NRP 8TH EDITION QUIZLET Q AND A

What is the normal infant respiratory rate?

40-60 breaths per minute

What is a normal infant heart rate?

120-160 bpm

What do you do if the baby has labored breathing or persistently low oxygen saturation?
CPAP

Can CPAP be given using a self-inflating bag?

No

What are the 5 initial steps after birth:

provide warmth, position head and neck, clear secretions if necessary, dry, and stimulate

What are the 4 pre-birth questions?

gestational age?
clear fluid?
how many babies expected?
additional risk factors?

The baby has been born, what 3 rapid evaluation questions are asked?
Term?
Muscle tone?
Breathing or crying?

41-week newborn with meconium-stained amniotic fluid is born and is crying upon birth, what
are your initial steps?
Suction mouth and nose with bulb syringe, dry newborn, place skin to skin with mother,
cover with warm blanket and continue ongoing evaluation

You have a newborn with central cyanosis that is not resolving after 5 minutes and a pulse
oximeter reading of 68%; they are breathing with no distress and heart rate is 140; what
intervention is next?
Administer free-flowing oxygen

A newborn is 36 weeks’ gestation with no muscle tone or breathing present; after the 5 initial
steps the newborn is still not breathing; what is indicated?
PPV

What is the 1-minute pre-ductal spo2 target?

60-65%

What is the single most important and effective step in neonatal resuscitation?
Ventilation of the newborn's lungs

After initial steps post birth, the newborn is breathing but has a heart rate less than 100 bpm;
what is indicated?
PPV
For initial resuscitation of newborns greater than or equal to 35 weeks’ gestation, set the
blender to ________ % oxygen; for less than 35 weeks?
21%; 21-30%

What ventilation rate should be used during positive pressure ventilation?

40-60 breaths per minute

What is the initial PIP and PEEP settings for PPV?

PIP of 20-25 cm H20
PEEP of 5 cm H20

What are the 6 ventilation corrective steps?

MR. SOPA
Mask adjustment
Reposition airway
Suction mouth and nose
Open mouth
Pressure increase
Alternative airway

How soon should you see an increase in heart rate after PPV is started?
15 seconds

What two ways can CPAP be administered to newborn?

mask attached to a T-piece resuscitator or a flow-inflating bag

The most important indicator of successful PPV is:

a rising heart rate

If the heart rate is not increasing within the first 15 seconds of PPV, do what?
check for chest movement; if no chest movement, start the ventilation corrective steps

Which resuscitation device does NOT require a compressed gas source?

self-inflating bags

What size laryngoscope blade would be used for a term newborn?

size 1

What size ETT would be used for a term newborn?

3.5 mm ID

What problems should you consider if a baby's condition worsens after endotracheal
intubation?
DOPE
Displaced ETT
Obstructed ETT
Pneumothorax
Equipment failure

For babies weighing less than 1,000 grams, what size ETT should be used?
2.5 mm

When do you begin chest compressions?

If the baby's heart rate remains less than 60 bpm after at least 30 seconds of PPV
What oxygen concentration should be used with PPV during chest compressions?
100%

When should you check the baby's heart rate after starting compressions?
After 1 minute of compressions

If an advanced airway has been placed and the color is not changing on the CO2 detector and
the heart rate is not increasing, what should be done next?
Remove the device
Resume PPV by face mask
Repeat insertion attempt

When is epinephrine indicated?

If the baby's heart rate remains less than 60 bpm after:
at least 30 seconds of PPV with chest rise
another 60 seconds of chest compressions with PPV using 100% O2

What concentration of epinephrine is used for neonatal resuscitation?

1:10,000 (0.1 mg/mL)

When should you consider administering a volume expander?

If the baby is not responding to the steps of resuscitation and has signs of shock or a history of
acute blood loss.

How should normal saline be administered as an emergent volume expander? What is the initial
dose?
0.9% NaCL solution via IV or IO using a 30-60 mL labeled syringe over 5-10 minutes; initial
dose is 10ml/kg

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?
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?
100 beats per minute

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?
21 - 30% oxygen

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?
Provide positive-pressure ventilation

What is the most effective maneuver to establish spontaneous breathing in a baby that is apneic
after initial steps?
Administration of positive-pressure ventilation that inflates the lungs
Remembering MR. SOPA helps your team correct problems with ventilation. Which of the
following steps are included in MR. SOPA?
Adjust Mask and Reposition head and neck; Suction mouth then nose and Open the mouth;
increase Pressure; insert Alternative airway.

Mouth opened, reposition head, Saturation check, Obstruction check, Pulse oximeter sensor,
apply cardiac monitor leads.

Ensure Mask seal, repeat stimulation, Suction the airway, Oxygen regulation, Pulse oximeter
sensor, assess heart rate.

Mouth opened, repeat stimulation, Saturation check, occlude pop-off valve, Perfusion check,
Auscultate breath sounds.

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?
Initiative positive-pressure ventilation, place a pulse oximeter sensor on the right hand or
wrist, evaluate heart rate.

You are called to attend to a newborn at birth. At the time the baby is delivered, which 3
questions should you ask to evaluate whether the baby can stay with his mother or be moved to
the radiant warmer for further assessment?
Is the baby term? Does the baby have good muscle tone? Is the baby breathing or crying?

A full-term baby is born by emergency cesarean delivery because of fetal bradycardia

(Category III fetal heart rate tracing). The baby is limp and not breathing after initial steps.
What is the next step in the resuscitation process?
Initiate positive-pressure ventilation and check for increasing heart rate.

What is the recommended way to determine if a baby requires supplemental oxygen in the
delivery room?
Place an oximeter sensor on the baby's right hand or wrist and assess oxygen saturation.

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?
Before birth, when you have identified the presence of a perinatal risk factor that increases the
likelihood of requiring neonatal resuscitation.

Effective team functioning is critical in ensuring the best performance. Which of these
characteristics is critical in team leaders?
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
Present at the birth.

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?
Start positive-pressure ventilation and check heart rate response after 15 seconds.
Your hospital is planning Neonatal Resuscitation Program® training and trying to decide who
should be included. For every delivery, what is the minimum requirement for the care of the
newborn at birth?
Someone capable of initiating neonatal resuscitation should be present at every delivery
whose only responsibility is management of the newborn.

Which statement describes recommended practice when using a pulse oximeter in the delivery
room?
Place the pulse oximeter sensor on the right hand and use the minute specific oxygen
saturation target to guide oxygen supplementation.

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?
A rising heart rate

What is the appropriate technique to stimulate a baby to breathe?

Gently rub the baby's back or extremities

Which of the following is an indication for endotracheal intubation?

The need for positive-pressure ventilation lasting more than a few minutes

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?
Insert a laryngeal mask

You are uncertain whether you have successfully intubated a newborn. Which of the following
is an indication that the endotracheal tube is correctly placed in the trachea, and not in the
esophagus?
CO2 detector indicates the presence of expired CO2

You have determined a baby needs resuscitation at birth. What are the initial steps of newborn
care?
Provide warmth, position head and neck to open the airway, clear secretions from the airway
if needed, dry, stimulate

The steps of intubation should ideally be completed within which duration?

30 seconds

Which statement best describes normal transitional physiology at the time of birth?
Babies may take as long as 10 minutes after birth to increase their oxygen saturation to
greater than 90%.

You are at a delivery of a baby born through meconium-stained amniotic fluid, and the baby is
not vigorous. What steps should be taken immediately after birth?
The baby should be brought to the radiant warmer for initial steps of newborn care.

Which of the following may be associated with delayed cord clamping in vigorous preterm
newborns?
Decreased need for blood transfusions

When are chest compressions indicated?

When the heart rate remains less than 60 beats per minute after 30 seconds of positive-
pressure ventilation that moves the chest, preferably through an alternative airway
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?
Stop chest compressions; continue positive-pressure ventilation.

What is the preferred method for assessing heart rate during chest compressions?
Electronic cardiac (ECG) monitoring

What is the ideal depth of chest compressions for a newborn?

One-third of the anterior-posterior diameter of the chest

What time frame should be used to administer intravenous epinephrine?

Rapid push, as quickly as possible

Which of the following is the best indication for volume expansion after resuscitative efforts that
included intubation, chest compressions, and IV epinephrine?
The baby's heart rate remains 50 beats per minute after resuscitative efforts and pulses are
weak.

Which statement best describes the ethical principle(s) that guide the resuscitation of a
newborn?
The approach to decisions in the newborn should be guided by the same principles used for
adults and older children

When coordinating positive-pressure ventilation with chest compressions, how many events are
performed each minute?
30 breaths, 90 compressions

Which of the following statements about post-resuscitation care is true?

Among babies with brain injury from decreased oxygen and blood flow to the brain (hypoxic-
ischemic encephalopathy), high body temperature (hyperthermia) may worsen neurologic
outcomes.

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 beats per minute and the
oxygen saturation is 90% in room air. The baby's respirations are labored. Which of the
following is an appropriate action?
Administer CPAP at 5 cm H20 pressure

How soon after administration of intravenous epinephrine should you pause compressions and
reassess the baby's heart rate?
1 minute

After what duration of time might it be reasonable to consider discontinuing resuscitation

following complete resuscitation efforts with no detectable heart rate?
10 minutes

A mother had an emergency cesarean birth at 39 weeks' gestational because of sudden fetal
bradycardia and a suspected placental abruption. After birth, the baby required extensive
resuscitation including positive pressure ventilation, intubation, chest compressions and
intravenous epinephrine. Afterward, the baby has poor tone, lethargy, and apnea. Which of the
following statements is true?
Promptly evaluate her for possible therapeutic hypothermia (cooling) treatment and contact
the nearest cooling center.
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 common cause of
asymmetric breath sounds in an intubated baby?
Endotracheal tube inserted too deep

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?
Left-sided pneumothorax

For a newborn weighing 1 kg, what dose of 1: 10,000 (0.1 mg/mL) concentration of intravenous
epinephrine is indicated?
0.1 mL

In most cases, who is (are) the usual and appropriate surrogate decision maker(s) 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 your discussion with the parents concerning
options for resuscitation?
The option of providing comfort care can be considered.

A baby born at 36 weeks' gestation was apneic after birth and required positive-pressure
ventilation and oxygen supplementation in the delivery room. He continues to require
supplemental oxygen after birth. Which of the following statements is true?
His blood glucose level should be checked soon after resuscitation and then at regular
intervals until stable and normal.

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?
Monitor blood glucose levels because of the risk of hypoglycemia after birth.

After chest compressions with coordinated ventilations are started, the heart rate should be
assessed:
After 60 seconds

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?
Respirations, heart rate, oxygen saturation

A woman is admitted at 24 weeks' gestation with rupture of membranes, maternal fever, and
premature labor. The care team offers the parents counseling. What is likely to be helpful?
Provide parents with accurate prognostic information using all relevant information affecting
their baby's prognosis.

Which of the following is true about the preparation and resources needed for a very preterm
birth?
Prepare the preheated radiant warmer with a thermal mattress, plastic wrap or bag, and a hat.
During a delivery, when and where should a person with intubation skills be available?
In the hospital and immediately available

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.

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

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?
3ML

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 are the five blocks of the NRP algorithm?

1) Rapid evaluation: this evaluation determines if the baby can stay with the mother for
routine care or should be moved to the radiant warmer
2) Airway: The initial steps open the airway and support spontaneous respirations.
3) Breathing: Assist breathing with PPV if baby apneic, gasping, or bradycardic. CPAP or O2
may be appropriate for labored breathing or low O2 sat.
4) circulation: Perform chest compressions coordinated with PPV if severe bradycardia exists
despite assisted ventilation
5) 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.

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

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 pre-birth 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 are 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?
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
-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 bradycardic.

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 stethoscope 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

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 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
-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.

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
-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?

-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?

-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 need 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?
-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

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

According to the NRP algorithm, what are the indicators for PPV?
Heart rate less than 100 bpm
apnea
gasping

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

No breathing. Next intervention

A- Start PPV

Surrogate
B- Newborn parents
Morbidity burden and option for resuscitations
A-Comfort care

Labored breathing
A- CPAP 5 cm h2o

Intubation speed
A- 30 sec

Need for alternative airway

D- need for PPV is prolonged

Gestation age of 26 weeks

A- 2.5 mm

3 compressions and 1 breath

A- 2 seconds

How often HR during compression

A- Every 60 sec

CPAP inc O2 so next step

A- Dec o2 concentration
 (Q1) NRP 8TH EDITION QUIZLET Q AND A

 What is the single most important and effective step in neonatal resuscitation?
o Ventilation of the newborn's lungs

 Abnormal Transition Findings

o -Irregular Breathing, absent breathing, or rapid breathing
-Slow or fast heart rate
-Decreased Muscle Tone
-Pale Skin or Blue Skin
-Low oxygen saturation

 NRP algorithm- First Step

o Antenatal Counselling
Team Debriefing
Equipment Check

 After the birth of the baby, what do you ask?

o Term Gestation?
Good Tone?
Breathing or crying?

 FIVE INITIAL STEPS: If you answer NO to any of the three questions (term, tone,
breathing) what do you do?
o Warm
Dry
Stimulate
Position airway
Suction if needed

 Apnea or gasping? HR <100bpm= NO with laboured breathing/cyanosis

o Position airway, suction if needed
Pulse oximeter
Oxygen if needed
Consider CPAP

 Apnea or gasping? HR <100bpm= YES

o PPV
Pulse Oximeter
Consider Cardiac Monitor

 HR STILL less than 100bpm= YES

o Ensure adequate ventilation
Consider ETT or laryngeal mask
Cardiac Monitor

 HR <60 bpm?
o ETT or laryngeal mask
Chest compressions
Coordinate PPV-100% oxygen
UVC
 HR STILL <60 bpm?
o IV Epinephrine every 3-5 minutes

If still less than 60, consider hypovolemia or pneumothorax

 Rapid Evaluation
o Determine if the newborn can remain with the mother or should be moved to the
radiant warmer for further evaluation

 REVIEW: Three questions you ask during rapid evaluation?

 Term?
2. Good Muscle Tone?
3. Breathing/crying?

If the answer is NO to any of these, baby should be brought to radiant warmer.

 Airway
o Perform the initial steps to establish an open Airway and support spontaneous
respiration

 Breathing
o PPV is provided to assist Breathing for babies with apnea or bradycardia

 Circulation
o If severe bradycardia persists despite assisted ventilation, Circulation is supported by
performing chest compressions coordinated with PPV

 Drug
o If severe bradycardia persists despite assisted ventilation and coordinated chest
compressions, the Drug Epinephrine is administered as coordinated PPV and chest
compressions continue

 What are the 4 pre-birth questions to ask the provider before every delivery?
 Expected Gestational Age
2. Is the amniotic fluid clear?
3. Are there any additional Risk Factors?
4. What is our umbilical cord management plan?

 Equipment Check- Warm

o -Preheated radiant warmer
-Towels/Blankets
-Temp Sensor/sensor cover
-Hat
-Plastic Wrap (<32 weeks)
-Thermal Mattress (<32 weeks)

 Equipment Check- Clear the airway

o -Bulb Syringe
-10F or 12F Suction catheter attached to wall suction set at 80-100mm Hg
-Tracheal Aspirator

 Equipment Check- Auscultate

 o -Stethoscope

 Equipment Check- Ventilate

o -Sets flowmeter to 10 L/min
-Sets oxygen blender to 21% (21-30 if less than 35 weeks gestation)
-Checks presence/function of PPV devices, including pressure settings and pressure
pop-off valves
-Sets T-Piece resuscitator at peak inflation pressure
(PIP=20-25cm H20 for term, 20cm H20 for preterm) (PEEP= 5 cm H20)
-Term and preterm sized masks
-Laryngeal mask (size 1) and 5ml syringe
-5F or 6F orogastric tube if insertion port present on laryngeal mask
-8F orogastric tube and 20ml syringe
-Cardiac Monitor and leads

 Equipment Check- Oxygenate

o -Equipment to give free-flow oxygen
-Target Oxygen Saturation Table
-Pulse Oximeter with sensor and sensor cover

 Equipment Check- Intubate

o -Laryngoscope with size 0/1 straight blades and bright light
-Stylet
-Endotracheal tubes (2.5/3.0/3.5)
-Co2 Detector
-Measuring tape and/or endotracheal tube insertion depth table
-Waterproof tape
-Scissors

 Equipment Check- Medicate

o Ensure access to:
-Epinephrine (1mg/10ml=0.1mg/mL)
-Normal Saline (100/250ml bag or syringes)
-Supplies for administering medications and placing emergency umbilical venous
catheter
-Pre-calculated medication dose chart

 When do you use pulse oximetry and the Target Oxygen Saturation Table to guide
oxygen therapy?
 When resuscitation is anticipated
2. To confirm your perception of persistent central cyanosis
3. If you give supplemental oxygen
4. If PPV is required

 How do you evaluate the newborns response to the initial steps?

o Assess the newborns respirations to determine if the baby is responding to the initial
steps.

If the baby has not responded to the initial steps within the first minute of life, it is not
appropriate to continue with only tactile stimulation.
 This should take NO more than 30 additional seconds

 REVIEW: Initial Steps

o Warm
Dry
Stimulate
Position Airway
Suction if needed

 After initial steps, what do you do if the baby is apneic/gasping?

o If apneic/gasping= PPV
Call for immediate additional help

 If the baby is breathing after initial steps, assess the heart rate. What should the heart
rate be?
o The heart rate should be at least 100.

If LESS than 100, start PPV even if the baby is breathing

 How do you estimate the heart rate quickly?

o Count the number of beats in 6 seconds and multiply by 10. Clearly report this to
your team members.

 What do you do if the baby is breathing and the heart rate is at least 100bpm, but the
baby appears persistently cyanotic?
o If persistent central cyanosis is suspected, a pulse oximeter placed on the right hand
or wrist should be used to assess the baby's oxygenation.

 When is PPV indicated?

o 1)Not breathing
2) Gasping
3) HR less than 100

 What is the initial oxygen concentration for newborns greater than or equal to 35
weeks’ gestation?
o 21%

 What is the initial oxygen concentration for preterm newborns less than 35 weeks’
gestation?
o 21-30%
 What is the ventilation rate?
o 40-60 breaths per min
Use the rhythm "Breathe, two, three, Breathe, two, three, Breathe, two, three"

 What do you set the flowmeter to?

o 8 L/minute (FH policy)

 What is the initial ventilation pressure?

o 20-25 cm H20 (PIP)

 Initial settings for PPV

 o O2= 21%
Gas Flow= 8 L/min
Rate= 40-60 breaths/min
PIP= 20-25 cm H20
PEEP= 5 cm H20

 What is the most important indicator of successful PPV?

o Rising heart rate

 TRUE OR FALSE: Once PPV begins, an assistant should apply a pulse oximeter to
assess baby oxygen saturation
o TRUE

 Within 15 seconds of starting PPV....

o The baby's heart rate should be increasing

 If the baby's heart rate is NOT increasing after 15 seconds, what do you do?
o Ask your assistant if the chest is moving

 If the chest is moving...

o Continue PPV while you monitor your ventilation technique. You will check again
after 30 seconds of PPV

 If the chest is NOT moving

o You may NOT be ventilating the baby's lungs. Perform MR. SOPA until you achieve
chest
o movement with PPV

 Within 30 seconds of starting PPV, the baby's heart rate....

o should be greater than 100bpm

 If the HR is not increasing within the first 15 seconds of PPV and you do not observe
chest movement, what do you do?
o Start the ventilation corrective steps

 What are the ventilation corrective steps?

o MR. SOPA

 M- Mask Adjustment
o Reapply the mask and lift the jaw forward. Consider the two hand hold

 R- Reposition the head and neck

o Place head neutral or slightly extended

 After attempting M and R (mask adjustment and repositioning), what do you do?
o Give 5 breaths and assess chest movement. If not chest movement do the next steps

 S- Suction the mouth and nose

o Use a bulb syringe or suction catheter

 O- Open the mouth

o Use a finger to gently open the mouth
 After attempting MR and SO, what do you do?
o Give 5 breaths and assess chest movement, if no chest movement, do the next step.

 P- Pressure Increase
o Increase in 5-10cm H20 increments to maximum recommended pressures
-MAX 40cm in term
-MAX 30 in preterm

 After the pressure increase...

o Give 5 breaths and assess chest movement. If no chest movement, do the next step

o Alternative airway
o Insert a laryngeal mask or endotracheal tube

 If the baby cannot be successfully ventilated with a face mask and intubation is
unfeasible or unsuccessful, what do you use?
o A laryngeal mask may provide a successful rescue airway

 If the HR remains less than 60bpm despite at least 30 seconds of face-mask PPV that
inflates the lungs, what do you do?
 Reassess your ventilation technique
2. Consider Mr. SOPA
3. Adjust the Fi02 as indicated by pulse oximetry
4. Insert an alternative airway
5. Provide 30 seconds of PPV through an alternative airway

After these steps, if the HR remains less than 60bpm, increase FiO2 to 100% and begin chest
compressions.

 When should an orogastric tube be inserted to act as a vent for gas in the stomach?
o If you continue face mask PPV or CPAP for more than several minutes

 What colour does a Co2 detector turn if you are effectively ventilating the lungs?
o YELLOW during each exhalation

 When do you consider CPAP?

o If the baby is breathing spontaneously and has a heart rate of at least 100bpm, but has
laboured or grunting respirations or low oxygen saturation

Is a technique for maintaining pressure within the lungs of a spontaneously breathing

baby

 What are the MR. SOPA steps?

o Mask Adjustment.
Reposition head and neck.
Suction mouth then nose.
Open mouth.
 Pressure increase.
Alternative Airway.

 When do you insert an endotracheal tube?

o If the baby's HR remains less than 100 bpm and is not increasing after PPV with a
face mask or laryngeal mask.

An endotracheal tube should be inserted for direct tracheal suction if the trachea is
obstructed by thick secretions, for surfactant admin, and for stabilization of a
newborn with a suspected diaphragmatic hernia

 Do you insert an endotracheal tube prior to chest compressions?

o Insertion of an endotracheal tube is strongly recommended before starting chest
compressions. If intubation is not successful or feasible, and the baby weighs more
than 2kg, a laryngeal mask may be used.

 What size laryngoscope blade for a term newborn?

o No 1

 What size laryngoscope blade for preterm newborn?

o No 0

 How do you confirm endotracheal tube insertion within the trachea?

o Exhaled Co2 and observing a rapidly increasing HR

 If a correctly inserted endotracheal tube does not result in PPV with chest movement,
what do you suspect?
o Airway obstruction and suction the trachea with a suction catheter or tracheal
aspirator

 If a baby's condition worsens after endotracheal intubation, list 4 possible causes.

o Displaced
Obstructed
Pneumothorax
Equipment Failure

(DOPE)

 When are chest compressions indicated?

o When the heart rate remains less than 60 beats per minute after 30 seconds of
positive-pressure ventilation that moves the chest, preferably through an alternative
airway.

If the chest is to moving with PPV, the lungs have not been inflated and chest
compressions are not yet indicated.
 If the heart rate is less than 60bpm, the pulse oximeter may not have a reliable signal,
therefore...
o When chest compressions begin, ventilate using 100% oxygen until the heart rate is at
least 60bpm and the pulse oximeter has a reliable signal

 Proper technique for chest compressions

o Place your thumbs on the sternum, in the center, just below an imaginary line
connecting the baby's nipples. Encircle the torso with both hands. Support the back
with your fingers (they do not need to touch)

 What is the appropriate pressure during chest compressions?

o Use enough downward pressure to depress the sternum approximately one-third of
the anterior-posterior diameter of the chest

 What is the compression rate?

o 90 compressions per minute and the breathing rate is 30 breaths per minute

This is a slower ventilation rate than used during assisted ventilation without
compressions

 What do you say out loud to achieve the correct compression rate?
o One-and-two-and-three-and breathe- and

 How long do you do chest compressions/ventilation before checking the HR?

o After 60 seconds of chest compressions and ventilation, briefly stop compressions
and check the HR (cardiac monitor is ideal at this time)

 When can you discontinue chest compressions?

o If the heart rate is 60bpm or greater, discontinue compressions and resume PPV at 40-
60 breaths per minute.

 When is epinephrine administration indicated?

o If the baby's heart rate is less than 60bpm despite 60 seconds of effective ventilation
and high quality, coordinated chest compressions, epinephrine admin is indicated and
emergency vascular access is needed

Epinephrine is NOT indicated before you have established ventilation that effectively
inflates the lungs, as evidenced by chest movement

 Questions to ask when HR is not improving with compressions and ventilation?

(CARDIO)
o Chest movement
A- Airway secured
R- Rate (3 compressions, with 1 ventilation, every 2 seconds)
D- Depth (1/3 of the AP diameter)
IO- Is 100% oxygen being administered through the PPV device?

 Epinephrine concentration
o 0.1mg/mL= 1mg/10mL

 Epinephrine Route
 o Intravenous or Intraosseous

1x endotracheal dose may be considered while vascular access is established

 Epinephrine Preparation
o IV or Intraosseous: 1mL syringe (labeled Epinephrine IV)

Endotracheal: 3-5ml syringe (labeled Epinephrine-ET ONLY)

 Epinephrine Dose
o IV= 0.02mg/kg (equal to 0.2ml/kg)

May repeat Q3-5 minutes

Range: 0.01 to 0.03mg/kg
Rate: Rapidly
Flush: Follow with 3ml saline flush
 When is a volume expander indicated?
o If the baby is not responding to the steps of resuscitation and there are signs of shock
or
o history of acute blood loss

 Volume expansion recommendations

o Normal Saline or O- Blood
IV or IO
Prep in 30-60 mls syringe
Dose: 10ml/kg
Rate: Over 5-10 minutes

 What is a reasonable timeframe for considering cessation of resuscitation efforts?

o 20 minutes after birth

 REVIEW: Epinephrine is indicated if the baby's heart rate...

o If the baby's heart rate remains less, then 60 after
-At least 30 seconds of PPV that inflates the lungs as evidenced by chest movement
-Another 60 seconds of chest compressions coordinated with PPV using 100%
oxygen

 List 4 additional steps (other than radiant warmer) that will help maintain a pre-term
baby's temperature
o Increase room temp
Prep a thermal mattress
Prep a polyethylene plastic bag
Pre-warm a transport incubator

 When do you suspect a pneumothorax?

o If a baby fails to improve despite resuscitative measures or suddenly develops severe
respiratory distress
 Can be detected by decreased breath sounds and increased transillumination on the
affected side
 When do you suspect a pleural effusion?
o If the newborn has respiratory distress and generalized edema (hydros fetalis)