Chapter 4: Examination and Assessment of the Neonatal and Pediatric Patient

The preferred way to administer epinephrine during neonatal resuscitation is by A The intravenous route B Down the endotracheal tube C Intramuscular injection D Subcutaneous injection

A Rationale: Epinephrine is given either intravenously or through an endotracheal tube, although the intravenous route is strongly preferred.

Which of the following actions is the initial step in stabilizing an infant? A Proper positioning under a radiant warmer B Suctioning of mouth and nose with a bulb syringe C Determining the heart rate D Determining the Apgar score

A Rationale: Immediately after delivery the first step in stabilizing the infant is to place the infant on a preheated radiant warmer before any other interactions.

The best indicator of an infant's overall cardiopulmonary status immediately after birth is A Heart rate B Apgar score C Color D Respiratory effort

A Rationale: The most important of the signs is heart rate, which indicates life or death. Failure of the heart rate to respond to resuscitation is an ominous prognostic sign. Heart rate appears to be least affected by developmental maturity but may still be inadequate because of developmental difficulties in establishing cardiorespiratory function at birth. In the immediate newborn period, skin color has the weakest correlation with the other four components of the Apgar score.

Infants not requiring delivery room resuscitation will show all of the following characteristics except: A Born at full-term gestation B Heart rate of 80 to100 beats/minute C Crying or normal breathing D Amniotic fluid clear with no indication of infection

B Rationale: Heart rate is a critical determinant of the resuscitation sequence and should be more 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 more 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. In the case of a heart rate of 80 to 100 beats/minute, assisted ventilation is indicated only if the heart rate continues to be less than 100 beats/minute.

Appropriate stimulation of a newborn includes all of the following except: A Flicking the bottoms of the feet B Gently shaking the shoulders C Drying with a warm towel D Gently rubbing the back

B Rationale: If the newborn does not respond to the extrauterine environment with a strong cry, good respiratory effort, and the 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, shaking, spanking, and holding the newborn upside down are contraindicated and potentially dangerous to the infant.

According to guidelines described in the chapter, "After ___ minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life." A 5 B 10 C 20 D 30

B Rationale: Research shows that infants with no heart beat or respiratory effort after 10 minutes of resuscitative effort have high rates of mortality, or if they survive high rates of severe neurological damage and developmental delay. "After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life"

The Apgar score includes all of the following criteria except: A Color B Evaluation of the Moro reflex C Heart rate D Reflex irritability

B Rationale: The Apgar score is an evaluation of newborns based on five factors: heart rate, respiratory effort, muscle tone, reflex irritability, and skin color (see Table 4-1)

When delivering positive-pressure ventilation, the recommended breath rate is A 20-40 breaths/minute B 40-60 breaths/minute C 60-80 breaths/minute D At least 100 breaths/minute

B Rationale: The recommended ventilation rate is from 40 to 60 breaths/minute.

The one procedure that should always be carried out immediately after the birth of an infant known or suspected to have a diaphragmatic hernia is A Intubation and suctioning of the trachea as the first step in resuscitation B Prompt use of bag-mask ventilation to ensure adequate gas exchange C Placement of a nasogastric tube hooked to suction D Procurement of an X-ray of the chest and abdomen

C Rationale: A nasogastric tube to decompress the bowel and allow the lungs to inflate should always be placed in these infants. During resuscitation endotracheal intubation should be performed to minimize overdistention of the stomach resulting from bag-mask ventilation if the infant is clearly unable to sustain adequate ventilation on its own with only the addition of supplemental oxygen.

Chest compressions should be initiated on a newborn when A Heart rate is less than 100 beats/minute B Heart rate is less than 80 beats/minute C Heart rate is less than 60 beats/minute D Only when heart rate is completely absent

C Rationale: If the heart rate is 60 beats/minute or less and adequate ventilation is being provided, chest compressions should be initiated immediately.

What is the proper procedure to implement for an infant known to have experienced meconium aspiration before birth? A The obstetrician should suction the mouth, nose, and pharynx after delivery of the head, but before delivery of the shoulders. B Intubate immediately and aspirate the trachea, using a meconium aspirator regardless of whether the infant is vigorous. C Treat the infant exactly as if meconium was not present. D Intubate and suction only if the infant is not vigorous; otherwise, follow the normal resuscitation procedures.

D Rationale: Infants who are vigorous at birth (strong respiratory effort, heart rate >100 beats/min, good muscle tone) should not receive tracheal suctioning. Infants who are not vigorous (no or poor respiratory effort, heart rate <100 beats/min, poor muscle tone) may receive direct laryngotracheal suctioning.

The single most effective step in the resuscitation of a newborn is to A Administer epinephrine down the endotracheal tube B Administer external chest compressions at a rate of 100/minute C Vigorously dry and stimulate immediately after birth D Establish and maintain adequate ventilation (al

D Rationale: Providing adequate ventilation is the primary factor in the effective resuscitation of a neonate. Most neonates will respond once ventilation is established. After 30 seconds of effective positive-pressure ventilation with 100% O2, if the heart rate remains less than 60 beats/minute, begin chest compressions.

The self-inflating bag is ideal for neonatal resuscitation because it A Always provides 100% O2 when hooked to an O2 source B Can easily and dependably be used to deliver free-flow or "blow-by" O2 as well as positive-pressure ventilation through the mask C Does not require a PEEP valve to deliver CPAP by mask D Requires the least experience and training for the individual using it

D Rationale: The flow-inflating (anesthesia) bag inflates only with pressure and flow from a compressed gas source of air, oxygen, or both. Successful use of this type of resuscitation bag requires appropriate gas flow (8 to 10 L/min), correct adjustment of the flow control valve, and careful attention to a tight seal at the face mask. To control all these factors, more training is required than with a self-inflating bag.

The ideal heart rate for a term newborn is _____ per minute. A 60 to 80 beats B 80 to 100 beats C 100 to 120 beats D 120 to 140 beats

D Rationale: Heart rate is a critical determinant of the resuscitation sequence and should be more than 100 beats/minute.