the air. - correct answer True (Symptomatic pneumothorax should be treated emergently with thoracentesis using a syringe attached to a 23 or 25-gauge scalp vein needle or 18 to 20-gauge angiocather. The procedure may be used as the lone intervention in infants not requiring mechanical ventilation, or as a temporizing measure.) If you place the endotracheal tube in too far, where is it most likely to end up? - correct answer Right mainstem bronchus (The right mainstem bronchus is angulated 25 degrees from the trachea versus the 45-degree angulation of the left mainstem bronchus. This results in easier intubation of the right mainstem when the endotracheal tube is inserted too far.) Pulmonary hypoplasia is most commonly caused by which of the following conditions? - correct answer Severe oligohydramnios (Oligohydraminos = 'oligo means few nd hydramnios means amnio-fluid', refers to amniotic fluid volume less than expected for a particular gestational age. Amniotic fluid movement is regulated through fetal swallowing, fluid in the lungs, and urination; with movement of fluid into the lungs resulting in proper expansion and
Which statement describes recommended practice when using a pulse oximeter in the delivery room? - correct answer place pulse oximeter on right hand and use minute by minute specific O2 SAT TARGET A baby is born at term with a bilateral cleft lip and palate and a very small mandible. She requires positive-pressure ventilation because she is not breathing. You are unable to achieve a seal with bag and mask. Which intervention is indicated? - correct answer insert a laryngeal mask The steps of intubation should ideally be completed within which duration? - correct answer 30 seconds What is the most effective maneuver to establish spontaneous breathing in a baby that is apneic after initial steps? - correct answer POSITIVE PRESSURE VENTILATION You are at the resuscitation of a newborn who is gasping and has a heart rate of 60 beats per minute. What is the most important action you can take? - correct answer Provide PPV (positive pressure ventilation). You have determined a baby needs resuscitation at birth. What are the initial steps of newborn care? - correct answer Provide warmth, position head and neck to open the airway, clear secretions from the airway if needed, dry, stimulate A baby is born at 34 weeks' gestation. After the initial steps of resuscitation, the baby is not breathing (apneic). What are the next steps? - correct answer Initiative positive-pressure ventilation, place a pulse oximeter sensor on the right hand or wrist, evaluate heart rate. Remembering MR. SOPA helps your team correct problems with ventilation. Which of the following steps are included in MR. SOPA? - correct answer Adjust Mask and Reposition head and neck; Suction mouth then nose and Open the mouth; increase Pressure; insert Alternative airway You have been called to attend a birth and are the only healthcare provider responsible for the management of the newborn in the room. When should you first call for additional help? - correct answer Before birth, when you have identified
the presence of a perinatal risk factor that increases the likelihood of requiring neonatal resuscitation. After the initial steps of newborn care, a baby is apneic. What is the most important and effective action to take in the resuscitation of this baby? - correct answer Provide positive pressure ventilation. During the resuscitation of a newborn, you auscultate the apical pulse and count 10 beats over a 6 second period. What heart rate do you report to your team? - correct answer 100 beats per minute Your team attends an emergency cesarean delivery of a term baby because of chorioamnionitis, meconium-stained amniotic fluid, and fetal heart rate decelerations. At delivery, the newborn is term as expected, with very poor tone and he is not breathing (apneic). You quickly perform initial steps, but the newborn is still not breathing. What is the most appropriate next step of resuscitation? - correct answer Start positive-pressure ventilation and check heart rate response after 15 seconds Effective team functioning is critical in ensuring the best performance. Which of these characteristics is critical in team leaders? - correct answer They should be able to maintain situational awareness. You are part of a team preparing for the birth of a baby who has meconium-stained fluid and a category III fetal heart rate tracing. A person skilled in endotracheal intubation should be - correct answer present at birth You have started positive-pressure ventilation for a newborn because her heart rate is low (bradycardia). What is the most important indicator of successful positive- pressure ventilation? - correct answer A rising heart rate A newborn of 34 weeks' gestation is not breathing (apneic) at birth, does not respond to initial steps and requires positive-pressure ventilation. What concentration of oxygen should be used as you begin positive-pressure ventilation?
- correct answer 21 - 30% oxygen
statements is true? - correct answer His blood glucose level should be checked soon after resuscitation and then at regular intervals until stable and normal. When a newborn has a high risk of mortality and there is a significant burden of morbidity among survivors, what should be included in your discussion with the parents concerning options for resuscitation? - correct answer The option of providing comfort care can be considered. When coordinating positive-pressure ventilation with chest compressions, how many events are performed each minute? - correct answer 30 breaths, 90 compressions What time frame should be used to administer intravenous epinephrine? - correct answer Rapid push, as quickly as possible What is the preferred method for assessing heart rate during chest compressions? - correct answer Electronic cardiac (ECG) monitoring Which of the following may be associated with delayed cord clamping in vigorous preterm newborns? - correct answer Decreased need for blood transfusions You attend the birth of a baby with prenatally diagnosed congenital diaphragmatic hernia. After birth, you should - correct answer Intubate the trachea and insert an orogastric tube into the stomach Which of the following is the best indication for volume expansion after resuscitative efforts that included intubation, chest compressions, and IV epinephrine? - correct answer The baby's heart rate remains 50 beats per minute after resuscitative efforts and pulses are weak. After chest compressions with coordinated ventilations are started, the heart rate should be assessed: - correct answer After 60 seconds You are in the delivery room caring for a preterm newborn at 27 weeks' gestation. Resuscitation has been completed and the baby is ready to be transported to the neonatal intensive care unit. Which of the following is a true statement about the
baby's subsequent care? - correct answer Monitor blood glucose levels because of the risk of hypoglycemia after birth. Which statement best describes the ethical principle(s) that guide the resuscitation of a newborn? - correct answer The approach to decisions in the newborn should be guided by the same principles used for adults and older children. A baby required ventilation and chest compressions. After 60 seconds of chest compressions, the electronic cardiac monitor indicates a heart rate of 70 beats per minute. What is your next action? - correct answer Stop chest compressions; continue positive-pressure ventilation. A newborn requires complex resuscitation. You have intubated and are administering positive-pressure ventilation and chest compressions. Which 3 signs are used to evaluate the effectiveness of your actions, and the need to continue one or both of these measures? - correct answer Respirations, heart rate, oxygen saturation For a newborn weighing 1 kg, what dose of 1:10,000 (0.1 mg/mL) concentration of intravenous epinephrine is indicated? - correct answer 0.1ml In most cases, who is (are) the usual and appropriate surrogate decision maker(s) for a newborn? - correct answer The newborn's parents During resuscitation, a baby is responding to positive-pressure ventilation with a rapidly increasing heart rate. Her heart rate and oxygen saturation suddenly worsen.She has decreased breath sounds on the left side and transillumination also reveals a bright glow on the left side.What is the most likely cause of this distress? - correct answer Left-sided pneumothorax Which of the following is true about the preparation and resources needed for a very preterm birth? - correct answer Prepare the preheated radiant warmer with a thermal mattress, plastic wrap or bag, and a hat. A baby's heart rate does not increase after intubation and the breath sounds are louder on the right side than the left side of the chest. Which of the following is a
