NRP Medication Administration 2 — Questions and Answers

Question 1: What is the recommended intravenous/intraosseous dose of epinephrine during neonatal resuscitation?

0.01–0.03 mg/kg (0.1–0.3 mL/kg of 1:10,000 solution) (Correct answer)
0.05–0.1 mg/kg (0.5–1 mL/kg of 1:10,000 solution)
0.1–0.2 mg/kg (1–2 mL/kg of 1:10,000 solution)
0.001–0.003 mg/kg (0.01–0.03 mL/kg of 1:10,000 solution)

Correct answer: 0.01–0.03 mg/kg (0.1–0.3 mL/kg of 1:10,000 solution)

The recommended IV/IO dose of epinephrine is 0.01–0.03 mg/kg, which equals 0.1–0.3 mL/kg of a 1:10,000 (0.1 mg/mL) solution, per NRP 8th edition.

During neonatal resuscitation, when cardiac compressions are being performed and vascular access is established, epinephrine should be administered IV or IO at a dose of 0.01–0.03 mg/kg (0.1–0.3 mL/kg of the 1:10,000 solution). This concentration means each mL contains 0.1 mg epinephrine. The lower end of the dosing range is preferred for initial doses. After giving epinephrine IV/IO, flush the line with normal saline (0.5–1 mL) to ensure delivery. Repeat every 3–5 minutes if heart rate remains below 60 bpm.

Question 2: Which of the following is the FIRST-LINE route for medication administration during neonatal resuscitation once IV access is needed?

Endotracheal tube
Umbilical venous catheter (Correct answer)
Peripheral IV
Intraosseous

Correct answer: Umbilical venous catheter

The umbilical venous catheter (UVC) is the preferred and first-line route for emergency vascular access in neonatal resuscitation due to its accessibility in the delivery room.

During neonatal resuscitation, establishing vascular access is critical for medication administration. The umbilical venous catheter is the preferred route because the umbilical cord stump is readily accessible at birth, UVC insertion is a well-established skill, and it provides a central venous route for reliable medication delivery. A catheter is inserted into the umbilical vein and advanced until blood can be freely aspirated, then secured. Intraosseous access is an acceptable alternative when UVC placement is not feasible or is delayed.

Question 3: What is the normal saline flush volume recommended after giving epinephrine through an umbilical venous catheter in a neonate?

0.1 mL
0.5–1 mL (Correct answer)
2–3 mL
5 mL

Correct answer: 0.5–1 mL

After administering epinephrine via UVC, a flush of 0.5–1 mL of normal saline is recommended to ensure the full drug dose reaches the circulation.

When epinephrine or other medications are administered via the umbilical venous catheter, the catheter lumen retains a small volume of fluid. A normal saline flush of 0.5–1 mL is used to push the medication into the bloodstream and prevent the drug from remaining in the catheter dead space where it would be inactive. This flush volume is appropriate for neonates given their small total blood volume and sensitivity to volume overload.

Question 4: When should volume expansion with normal saline be considered during neonatal resuscitation?

Routinely after every 10 minutes of resuscitation
When the infant is suspected to have hypovolemia not responding to epinephrine (Correct answer)
As the first intervention after confirming absent heart rate
Only after three doses of epinephrine have been given

Correct answer: When the infant is suspected to have hypovolemia not responding to epinephrine

Volume expansion with isotonic saline is indicated when the infant shows signs of hypovolemia (pallor, weak pulses, poor response to resuscitation) and the cause is suspected to be blood loss or severe hypovolemia.

Volume expansion is not routinely used in neonatal resuscitation. It is specifically indicated when hypovolemia is suspected — for example, in cases of significant fetal blood loss (placenta previa, vasa previa, cord avulsion) or when the infant remains severely compromised despite adequate ventilation, oxygenation, and epinephrine. The recommended fluid is isotonic saline (or O-negative blood if significant hemorrhage is suspected), given as a 10 mL/kg bolus over 5–10 minutes via UVC or IO. Excessive volume can worsen outcomes including intraventricular hemorrhage in preterm infants.

Question 5: What is the endotracheal dose of epinephrine if IV/IO access is unavailable during neonatal resuscitation?

0.01–0.03 mg/kg (0.1–0.3 mL/kg of 1:10,000 solution)
0.05–0.1 mg/kg (0.5–1 mL/kg of 1:10,000 solution) (Correct answer)
0.1–0.3 mg/kg (1–3 mL/kg of 1:10,000 solution)
0.001–0.005 mg/kg (0.01–0.05 mL/kg of 1:10,000 solution)

Correct answer: 0.05–0.1 mg/kg (0.5–1 mL/kg of 1:10,000 solution)

The endotracheal dose of epinephrine is 0.05–0.1 mg/kg (0.5–1 mL/kg of 1:10,000 solution) — significantly higher than the IV/IO dose — because absorption via the pulmonary route is unreliable.

When IV or IO access cannot be rapidly established, epinephrine may be administered via the endotracheal tube. However, absorption via the ET route is unreliable and variable, necessitating a much higher dose: 0.05–0.1 mg/kg (0.5–1 mL/kg of 1:10,000 solution). NRP emphasizes that IV/IO access should be obtained as quickly as possible so that the more reliable and effective IV/IO route can be used. The ET route is considered a temporary measure of last resort while IV/IO access is being established.

Question 6: Which medication is used for neonatal resuscitation in cases of suspected opioid-induced respiratory depression?

Atropine
Adenosine
Naloxone (Correct answer)
Dextrose

Correct answer: Naloxone

Naloxone is an opioid antagonist used to reverse respiratory depression caused by maternal opioid administration. However, NRP emphasizes that PPV should be the primary intervention, and naloxone is used as an adjunct.

Naloxone (Narcan) may be used in newborns with respiratory depression attributed to maternal opioid use within 4 hours of delivery. However, NRP 8th edition cautions against its routine use and stresses that positive-pressure ventilation is the most important intervention. Naloxone should not be given to infants of mothers with chronic opioid use or on methadone/buprenorphine maintenance, as it can precipitate severe acute withdrawal seizures. When used, the dose is 0.1 mg/kg IV/IO or IM, and the infant should be monitored for re-narcotization as naloxone's effect may wear off before the opioid does.

NRP Medication Administration 2

What is the recommended intravenous/intraosseous dose of epinephrine during neonatal resuscitation?