Neonatal Resuscitation Practice Test

When a newborn isn't breathing and doesn't respond to stimulation, you cannot tell at the bedside whether they are in primary apnea (which might resolve) or secondary apnea (which requires ventilation). Because secondary apnea cannot recover on its own and waiting costs time, the correct response is always to start positive-pressure ventilation immediately rather than waiting for more evidence.

The pulse oximeter goes on the right hand or wrist. This location measures oxygen saturation before the blood passes through the ductus arteriosus is called preductal saturation. This reflects how much oxygen is reaching the brain. Readings from the left hand or foot (postductal) may be significantly lower and would give a misleading picture of the infant's true oxygen status.

Current guidelines are clear, if a baby born through meconium is vigorous (heart rate above 100, good tone, strong breathing effort), routine initial steps proceed without any suctioning. Suctioning a vigorous infant does not improve outcomes and delays the assessment. The old practice of routine suctioning regardless of infant condition is no longer recommended.

While chest rise and breath sounds tell you air is getting in, the real measure of whether PPV is working is the heart rate. If the heart rate is rising toward or above 100 beats per minute, the ventilation is effective. A baby can have improving chest rise but still be in trouble if the heart rate isn't responding and this is when the team needs to reassess.

Chest compressions in newborns start when the heart rate is below 60 beats per minute even after 30 seconds of effective breathing support through an advanced airway. The requirement for an advanced airway first is deliberate (coordinating compressions with a face mask is much less effective), and the 30-second window ensures the infant genuinely isn't responding to ventilation.

The two-thumb encircling technique (both thumbs on the lower third of the sternum with fingers wrapped around the chest supporting the back) is strongly preferred. Research shows it generates better blood pressure and coronary perfusion pressure than the two-finger technique. The two-finger technique is only used when the provider needs access to the umbilical area to place a catheter simultaneously.

The 3:1 ratio means 3 compressions for every 1 breath, producing 90 compressions and 30 ventilations per minute (120 events per minute in total). The counting rhythm is 'one-and-two-and-three-and-breathe.' This ratio is unique to newborns and differs from adult or paediatric CPR, because neonatal cardiac arrests are almost always caused by a lack of oxygen rather than a primary heart problem.

Epinephrine is given when the heart rate stays below 60 beats per minute even after at least 30 seconds of effective chest compressions and breathing support through an advanced airway. The key word is 'effective' (epinephrine will not work if the CPR itself is inadequate). Before each dose, confirm the airway is correctly placed, ventilation is producing chest rise, and compressions are at the correct depth and rate.

Epinephrine for neonatal resuscitation is a 1:10,000 solution (0.1 milligrams per millilitre). The IV or IO dose is 0.1 to 0.3 mL per kilogram of the infant's weight, followed by a 0.5 to 1 mL normal saline flush. Using the wrong concentration or dose range is one of the most common medication errors in resuscitation, therefore, knowing this precisely matters.

If the heart rate stays below 60 beats per minute after the first epinephrine dose, repeat doses can be given every 3 to 5 minutes. If the infant isn't responding after multiple doses, stop and reassess (check whether CPR is being done correctly), whether the airway is in the right position, and whether there is a fixable cause such as unrecognised volume loss.