NRP Neonatal Resuscitation Program Exam — Questions and Answers

Question 1: Which of the following is an example of appropriate documentation of epinephrine administration during a neonatal resuscitation?

'Resuscitation medications given as needed'
'Epi given'
'Epinephrine 0.2 mL (0.02 mg) 1:10,000 IV via UVC at 14:37' (Correct answer)
'Epinephrine administered per protocol'

Correct answer: 'Epinephrine 0.2 mL (0.02 mg) 1:10,000 IV via UVC at 14:37'

Complete medication documentation includes: drug name, volume, dose in mg, concentration, route, access type, and exact time — all necessary for clinical decision-making and medical record accuracy.

Question 2: What is 'delayed cord clamping' contraindicated in?

All preterm deliveries
Maternal hemorrhage requiring rapid placental delivery and infants needing immediate resuscitation (Correct answer)
Elective cesarean sections
MSAF deliveries

Correct answer: Maternal hemorrhage requiring rapid placental delivery and infants needing immediate resuscitation

Delayed cord clamping is contraindicated when the mother is hemodynamically unstable or when the infant requires immediate resuscitation on the warmer.

Question 3: What is the recommended mask size for PPV in a term newborn?

A mask covering the mouth, nose, and eyes
A mask that covers the mouth and nose but not the eyes (Correct answer)
A mask covering the nose only
The largest mask that fits the face

Correct answer: A mask that covers the mouth and nose but not the eyes

The mask should cover the mouth and nose completely but not extend over the eyes, to ensure an adequate seal without pressure on the eyes.

Question 4: In which clinical scenario would IO access be MOST appropriate during neonatal resuscitation?

A newborn with omphalocele requiring emergency vascular access for medications (Correct answer)
A newborn with a heart rate of 80 bpm requiring supplemental oxygen only
A preterm infant who has already been stabilized and admitted to the NICU
A term infant with a normal umbilical cord who needs epinephrine after 3 minutes of failed PPV

Correct answer: A newborn with omphalocele requiring emergency vascular access for medications

Omphalocele is a contraindication to UVC insertion. IO access is the appropriate alternative for emergency vascular access in a newborn with an umbilical abnormality requiring medications.

Question 5: What is the purpose of the MRSOPA step 'Airway alternative' in the context of a failed mask?

Increase flow rate to the bag
Consider intubation or LMA placement (Correct answer)
Switch to a different mask size
Apply CPAP instead of PPV

Correct answer: Consider intubation or LMA placement

If all mask-correction steps fail to produce adequate ventilation, the provider should consider an airway alternative such as intubation or LMA.

Question 6: Why is glucose monitoring particularly important for preterm infants after delivery room resuscitation?

Preterm infants have higher insulin levels that rapidly lower blood glucose
Glucose monitoring is needed only for infants who received dextrose during resuscitation
Preterm infants preferentially metabolize glucose faster than term infants during stress
Preterm infants have limited glycogen stores and immature gluconeogenesis, making hypoglycemia common and potentially causing brain injury (Correct answer)

Correct answer: Preterm infants have limited glycogen stores and immature gluconeogenesis, making hypoglycemia common and potentially causing brain injury

Preterm infants have limited hepatic glycogen stores, immature gluconeogenesis, and increased metabolic demands — putting them at high risk for hypoglycemia, which if undetected can cause seizures and permanent brain injury.

Question 7: What is a laryngeal mask airway (LMA) used for in neonatal resuscitation?

Airway for infants requiring chest compressions
Alternative airway when intubation fails or is not feasible in ≥34-week infants (Correct answer)
First-line airway device replacing bag-mask ventilation
Routine airway for all preterm infants

Correct answer: Alternative airway when intubation fails or is not feasible in ≥34-week infants

An LMA is an acceptable alternative when intubation is not possible and may be used in infants ≥34 weeks gestation and ≥2 kg.

Question 8: A gastric tube should be inserted during prolonged PPV primarily to:

Monitor gastric pH during resuscitation
Provide a route for medication delivery
Decompress the lungs
Prevent stomach distension that can impair ventilation (Correct answer)

Correct answer: Prevent stomach distension that can impair ventilation

Prolonged bag-mask ventilation can inflate the stomach, causing diaphragmatic elevation and compromising lung expansion.

Question 9: How does fetal hemoglobin (HbF) differ from adult hemoglobin (HbA) in terms of oxygen affinity, and why is this important?

HbF and HbA have identical oxygen affinity, but HbF is present in higher concentrations
HbF has lower oxygen affinity than HbA, enabling efficient oxygen delivery to fetal tissues
HbF has higher oxygen affinity than HbA, enabling oxygen loading at the lower PO2 of placental blood (Correct answer)
HbF binds only to carbon monoxide, not oxygen, protecting the fetus

Correct answer: HbF has higher oxygen affinity than HbA, enabling oxygen loading at the lower PO2 of placental blood

Fetal hemoglobin (HbF) has a higher oxygen affinity than adult hemoglobin due to reduced binding of 2,3-DPG, allowing it to load oxygen efficiently at the lower PO2 of placental blood (~35–40 mmHg).

Question 10: What is the significance of a cord pH below 7.0 in the post-resuscitation assessment?

Is a normal value for preterm infants
Requires immediate sodium bicarbonate administration
Indicates respiratory alkalosis from hyperventilation
Indicates severe metabolic acidosis consistent with significant birth asphyxia (Correct answer)

Correct answer: Indicates severe metabolic acidosis consistent with significant birth asphyxia

A cord pH below 7.0 indicates severe metabolic acidosis, suggesting significant hypoxic-ischemic insult and supporting evaluation for HIE/cooling criteria.

Question 11: What is CPAP (continuous positive airway pressure) used for in the delivery room setting for preterm infants?

To replace positive-pressure ventilation for apneic preterm infants
To prevent intraventricular hemorrhage by controlling cerebral blood flow
To deliver epinephrine via the airway to stimulate cardiac function
To provide continuous distending pressure that maintains functional residual capacity in spontaneously breathing preterm infants (Correct answer)

Correct answer: To provide continuous distending pressure that maintains functional residual capacity in spontaneously breathing preterm infants

CPAP maintains positive airway pressure throughout the respiratory cycle in spontaneously breathing infants, preventing alveolar collapse and supporting FRC — particularly valuable in preterm infants with surfactant deficiency.

Question 12: What is the recommended room temperature for a newborn resuscitation?

Above 25°C (77°F) (Correct answer)
Below 20°C (68°F)
Exactly 37°C (98.6°F)
Between 15–18°C (59–64°F)

Correct answer: Above 25°C (77°F)

The delivery room should be warm (above 25°C/77°F) to minimize heat loss in the newborn.

Question 13: For the atticoantral variant of chronic suppurative otitis media, the recommended course of treatment is:

Mastoidectomy (Correct answer)
Myringoplasty beneath the surface
medical supervision
placing the ventilation tube in

Correct answer: Mastoidectomy

For the atticoantral variant of chronic suppurative otitis media (CSOM), which is typically associated with cholesteatoma formation, the recommended course of treatment is mastoidectomy. Cholesteatoma is an erosive and destructive lesion that requires surgical removal to prevent further bone destruction, hearing loss, and potentially serious intracranial complications. Medical management or ventilation tubes are insufficient for this aggressive form of CSOM.

Question 14: How is the 3:1 compression-to-ventilation ratio delivered in practice?

Three compressions, then three breaths
Alternate compressions and ventilations every 15 seconds
Three compressions while simultaneously delivering a breath
Three compressions followed by a brief pause for one ventilation, repeated continuously (Correct answer)

Correct answer: Three compressions followed by a brief pause for one ventilation, repeated continuously

The provider performs three rapid compressions followed by a brief pause during which the ventilator delivers one effective breath.

Question 15: Why is pulse oximetry preferred over visual assessment of skin color for monitoring oxygenation during neonatal resuscitation?

Visual assessment of skin color is unreliable, especially in darker-skinned infants and in the first minutes of life (Correct answer)
Pulse oximetry is faster than visual inspection and provides more objective data
Pulse oximetry can detect arrhythmias in addition to oxygen saturation
Visual inspection requires more training and is subject to bias

Correct answer: Visual assessment of skin color is unreliable, especially in darker-skinned infants and in the first minutes of life

Skin color assessment is subjective, affected by lighting, infant skin tone, and peripheral vasoconstriction, and is an unreliable indicator of oxygenation. Pulse oximetry provides continuous, objective SpO2 data independent of these factors.

Question 16: What is the maximum time an emergency UVC placed during delivery room resuscitation should be left in place before being removed or replaced with a properly positioned central line?

Until the infant no longer needs vascular access
Up to 7–14 days if no signs of infection are present
24–48 hours — it should be removed or repositioned as soon as the infant is stabilized (Correct answer)
24 hours

Correct answer: 24–48 hours — it should be removed or repositioned as soon as the infant is stabilized

An emergency UVC placed rapidly in the delivery room without optimal sterile technique or confirmed position should be removed or replaced with a properly placed and confirmed central line within 24–48 hours to reduce infection risk.

Question 17: If the heart rate does not respond after epinephrine and effective CPR, what should be considered?

Hypovolemia, pneumothorax, or other reversible causes (Correct answer)
Withholding further epinephrine permanently
Increasing PPV rate to 80 breaths per minute
Switching to only oxygen without compressions

Correct answer: Hypovolemia, pneumothorax, or other reversible causes

Reversible causes such as hypovolemia, tension pneumothorax, or equipment failure must be considered when resuscitation is not effective.

Question 18: Which type of resuscitation device does NOT require a compressed gas source to deliver PPV?

T-piece resuscitator
Flow-inflating bag
Self-inflating bag (Correct answer)
Anesthesia bag

Correct answer: Self-inflating bag

A self-inflating bag reinflates automatically after each compression and does not require a compressed gas source, making it available in any setting.

Question 19: Which of the following is a key stimulus for the first breath after delivery?

Cold exposure, tactile stimulation, and chemoreceptor response to rising CO2 and falling O2 (Correct answer)
Increased intracranial pressure from the birth process
Rising blood pH as CO2 is cleared by the lungs
Prostaglandin release from the placenta

Correct answer: Cold exposure, tactile stimulation, and chemoreceptor response to rising CO2 and falling O2

The first breath is triggered by multiple stimuli: the sudden change in temperature (cold exposure), tactile stimulation during delivery, and chemoreceptor activation from rising PCO2 and falling PO2 as placental circulation ends.

Question 20: What is the recommended response if an intubated infant suddenly deteriorates after initial improvement?

Extubate and resume bag-mask ventilation
Consider DOPE: Displacement, Obstruction, Pneumothorax, Equipment failure (Correct answer)
Give a second dose of epinephrine
Immediately start compressions

Correct answer: Consider DOPE: Displacement, Obstruction, Pneumothorax, Equipment failure

The DOPE mnemonic (Displacement, Obstruction, Pneumothorax, Equipment failure) guides systematic evaluation of sudden deterioration in an intubated neonate.

Question 21: What is the correct technique for holding the laryngoscope during neonatal intubation?

In the left hand with the blade angled 45°
In the right hand with fingers around the blade
In both hands for stability
In the left hand, blade down, with the handle vertical (Correct answer)

Correct answer: In the left hand, blade down, with the handle vertical

The laryngoscope is held in the left hand with the blade pointing down, allowing the right hand to insert the ETT.

Question 22: When should chest compressions be stopped?

After epinephrine is given
When heart rate rises above 60 bpm (Correct answer)
After 2 minutes regardless of response
When SpO₂ reaches 90%

Correct answer: When heart rate rises above 60 bpm

Chest compressions are discontinued when the heart rate rises above 60 bpm, at which point PPV alone may sustain circulation.

Question 23: What is the primary physiological change that must occur in the lungs immediately after birth for successful transition to extrauterine life?

Clearing of meconium from the airways
Replacement of lung fluid with air and establishment of functional residual capacity (Correct answer)
Increase in pulmonary vascular resistance
Closure of the ductus venosus

Correct answer: Replacement of lung fluid with air and establishment of functional residual capacity

At birth, the fluid-filled lungs must be cleared and air must replace the fluid to establish functional residual capacity (FRC), enabling effective gas exchange for the first time.

Question 24: Which of the following best demonstrates effective use of 'direct communication' during neonatal resuscitation?

'Does anyone know where the epinephrine is?'
'Nurse Jones, please draw up 0.6 mL of 1:10,000 epinephrine now.' (Correct answer)
'Someone should go get epinephrine — we might need it.'
'We should probably start compressions if this doesn't improve.'

Correct answer: 'Nurse Jones, please draw up 0.6 mL of 1:10,000 epinephrine now.'

Direct communication means addressing a specific team member by name with a clear, actionable instruction. Vague requests addressed to 'someone' or the group are easily missed and delay action.

Question 25: What guidance does NRP provide regarding resuscitation of an extremely preterm infant at the threshold of viability?

All infants below 24 weeks should receive comfort care only
All infants ≥22 weeks must receive full resuscitation
Gestational age alone determines whether to resuscitate
Decisions should be individualized based on gestational age, family wishes, and prognosis (Correct answer)

Correct answer: Decisions should be individualized based on gestational age, family wishes, and prognosis

NRP emphasizes individualized, family-centered decisions at the threshold of viability, considering GA, clinical condition, and parental values.

Question 26: Which of the following is NOT an indication for volume expansion during neonatal resuscitation?

Suspected blood loss from placenta previa
Suspected cord avulsion with fetal hemorrhage
Pale skin color with poor pulse volume unresponsive to resuscitation
Routine use to improve response to epinephrine (Correct answer)

Correct answer: Routine use to improve response to epinephrine

Volume expansion is not used routinely in neonatal resuscitation. It is reserved for specific situations of suspected or confirmed hypovolemia such as blood loss. Routine use can cause harm.

Question 27: What is 'situational awareness' in the context of neonatal resuscitation, and who is primarily responsible for maintaining it?

Awareness of the location of all resuscitation equipment; responsibility of the equipment nurse
Real-time documentation of vital signs; primarily the recorder's responsibility
Continuous monitoring and integration of all available clinical information to understand current status and anticipate next steps; primarily the team leader's responsibility (Correct answer)
Knowledge of the parents' wishes regarding resuscitation; primarily the social worker's responsibility

Correct answer: Continuous monitoring and integration of all available clinical information to understand current status and anticipate next steps; primarily the team leader's responsibility

Situational awareness is the continuous process of gathering, integrating, and interpreting all available information to understand the current clinical state and anticipate future needs. The team leader bears primary responsibility for maintaining it.

Question 28: What characteristic of right heart failure is not present?

Basal crepitations (Correct answer)
Venous distension in the jugular
Ascites
Hepatomegaly

Correct answer: Basal crepitations

Basal crepitations (rales) are typically a sign of pulmonary edema, which is characteristic of left heart failure due to fluid backing up into the lungs. Right heart failure, in contrast, primarily causes systemic venous congestion, leading to symptoms such as hepatomegaly (enlarged liver), jugular venous distension, and ascites (fluid accumulation in the abdomen), rather than lung crackles.

Question 29: What is the recommended initial peak inspiratory pressure for a preterm infant's first breaths during PPV?

10–15 cm H₂O
20–25 cm H₂O (Correct answer)
40 cm H₂O
30–35 cm H₂O

Correct answer: 20–25 cm H₂O

Preterm infants typically require the same initial PIP of 20–25 cm H₂O as term infants, adjusted based on chest rise.

Question 30: What is cardiac monitoring's role during neonatal resuscitation with chest compressions?

Replaces the need for pulse oximetry
Provides rapid, accurate heart rate assessment to guide resuscitation decisions (Correct answer)
Indicates when to give epinephrine based on waveform
Is required before compressions can begin

Correct answer: Provides rapid, accurate heart rate assessment to guide resuscitation decisions

A three-lead cardiac monitor provides continuous, accurate heart rate data faster than pulse oximetry during compressions.

Question 31: What is the primary responsibility of the designated team leader during neonatal resuscitation?

Documenting all medications and interventions in real time
Maintaining airway management throughout the resuscitation
Directing the team, monitoring the overall clinical picture, and making key decisions without becoming task-focused (Correct answer)
Performing the most technically difficult procedure

Correct answer: Directing the team, monitoring the overall clinical picture, and making key decisions without becoming task-focused

The team leader directs the overall resuscitation effort, maintains situational awareness, assigns tasks, makes clinical decisions, and communicates with the team and family — without becoming focused on any single task.

Question 32: What is the correct hand position when using the E-C clamp technique for mask ventilation?

Index finger on top of mask; four fingers under the jaw
Two fingers press the mask; palm lifts the chin
All five fingers grip the mask tightly
Thumb and index finger form a 'C' on the mask; remaining fingers form an 'E' under the jaw (Correct answer)

Correct answer: Thumb and index finger form a 'C' on the mask; remaining fingers form an 'E' under the jaw

The E-C technique uses the thumb and index finger in a 'C' to hold the mask and the remaining three fingers in an 'E' to lift the jaw.

Question 33: What happens to pulse oximetry accuracy if the probe is placed on the newborn before connecting it to the oximeter?

Probe placement order does not affect measurement accuracy
The probe should be connected to the oximeter first, then applied to the infant, for faster signal acquisition (Correct answer)
The oximeter will immediately read the correct SpO2
The probe must warm the skin before being connected to the oximeter

Correct answer: The probe should be connected to the oximeter first, then applied to the infant, for faster signal acquisition

NRP recommends connecting the probe to the oximeter before applying it to the infant, which significantly speeds up signal acquisition and reduces the time to first reliable SpO2 reading.

Question 34: What is the most important intervention for preventing heat loss in a preterm infant less than 32 weeks gestation in the delivery room?

Using a radiant warmer set to the highest temperature
Giving the infant directly to the parent for skin-to-skin contact
Warm blankets and vigorous drying
Placing the infant in a polyethylene plastic wrap or bag without drying (Correct answer)

Correct answer: Placing the infant in a polyethylene plastic wrap or bag without drying

For preterm infants less than 32 weeks, NRP recommends placing the infant immediately (without drying) into a polyethylene wrap or bag under a radiant warmer to minimize evaporative and conductive heat loss.

Question 35: Why is a preterm infant at increased risk for intraventricular hemorrhage (IVH) during delivery room resuscitation?

Preterm infants have a larger brain volume that is more susceptible to pressure
Preterm infants have thinner skull bones that allow external compression during delivery
Preterm infants have fragile germinal matrix vessels that are vulnerable to fluctuations in cerebral blood flow (Correct answer)
Preterm infants receive more medication during resuscitation, which increases bleeding risk

Correct answer: Preterm infants have fragile germinal matrix vessels that are vulnerable to fluctuations in cerebral blood flow

Preterm infants have a highly vascularized germinal matrix adjacent to the lateral ventricles. These immature vessels lack the structural support and autoregulatory capacity of mature vessels, making them vulnerable to rupture from abrupt changes in cerebral blood flow and pressure.

NRP Neonatal Resuscitation Program Exam

The NRP examination assesses healthcare professionals on neonatal resuscitation knowledge per the AAP/AHA 8th Edition curriculum, covering initial assessment, positive pressure ventilation, airway management, chest compressions, medication administration, and team-based resuscitation skills.

Questions

90 min

Time Limit

80%

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