NRP 8th edition study guide
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
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)
What size laryngoscope blade is recommended to intubate a preterm newborn with an estimated gestational age of 28 weeks?
00
· According to the NRP Quick equipment checklist, how should the flowmeter be set to prepare for ventilation?
10 L/min
When coordinating PPV with chest compressions how long does it take to complete a cycle of 3 compressions and 1 breath?
2 seconds
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
What is the positive inspiratory pressure you should start with for a term neonate when using a T-piece?
20-25 cm H2O, may have to increase up to 40 cm H2O for effective ventilation PIP is the highest pressure delivered with each breath
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?
21-30% oxygen
What are typical CPAP settings for the term newborn?
25/5
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
Ideally, how quickly should the intubation procedure be completed?
30 seconds
How long should delayed cord clamping last?
30-60 seconds If baby not vigorous at birth but placental circulation intact, it's reasonable to briefly delay cord clamping while the provider clears the airway with a bulb syringe and gently stimulates the baby to breathe. If the baby does not breathe after suction and brief stimulation, the cord should be clamped and cut, and the baby brought to the radiant warmer.
When providing ventilation, what is the correct ventilation rate?
40-60
How soon after administration of intravenous epinephrine should you pause compressions and reassess the baby's heart rate?
60 seconds
What is the target oxygen saturation for a baby that is 3 minutes old?
70-75%
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.
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 capability to perform therapeutic hypothermia.
Who should attend a normal birth?
At every birth, at least ONE qualified provider skilled in initial steps of newborn care and PPV
· If a baby appears to be term, has good muscle tone, but is not breathing or crying, where should the baby receive initial steps?
At the radiant warmer
· To ensure immediate access to the laryngeal mask, where should it be located?
At the warmer
Where will you attach the infants pulse oximeter?
Attach the pulse oximeter to the newborns right hand or wrist (preductal)—gives the most accurate assessment of oxygenated blood feeding the brain since babies do have right-to-left shunt and lower extremities have lower post ductal sat
· What should you do if an apneic newborn is moved to a radiant warmer after birth and is still not breathing after the initial steps?
Begin PPV immediately
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
· If the baby is not vigorous and the heart rate is difficult to auscultate, what should you do?
Connect a pulse oximeter or a cardiac monitor
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
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
What equipment is included on the NPR quick equipment checklist?
ETT, equipment to give free-flow oxygen, bulb syringe, preheat warmer-towels-and blankets (blood pressure cuff not on this checklist)
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
When chest compressions are in progress, how often should the heart rate be assessed?
Every 60 seconds
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.
How do you know if the pulse oximeter is working properly?
If it displays a pulse that approximates the apical pulse, or the heart rate on the cardiac monitor
Who attend birth if RISK FACTORS are present?
If risk factors are present, at least TWO qualified providers to solely manage baby
During a delivery, when and where should a person with intubation skills be available?
In the hospital and immediately available
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.
uring 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 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
Explain the steps in MR. SOPA
Mask adjustment Reposition head -give 5 breaths Suction mouth and nose Open mouth -give 5 breaths Pressure increases -give 5 breaths Alternative airway
· When a baby is breathing well enough to sustain a heart rate over 100 bpm, do you continue giving PPV?
NO. discontinue PPV
What is the recommended depth of chest compressions?
One-third of the anterior-posterior diameter of the chest
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
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
· Healthy babies may have central cyanosis for several minutes after birth. What is the first montior you will use on ALL newborns?
Pulse oximetry can be a reliable method for assessing a baby's oxygen saturation.
Who should be present for every neonate resuscitation?
Qualified team with full resuscitation skills be immediately available for every resuscitation (FOUR or more providers)
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
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.
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 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.
Which of the following is an indication for placement of an alternate airway?
The need for PPV is prolonged
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.
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....
identify items on the standardized checklist for essential supplies
Warm: preheated warmer, warm towels or blankets, temperature sensor and sensor cover for prolonged resuscitation, hat, plastic bag or warm and thermal mattress for < 32 weeks' gestation Clear airway: bulb syringe, 10F or 12F suction catheter with wall suction set to 80-100 mm Hg, tracheal aspirator Auscultate: stethoscope Ventilate: flowmeter set to 10L, oxygen blender set to 21% (21-30% if < 35 weeks'), PPV device, term- and preterm-sized masks, 8F orogastric tube and mL syringe, laryngeal mask (size 1) and 5-mL syringe, 5F or 6F orogastric tube if insertion port present on laryngeal mask, access to cardiac monitor and leads Oxygenate: equipment to give free-flow oxygen, pulse ox, target oxygen saturation table Intubate: laryngoscope with size-0 and 1 straight blades (size 00 optional), stylet (optional), ETT (size 2.5, 3.0, and 3.5), CO2 detector, measuring tape and/or ETT insertion depth table, tube securement tape/device, scissors Medicate: 0.1 mg/mL epinephrine, normal saline for volume expansion and flush (100 L or 250 mL bag) or prefilled syringes, supplies for placing emergency umbilical venous catheter and administering medications, table of pre-calculated emergency medication dosages for babies weighing 0.5 to 4 kg
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
Who should be present for birth when meconium-stained fluid is the only risk factor?
When meconium-stained fluid is the only risk factor, at least TWO qualified providers must be present from time of birth to manage baby. Provider with intubation skills be immediately available.
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
During chest compression with of the following is correct?
Your team is resuscitating a newborn whose heart rate remains less than 60 bpm despite effective PPV and 60 seconds of chest compressions.
what happens in the drug phase?
administer epinephrine if HR remains < 100
When resuscitation is anticipated, when should you apply pulse oximetry?
after completing the inital steps
What are the indicators for performing PPV on a neonate?
apnea, gasping, and heart rate < 100
what happens in the breathing phase?
assist with PPV if the baby is apneic, gasping, or bradycardic (cpap or oxygen may be appropriate for labored breathing or low oxygen saturation)
· If the baby is breathing after initial steps, you should assess and monitor the heart rate. What should it be?
at least 100 bpm
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?
being PPV by mask
· When an alternative airway is required, what type of monitoring is recommended for the most accurate assessment of the baby's heart rate?
cardiac monitor
blood bypasses the lungs and passes into the aorta via ____ in the neonate?
ductus arteriosis
what is the pulmonary resistance in fetal lungs?
high pulmonary vascular resistance (high PVR, low SVR)
What happens in the rapid evaluation phase?
if baby can stay with mother or moved to radiant warmer
· Laryngeal mask: an alternative airway
o A in MR. SOPA denotes alternative airway o ETT and laryngeal mask are the two alternative airways used o Size 1 LMA for newborns 1500-2000 grams
· When placing an orogastric tube, measure the insertion depth. While positive pressure ventilation CPAP is in progress by measuring from the bridge of the nose to the earlobe and from the earlobe to?
o A point halfway between the xiphoid process and the umbilicus
· When the baby stays with the mother for initial steps after birth, what should be monitored to determine if additional interventions are required?
o Breathing, temp, color, tone, and activity
How would you assess the heart rate of a newborn?
o Count the number of beats in 6 seconds and multiply by 10 (add zero to the number of beats counted)
· PPV: oxygen management
o For babies > = 35 weeks, start with 21% oxygen (room air) o For preterm babies < 35 weeks, start with 21-30% oxygen o *** increasing oxygen concentration used for PPV may not help if the lungs are not being inflated (ensure good seal with mask ***
· How long after PPV should you perform the first heart rate assessment? 15 seconds
o HR increasing, continue PPV o If HR not increasing and chest is moving, continue PPV o If HR not increasing and chest is not moving, being MR. SOPA ventilation corrective steps
· If the baby stays with the mother for initial steps, when should you clear secretions with a bulb syringe?
o If secretions are obstructing the baby's breathing
· What are the potential benefits of delayed cord clamping for the term and late preterm babies?
o Improved early hematologic measurements o Although uncertain, it may be beneficial for neurodevelopmental outcomes
· You are performing the MR. SOPA ventilation corrective steps on a term baby. You have adjusted the mask and reposition the head. You have suctioned the mouth and nose and opened the mouth period there is still no chest movement. What is the next step?
o Increase the pressure in 5-10 cm H2O increments, up to 40 cm H2O
· What are the 3 rapid evaluation questions?
o Is the baby breathing or crying? o Does the baby have good muscle tone? o Does the baby appear to be term? If any answer is no, move baby to radiant warmer
· What are the first two steps of the MR. SOPA ventilation corrective steps that often solve the problem?
o Mask adjustment and reposition head
· If the baby is not term, move to radiant warmer immediately
o Mouth is suctioned in anticipation of PPV o PPV is initiated within 60 seconds of birth
· A T-piece resuscitator delivers consistent inspiratory pressure and PEEP. What does PEEP help achieve?
o Prevents air spaces form collapsing during exhalation, stable lung inflation, and removes fluid
· What are the potential benefits of delayed cord clamping for preterm babies?
o Requiring fewer blood transfusions during hospitalization o Decreasing the chance of needing medications to support blood pressure after birth o Possibly improved survival
· 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?
o Slow the rate of PPV and stimulate the baby
· If you are alone when a baby needs PPV, what is the first thing you should do?
o Start PPV and mobilize additional help
· What is included in the five initial steps of newborn care?
o Stimulate by gently rubbing the baby's back and extremities o Provide warmth o Dry the baby and remove wet linen (if > 32 weeks gestation) o Clear secretions from the airway, in needed o Position head and neck to open the airway (sniffing position)
· When should you consider using a cardiac monitor?
o The baby is not vigorous o When an alternative airway is required, a cardiac monitor is recommended o The heart rate is difficult to auscultate o Pulse oximetry does not work o PPV is required
· If supplemental oxygen is necessary, it is reasonable to start with 30%
o Then guided by pulse oximetry, adjust the FiO2 to maintain the baby's oxygen saturation within the target range for the baby's age in minutes
· When can free-flow oxygen be discontinued?
o When the newborn can maintain saturation within the target range without supplemental oxygen
· What are the indications for inserting a laryngeal mask airway?
o You cannot ventilate o You cannot intubate o Newborn has a large tongue o Newborn has a small mandible o Newborn has congenital anomalies involving the mouth, lip, tongue, palate, or neck
· After vaginal birth, the baby appears term, has good muscle tone, and is crying. Where can the baby receive the initial steps?
on mom's chest or abdomen
what happens in the airway phase?
opening neonates airway and support spontaneous respirations
· If a newborn requires PPV with a face mask, laryngeal mask, or required CPAP for more than several minutes, you will consider placing what?
orogastric tube for air decompression
what hapens in the circulation phase?
perform chest compressions if HR remains < 100 after giving effective PPV
5 steps in the NRP algorithm
rapid evaluation, airway, breathing, circulation, drug
· What is the most important indicator of successful PPV?
rising heart rate
What should you use when checking supplies and equipment before every birth?
standardized equipment checklist
How long may it take a newborn to achieve a oxygen saturation of 100%
up to 10 minutes preductal sat at 3-5 minutes is ~75%
What is the single and most important step in the neonatal resuscitation?
ventilation: Newborn arrest r/t respiratory failure Very few newborns will require chest compressions or medication Learning how to provide PPV is the foundation of NRP
What 3 questions will you ask to help determine if the baby will need resuscitation?
what is the expected gestational age, is the amniotic fluid clear, what is the umbilical cord management plan
risk factors for resuscitation?
§ Gestational age < 36 0/7 weeks § Gestational age > or = to 41 0/7 weeks § Preeclampsia or eclampsia § Maternal hypertension § Multiple gestation § Fetal anemia § Polyhydramnios § Oligohydramnios § Fetal hydrops § Fetal macrosomia § IUGR § Significant fetal malformation or anomalies § No prenatal care § Emergency cesarean delivery § Forceps or vacuum-assisted delivery § Breech or other abnormal presentation § Category 2 or 3 fetal heart rate pattern § Maternal general anesthesia § Maternal Magnesium therapy § Placental abruption § Intrapartum bleeding § Chorioamnionitis § Opioids administered to mother w/in 4 hours of delivery § Shoulder dystocia § Meconium-stained amniotic fluid § Prolapsed umbilical cord
At what point will you proceed to chest compressions in the newborn?
· DO NOT proceed to cardiac compressions or medication until the newborn has received 30 seconds of PPV that moves the chest, preferable through an alternative airway
