Respiratory Therapy - 244 Final Exam CH4

12. What ratio of chest compressions and positive-pressure breaths must the therapist administer to a newborn during cardiopulmonary resuscitation? A. One compression for every three breaths B. Two compressions for every five breaths C. One compression for every 15 breaths D. Three compressions for every 15 breaths

ANS: A Feedback A. Correct response: Chest compressions and positive-pressure ventilation must be coordinated with one breath for every three chest compressions, delivered at a rate of 30 breaths/minute and 90 chest compressions/minute. B. Incorrect response: See explanation A. C. Incorrect response: See explanation A. D. Incorrect response: See explanation A. OBJ: Recall

5. A preterm neonate with a heart rate of 55 beats/minute is receiving positive-pressure ventilation immediately after delivery. What should the therapist do at this time? A. Apply cardiac compressions and maintain positive-pressure ventilation. B. Defibrillate the infant. C. Administer medication to increase myocardial contractility and maintain positive ventilation. D. Increase the respiratory rate on the ventilator.

ANS: A Feedback A. Correct response: Heart rate is a critical determinant of the resuscitation sequence and should be greater than 100 beats/minute. If the heart rate is less than 100 beats/minute, positive-pressure ventilation should be started immediately. Frequently, effective positive-pressure ventilation alone will result in the heart rate accelerating to greater than 100 beats/minute. If the heart rate is 60 beats/minute or less and adequate ventilation is being provided, chest compressions should be initiated immediately. B. Incorrect response: See explanation A. C. Incorrect response: See explanation A. D. Incorrect response: See explanation A. OBJ: Application

8. The therapist, working with a neonate, observes that the newborn has adequate ventilatory efforts and a heart rate of 120 beats/minute. However, at the same time, the infant demonstrates cyanosis of the lips and mucous membranes. What should the therapist do at this time? A. Direct 100% oxygen at a flow of 8 L/minute about one-half inch above the infant's nose and mouth. B. Initiate positive-pressure mechanical ventilation. C. Begin resuscitative efforts. D. Perform pharyngeal and tracheal suctioning.

ANS: A Feedback A. Correct response: If central cyanosis is present, as assessed by examining the lips and mucous membranes, but ventilation is adequate with a heart rate greater than 100 beats/minute, administer 100% free-flow oxygen through a mask toward the infant's mouth and nose. If a mask is not available, use a funnel, or cup the hands around the oxygen tubing. Holding the oxygen one-half inch from the nose at a flow of 6 to 8 L/minute provides approximately 60% to 80% oxygen. Gradually withdraw the oxygen as the infant's color improves. B. Incorrect response: See explanation A. C. Incorrect response: See explanation A. D. Incorrect response: See explanation A. OBJ: Application

14. Which of the following medications is used to reverse respiratory depression induced by opioid overdose? A. Epinephrine B. Naloxone C. Sodium bicarbonate D. Oxygen

ANS: B Feedback A. Incorrect response: See explanation B. B. Correct response: Naloxone hydrochloride is a narcotic antagonist and is indicated in the neonate for reversal of respiratory depression induced by narcotics given to the mother within 4 hours of delivery. However, the administration of naloxone should occur only after the infant's heart rate and color are satisfactory. Naloxone is not recommended for the delivery room. A major caution with the use of naloxone is that the patient must be carefully monitored for possible recurrence of respiratory depression, because the duration of action of narcotics may exceed that of naloxone. Multiple injections of naloxone may be administered until the patient is out of danger. C. Incorrect response: See explanation B. D. Incorrect response: See explanation B. OBJ: Recall

3. While stabilizing a preterm neonate before resuscitation, the therapist notices the infant display laryngeal spasm, bradycardia, and a delayed onset of spontaneous breathing. What could have caused these events to occur? A. Applying vacuum pressure in the range of 50 to 60 mm Hg B. Performing aggressive pharyngeal suctioning C. Applying positive pressure to the airway before suctioning the airway D. Flicking the bottoms of the neonate's feet immediately on delivery

ANS: B Feedback A. Incorrect response: See explanation B. B. Correct response: The therapist should suspect airway obstruction if the neonate's respiratory efforts are ineffective. The neonate's head and neck must be immediately positioned to clear the airway of obstruction. Once positioned, suction the infant to clear secretions. Use either a bulb syringe or a suction catheter, and limit each pass to 3 to 5 seconds at a time, clearing the mouth first and then the nose. Monitoring the heart rate for possible bradycardia during suctioning is important. Aggressive pharyngeal or stomach suctioning may cause laryngeal spasm and vagal stimulation with bradycardia and may delay the onset of spontaneous breathing. To avert injury and atelectasis and interference with the infant's ability to establish adequate ventilation, avoid excessive suctioning of clear fluid from the nasopharynx. C. Incorrect response: See explanation B. D. Incorrect response: See explanation B. OBJ: Application

11. What appears to be the reason for the infrequent need to administer chest compressions and cardiopulmonary resuscitative drugs to neonates in the delivery rooms? A. Labor and delivery room personnel are highly trained and qualified with excellent assessment skills, thus avoiding the need for such actions. B. Manipulation and stimulation of the neonate at birth excite the heart, obviating the need for these interventions. C. The delivery of adequate ventilation is the primary factor in effective resuscitation of a neonate. D. The administration of oxygen to the infant's airway stimulates the heart.

ANS: C Feedback A. Incorrect response: See explanation C. B. Incorrect response: See explanation C. C. Correct response: Cardiopulmonary resuscitation in the delivery room requiring chest compressions and medications is an infrequent occurrence. A large study demonstrated that chest compressions and medications were given to 39 (0.12%) of 30,839 infants delivered. The delivery of adequate ventilation is the primary factor in effective resuscitation of a neonate. Most neonates will respond favorably once ventilation is established. After 30 seconds of effective positive-pressure ventilation with 100% oxygen, if the heart rate remains less than 60 beats/minute, chest compressions must be applied. D. Incorrect response: See explanation C. OBJ: Recall

1. A team has been summoned to the delivery room to perform neonatal resuscitation. Because no perinatal history is available, which of the following information would be useful for the resuscitation team to know in preparation for this event? I. Number of babies expected II. Age of the mother III. Gestational age of the infant IV. Presence or absence of meconium A. I and IV only B. II and III only C. I, III, and IV only D. I, II, III, and IV

ANS: C Feedback A. Incorrect response: See explanation C. B. Incorrect response: See explanation C. C. Correct response: Ideally, a detailed history of perinatal problems associated with an infant who may require resuscitation is available. Refer to Box 4-1 in Chapter 4 to view antepartum and intrapartum information that would be beneficial for the neonatal resuscitation team to have available to prepare for the situation. If this information cannot be obtained, the neonatal resuscitation team will be better prepared knowing at least: (1) whether the mother is in premature labor, (2) the approximate gestational age of the infant, (3) the number of babies expected, and (4) if meconium is present in the amniotic fluid. D. Incorrect response: See explanation C. OBJ: Recall

15. Which of the following actions constitutes appropriate stimulation of a neonate? I. Gently slapping the infant's buttocks II. Gently shaking the infant's upper torso III. Flicking the bottoms of the infant's feet IV. Drying with a towel A. III only B. I and II only C. III and IV only D. II, III, and IV only

ANS: C Feedback A. Incorrect response: See explanation C. B. Incorrect response: See explanation C. C. Correct response: If a newborn does not respond to the extrauterine environment with a strong cry, good respiratory effort, and movement of all extremities, the infant requires stimulation. Flicking the bottoms of the feet, gently rubbing the back, and drying with a towel are all acceptable methods of stimulation. Slapping the buttocks, shaking the upper torso, and holding the newborn upside down are contraindicated and potentially dangerous to the infant. D. Incorrect response: See explanation C. OBJ: Recall

10. While performing positive-pressure mechanical ventilation on a neonate, the therapist notices that the infant's thorax is not displaying bilateral expansion during each inspiration. Auscultation of the chest reveals diminished bilateral breath sounds. The infant's heart rate is 85 beats/minute, and observation demonstrates central cyanosis. Which of the following events may have caused this clinical situation? I. Pneumothorax II. Poorly positioned or leaking mask III. Inappropriately sized endotracheal tube IV. Airway obstruction A. I and IV only B. II and III only C. I, II, and IV only D. I, II, III, and IV

ANS: C Feedback A. Incorrect response: See explanation C. B. Incorrect response: See explanation C. C. Correct response: Positive-pressure ventilation should result in bilateral expansion of the lungs with chest wall during inspiration, and auscultation of bilateral breath sounds, a heart rate greater than 100 beats/minute, and progressive improvement in the infant's color. Failure to move the chest with positive-pressure ventilation may indicate a poorly positioned or leaking mask, an obstructed airway, inadequate inspiratory pressure, the presence of a pneumothorax, or some other respiratory compromise. Using an endotracheal tube that is too small can compromise ventilation, but not likely to the extent depicted in this scenario. On the other hand, too large an endotracheal tube may not adversely influence ventilation, but would potentially damage the infant's upper airway. D. Incorrect response: See explanation C. OBJ: Application

2. What measures can the therapist take to prevent heat loss and cold stress before performing resuscitation on a preterm neonate? I. Dry the infant's skin. II. Wrap the infant in prewarmed blankets. III. Remove wet linens from around the infant. IV. Measure the neonate's body temperature. A. IV only B. I and II only C. I, II, and III only D. I, II, and IV only

ANS: C Feedback A. Incorrect response: See explanation C. B. Incorrect response: See explanation C. C. Correct response: Preventing heat loss is critical when caring for a newborn because cold stress increases oxygen consumption and impedes effective resuscitation. The infant should be delivered in a warm, draft-free area. Heat loss is greatly reduced by rapidly drying the infant's skin, immediately removing wet linens, and wrapping the infant in prewarmed blankets. If the infant weighs less than 1500 g, wrapping the newborn in a topical polyethylene film reduces evaporative heat loss but permits radiant heat transfer. Using polyethylene wrapping on a very low birth weight infant at delivery reduces the risk of a decrease in postnatal temperature and may reduce mortality. Hyperthermia should also be avoided because increased body temperature causes increased oxygen consumption. D. Incorrect response: See explanation C. OBJ: Recall

7. The therapist has completed a 1-minute Apgar score. The following evaluations were obtained: (1) the infant is pale; (2) the heart rate is 90 beats/minute; (3) the respiratory effort is irregular; (4) some muscle tone is noted; and (5) no response to nasal suctioning is found. On the basis of these findings, what Apgar score should be assigned to this neonate? A. 1 B. 2 C. 3 D. 5

ANS: C Feedback A. Incorrect response: See explanation C. B. Incorrect response: See explanation C. C. Correct response: The Apgar scoring system is depicted in the following table: The infant evaluated in this question earned 1 point each for the heart rate, respiratory effort, and muscle tone. Scores for color and reflex irritability were both 0. The total Apgar score is therefore 3. Apgar scores are generally used to ascertain the need for resuscitation and are obtain at 1 minute and 5 minutes after birth. A score below 7 indicates the need for resuscitative efforts. D. Incorrect response: See explanation C. OBJ: Application

9. A respiratory therapy supervisor is observing a staff member perform bag-mask ventilation on an infant who is being resuscitated. The supervisor notices that the therapist places his fingers on the anterior margin of the infant's mandible, and lifts the infant's face into the mask. What should the supervisor do at this time? A. Recommend that the infant immediately receive endotracheal intubation. B. Correct the therapist and have him place his fingers onto the soft tissue under the mandible. C. Recommend that the therapist perform endotracheal suctioning. D. Take no action because the therapist is correctly performing valve-mask ventilation.

ANS: D Feedback A. Incorrect response: See explanation D. B Incorrect response: See explanation D. C. Incorrect response: See explanation D. D. Correct response: Proper technique is essential when performing mask ventilation. Place the fingers on the anterior margin of the mandible, and lift the face into the mask. See Figure 4-4 in the textbook for a depiction of the correct hand position. Placing the fingers onto the soft tissue under the mandible will collapse the floor of the mouth and obstruct the airway by pushing the tongue against the roof of the mouth. Figure 4-5 in the textbook illustrates the erroneous hand position. OBJ: Application

4. As the head of a neonate contaminated with meconium emerges at birth, the heart rate monitor indicates 120 beats/minute, and the physician notices that the infant has good muscle tone and a strong respiratory effort. What should the physician do at this time to provide airway care? A. Intubate the infant immediately. B. Perform pharyngeal and tracheal suctioning immediately. C. Perform tracheal suctioning only at this time. D. Do not perform tracheal suctioning on this infant at this time.

ANS: D Feedback A. Incorrect response: See explanation D. B. Incorrect response: See explanation D. C. Incorrect response: See explanation D. D. Correct response: Attempts to suction meconium from the pharynx or trachea before birth, during birth, or postpartum increase the likelihood of severe aspiration pneumonia. Some obstetricians perform oral and nasal suctioning on meconium-stained infants after delivery of the head, but before delivery of the shoulders. However, a large, multicenter, randomized trial showed no benefit from this practice. Therefore, current recommendations for infants with meconium are that (1) no intrapartum suctioning should occur; (2) infants who are vigorous at birth (strong respiratory effort, a heart rate of greater than 100 beats/min, good muscle tone) should not receive tracheal suctioning; and (3) infants who are not vigorous (no or poor respiratory effort, a heart rate of less than 100 beats/min, poor muscle tone) may receive direct laryngotracheal suctioning. OBJ: Application

13. The therapist has been performing cardiopulmonary resuscitation on a neonate for about 90 seconds, applying ventilation with 100% oxygen and chest compressions. The infant has maintained a spontaneous heat rate of 40 beats/minute. What should the therapist recommend at this time? A. Continuing resuscitative measures B. Initiating high-frequency ventilation C. Instituting extracorporeal membrane oxygenation D. Administering epinephrine

ANS: D Feedback A. Incorrect response: See explanation D. B. Incorrect response: See explanation D. C. Incorrect response: See explanation D. D. Correct response: Epinephrine is indicated when a neonate is in asystole or has a spontaneous heart rate of 60 beats/minute or less, after at least 30 seconds of ventilation with 100% oxygen and chest compressions. An epinephrine dose of 0.01 to 0.03 mg/kg body weight (0.1 to 0.3 ml/kg of a 1:10,000 solution) may be repeated every 3 to 5 minutes if required. Some children and adults who do not respond to standard doses of epinephrine may respond to doses as high as 0.2 mg/kg. Epinephrine is given either intravenously or through an endotracheal tube. The intravenous route is strongly preferred. Although giving epinephrine via the endotracheal route is expeditious, low plasma concentrations result. Thus, doses as high as 0.1 mg/kg may be considered for endotracheal tube administration before obtaining intravenous access. Use a concentration of 1:10,000 (0.1 mg/ml) epinephrine and administer it every 3 to 5 minutes during the treatment of pulseless arrest. OBJ: Application

6. A term infant is born displaying acrocyanosis. What should the therapist do at this time? A. Administer oxygen to the newborn. B. Begin resuscitative measures. C. Institute positive-pressure mechanical ventilation. D. Do nothing, as this condition is often transient.

ANS: D Feedback A. Incorrect response: See explanation D. B. Incorrect response: See explanation D. C. Incorrect response: See explanation D. D. Correct response: Many infants demonstrate acrocyanosis (blue extremities only) shortly after birth. This condition is common in the first few minutes of life because of sluggish peripheral circulation; oxygen therapy is unnecessary. On occasion, despite adequate ventilation and a heart rate greater than 100 beats/minute, an infant may continue to be cyanotic. If central cyanosis is present in an infant with spontaneous respirations and a heart rate greater than 100 beats/minute, free-flow oxygen should be given until the cause of the cyanosis is determined. OBJ: Application