NRP Neonatal Resuscitation Program Exam — Questions and Answers

Question 1: Five minutes after birth, what is the targeted pre-ductal SPO2 level?

90% to 95%
60% to 65%
70% to 75%
80% to 85% (Correct answer)

Correct answer: 80% to 85%

The targeted pre-ductal oxygen saturation (SpO2) for a newborn at 5 minutes after birth is 80% to 85%. This range reflects the normal physiological transition from fetal to neonatal circulation, where oxygen saturation gradually increases over the first 10 minutes of life. Achieving full adult SpO2 immediately after birth is not expected or necessarily desirable.

Question 2: What is the recommended room temperature for a newborn resuscitation?

Exactly 37°C (98.6°F)
Between 15–18°C (59–64°F)
Above 25°C (77°F) (Correct answer)
Below 20°C (68°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 3: After intubation, which clinical sign most reliably confirms bilateral equal lung ventilation?

Equal bilateral breath sounds in the axillae (Correct answer)
Equal chest rise visually
Absence of gastric gurgling
SpO₂ rise above 95%

Correct answer: Equal bilateral breath sounds in the axillae

Auscultation in both axillae (rather than over the chest wall) minimizes transmitted sounds and confirms equal bilateral ventilation.

Question 4: After successfully inserting a UVC and confirming blood can be aspirated, what is the next critical step before administering medications?

Obtain a chest X-ray to confirm tip position
Flush the catheter with heparinized saline and secure it with sutures
Measure the length of catheter inserted and document it
Flush the catheter with normal saline to confirm patency and ensure no air is present in the line (Correct answer)

Correct answer: Flush the catheter with normal saline to confirm patency and ensure no air is present in the line

Before administering medications, the UVC should be flushed with normal saline to confirm patency, clear any blood from the line, and ensure there are no air bubbles that could cause air embolism.

Question 5: For extremely preterm infants born at less than 28 weeks' gestation, NRP recommends that delivery room temperature be maintained at a minimum of:

24°C (75°F)
26°C (79°F) (Correct answer)
25°C (77°F)
23°C (74°F)

Correct answer: 26°C (79°F)

NRP guidelines recommend the delivery room temperature be at least 26°C (79°F) for extremely preterm infants, as they are at the highest risk for heat loss.

Question 6: When applying pressure to a newborn during compressions, where should it go?

Throughout the xiphoid process
Any of the sites listed above is suitable.
topmost section of the sternum
the sternum's lower third (Correct answer)

Correct answer: the sternum's lower third

When performing chest compressions on a newborn, pressure should be applied to the lower third of the sternum, just below an imaginary line connecting the nipples. This specific location ensures effective compression of the heart while minimizing the risk of injury to the xiphoid process or other abdominal organs. Proper hand placement is critical for both efficacy and safety.

Question 7: What should be done if cardiac monitoring (ECG) is unavailable during compressions?

Assess color and tone as surrogates
Rely solely on SpO₂ trends
Assess heart rate by auscultation or palpation of the umbilical pulse (Correct answer)
Continue compressions for a full 5 minutes before assessing

Correct answer: Assess heart rate by auscultation or palpation of the umbilical pulse

In the absence of a cardiac monitor, heart rate can be assessed by auscultation with a stethoscope or palpation of the umbilical cord base.

Question 8: What complication should be suspected if a preterm infant shows sudden deterioration with decreased breath sounds on one side after intubation and initiation of PPV?

Pneumothorax (Correct answer)
Esophageal intubation
Right main-stem bronchus intubation causing left lung collapse
Intraventricular hemorrhage

Correct answer: Pneumothorax

Sudden deterioration with decreased breath sounds on one side after PPV in a preterm infant should raise concern for pneumothorax — air leaking into the pleural space from alveolar overdistension or rupture.

Question 9: Which of the following clinical findings may indicate hypothermia in a newborn?

Poor feeding, lethargy, and cold extremities (Correct answer)
Hyperthermia and seizures
Hypertension and bounding pulses
Flushed skin and tachycardia

Correct answer: Poor feeding, lethargy, and cold extremities

Hypothermic newborns typically present with poor feeding, lethargy, cold extremities, and pallor due to peripheral vasoconstriction and decreased metabolic activity.

Question 10: Hyperthermia (temperature >38°C) during or after neonatal resuscitation is associated with which outcome?

Increased risk of brain injury and worsened outcomes (Correct answer)
Reduced risk of seizures
Faster restoration of normal cardiorespiratory function
Improved neurological outcomes

Correct answer: Increased risk of brain injury and worsened outcomes

Hyperthermia increases excitotoxicity and metabolic demands in injured brain tissue, and is associated with worsened neurological outcomes, particularly after perinatal asphyxia.

Question 11: What is the current NRP recommendation when a vigorous newborn is born through meconium-stained amniotic fluid (MSAF)?

Proceed with initial steps; routine intubation for suctioning is NOT recommended (Correct answer)
Suction the oropharynx on the perineum before delivery is complete
Withhold PPV until the airway is suctioned
Intubate all meconium-exposed newborns for tracheal suctioning

Correct answer: Proceed with initial steps; routine intubation for suctioning is NOT recommended

Routine intubation for tracheal suctioning in vigorous MSAF infants is no longer recommended; resuscitation proceeds as for any newborn.

Question 12: What is CPAP (continuous positive airway pressure) used for in the delivery room setting for preterm infants?

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

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

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

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 14: What is the correct ventilation rate during PPV for a newborn?

60–80 breaths per minute
10–15 breaths per minute
40–60 breaths per minute (Correct answer)
20–30 breaths per minute

Correct answer: 40–60 breaths per minute

PPV should be delivered at 40–60 breaths per minute during neonatal resuscitation.

Question 15: What is the acronym MR SOPA used for in NRP?

Steps to transition from PPV to free-flow oxygen
Steps to prepare the resuscitation area
Steps to correct ineffective PPV (Correct answer)
Steps to place an endotracheal tube

Correct answer: Steps to correct ineffective PPV

MR SOPA (Mask adjustment, Reposition airway, Suction, Open mouth, Pressure increase, Airway alternative) guides correction of ineffective PPV.

Question 16: Which statement best reflects NRP guidance on resuscitation of neonates with lethal anomalies?

All anomalies should be treated equally regardless of prognosis
Resuscitation is generally not indicated for conditions universally fatal in the neonatal period (Correct answer)
Parents have no role in decisions about lethal anomalies
Full resuscitation must always be attempted regardless of diagnosis

Correct answer: Resuscitation is generally not indicated for conditions universally fatal in the neonatal period

NRP guidance states that resuscitation is generally not indicated for conditions that are universally fatal in the neonatal period, such as confirmed anencephaly.

Question 17: A 3.2 kg newborn requires IV epinephrine during resuscitation. Using the dose of 0.02 mg/kg, what is the correct volume of 1:10,000 epinephrine to administer?

0.64 mL (Correct answer)
3.2 mL
0.32 mL
0.032 mL

Correct answer: 0.64 mL

Dose = 0.02 mg/kg × 3.2 kg = 0.064 mg. Volume = 0.064 mg ÷ 0.1 mg/mL (1:10,000) = 0.64 mL.

Question 18: What is the first corrective step in MR SOPA?

Mask adjustment (Correct answer)
Suction the mouth and nose
Open the mouth
Reposition the airway

Correct answer: Mask adjustment

The first step is to adjust the mask to achieve a proper seal on the face before moving to other corrective measures.

Question 19: A newborn receives 30 seconds of PPV with no improvement in heart rate. What is the next step?

Immediately start chest compressions
Verify adequate chest rise and apply MR SOPA if needed (Correct answer)
Call for intubation without further assessment
Switch to 100% oxygen immediately

Correct answer: Verify adequate chest rise and apply MR SOPA if needed

If heart rate does not rise after 30 seconds of PPV, the provider must verify chest rise and apply MR SOPA corrective steps before escalating.

Question 20: What specific precaution should be taken when using a warming mattress for a preterm infant in the delivery room?

The warming mattress should be pre-cooled to prevent overheating
Do not use a warming mattress in combination with a polyethylene wrap — it may cause hyperthermia
The warming mattress can be used under the polyethylene wrap but temperature should be monitored to prevent hyperthermia (Correct answer)
Warming mattresses are only appropriate for infants greater than 28 weeks gestation

Correct answer: The warming mattress can be used under the polyethylene wrap but temperature should be monitored to prevent hyperthermia

Chemical warming mattresses can be used in combination with polyethylene wrap and radiant warmer in very preterm infants, but their combined use may cause hyperthermia. Temperature must be continuously monitored to stay within the target 36.5–37.5°C range.

Question 21: What is the recommended approach for delayed cord clamping (DCC) in a preterm infant who requires immediate resuscitation in the delivery room?

DCC is absolutely contraindicated in any preterm infant requiring resuscitation
DCC should always be performed for a minimum of 3 minutes in preterm infants
DCC is only beneficial for infants greater than 32 weeks and is not recommended for very preterm infants
DCC of at least 30–60 seconds may be considered if the infant can be stabilized at the bedside; individualize based on clinical condition (Correct answer)

Correct answer: DCC of at least 30–60 seconds may be considered if the infant can be stabilized at the bedside; individualize based on clinical condition

For preterm infants requiring resuscitation, DCC of 30–60 seconds may be performed if initial stabilization can be done at the bedside. If the infant is severely compromised and immediate resuscitation is critical, the decision must be individualized.

Question 22: What is the preferred technique for chest compressions during neonatal resuscitation?

Two-finger technique
Heel-of-hand technique
Two-thumb encircling technique (Correct answer)
One-hand technique

Correct answer: Two-thumb encircling technique

The two-thumb encircling technique generates higher peak systolic pressures and is preferred over the two-finger technique.

Question 23: What volume expander is recommended for neonatal hypovolemia during resuscitation?

Normal saline (0.9% NaCl) at 10 mL/kg IV over 5–10 minutes (Correct answer)
Lactated Ringer's at 20 mL/kg bolus
D10W at 2 mL/kg
5% albumin at 20 mL/kg

Correct answer: Normal saline (0.9% NaCl) at 10 mL/kg IV over 5–10 minutes

Normal saline at 10 mL/kg administered IV over 5–10 minutes is the recommended volume expander in neonatal resuscitation.

Question 24: Which of the following represents appropriate oxygen management for a term newborn who is breathing spontaneously but has an SpO2 of 72% at 3 minutes of life?

Apply free-flow supplemental oxygen and reassess SpO2
Observe without intervention — this SpO2 is within normal range at 3 minutes (Correct answer)
Intubate the infant and ventilate with 50% oxygen
Immediately start PPV with 100% oxygen

Correct answer: Observe without intervention — this SpO2 is within normal range at 3 minutes

The NRP target SpO2 at 3 minutes is 70–75%. An SpO2 of 72% at 3 minutes is within target. No intervention beyond observation is needed for a spontaneously breathing infant whose SpO2 is meeting targets.

Question 25: In which clinical scenario would it be appropriate to use 100% oxygen during neonatal resuscitation despite NRP's standard recommendation to start at lower FiO2?

A term infant with SpO2 of 60% at 1 minute
Any infant whose Apgar score is below 5 at 1 minute
An infant receiving CPR for heart rate below 60 bpm despite PPV (Correct answer)
A preterm infant at 28 weeks needing intubation

Correct answer: An infant receiving CPR for heart rate below 60 bpm despite PPV

NRP recommends considering 100% oxygen during active CPR for heart rate below 60 bpm, as the priority in cardiac arrest is maximizing oxygen delivery. Wean as quickly as possible once circulation is restored.

Question 26: What is the role of CO₂ detectors in the presence of extremely poor cardiac output?

They may give a false negative (no color change) even with correct tracheal placement (Correct answer)
They consistently show positive CO₂ regardless of placement
They are more reliable than in normal perfusion states
They detect only esophageal placement accurately

Correct answer: They may give a false negative (no color change) even with correct tracheal placement

In severe bradycardia or cardiac arrest, little CO₂ may be exhaled, causing a false-negative reading even with correct tracheal tube position.

Question 27: Which of the following scenarios during birth transition would MOST likely require immediate resuscitative intervention?

A term infant who cries immediately, has good tone, and develops pink color by 2 minutes
A term infant who is mildly cyanotic at 1 minute with a heart rate of 110 bpm and regular breathing
A preterm infant at 36 weeks who requires 30 seconds of stimulation before initiating spontaneous breathing
A term infant with Apgar score of 2 at 1 minute who remains apneic with no tone (Correct answer)

Correct answer: A term infant with Apgar score of 2 at 1 minute who remains apneic with no tone

An apneic, hypotonic term infant with an Apgar of 2 at 1 minute represents failure of the birth transition and requires immediate positive-pressure ventilation and further resuscitation.

Question 28: What is the primary concern when resuscitating an infant with suspected hydrops fetalis?

Polycythemia causing airway obstruction
Hyperkalemia requiring emergent treatment
Skin fragility limiting chest compressions
Pleural effusions and ascites impair lung expansion and may require drainage (Correct answer)

Correct answer: Pleural effusions and ascites impair lung expansion and may require drainage

Hydrops is associated with large pleural effusions and ascites that significantly reduce lung volumes and may require needle thoracentesis.

Question 29: What should be used to achieve correct head positioning when the newborn has a large occiput?

A cervical collar
A thick neck pillow
No modification is needed
A small shoulder roll (Correct answer)

Correct answer: A small shoulder roll

Placing a small roll under the shoulders compensates for the large occiput and maintains the sniffing position.

Question 30: Which newborn population is generally considered a contraindication for therapeutic hypothermia?

Infants with Apgar score ≤3 at 5 minutes
Preterm infants <36 weeks gestational age (Correct answer)
Infants with pH <7.0 on cord blood gas
Term infants (≥36 weeks) with moderate HIE

Correct answer: Preterm infants <36 weeks gestational age

Therapeutic hypothermia is contraindicated in preterm infants <36 weeks because clinical trials establishing its safety and efficacy were conducted exclusively in term and near-term infants.

Question 31: Why is an endotracheal tube preferred over a mask when chest compressions are required?

It allows higher oxygen concentrations than a mask
It is required by NRP protocol for all compressions
It prevents gastric distension better than a mask
It provides a secure airway and more reliable ventilation during coordinated compressions (Correct answer)

Correct answer: It provides a secure airway and more reliable ventilation during coordinated compressions

An ETT secures the airway, prevents mask leak, and ensures effective ventilation that is synchronized with compressions.

Question 32: How is PPV effectiveness best assessed during neonatal resuscitation?

Oxygen saturation alone
Color change from blue to pink
Carbon dioxide detector color change only
Rising heart rate and visible chest rise (Correct answer)

Correct answer: Rising heart rate and visible chest rise

The most reliable indicators of effective PPV are a rising heart rate and appropriate chest rise with each breath.

Question 33: How long should an intubation attempt last before pausing to ventilate?

No more than 60 seconds
No more than 30 seconds (Correct answer)
Until SpO₂ falls below 80%
Until the tube is placed regardless of time

Correct answer: No more than 30 seconds

Each intubation attempt should be limited to 30 seconds; if unsuccessful, resume PPV before retrying.

Question 34: Which three questions should be answered at every birth to determine if resuscitation may be needed?

Gestational age, weight, and heart rate
Weight, Apgar score, and oxygen saturation
Heart rate, color, and temperature
Gestational age, tone, and breathing/crying (Correct answer)

Correct answer: Gestational age, tone, and breathing/crying

The NRP initial assessment asks: Is the baby term gestation, has good muscle tone, and is breathing or crying?

Question 35: In the fetus, what is the primary function of the foramen ovale?

Allowing oxygenated blood from the placenta to bypass the lungs by shunting from right to left atrium (Correct answer)
Connecting the pulmonary artery to the aorta to bypass the lungs
Draining blood from the portal circulation to the inferior vena cava
Providing a pathway for blood to flow from the left ventricle to the right atrium

Correct answer: Allowing oxygenated blood from the placenta to bypass the lungs by shunting from right to left atrium

The foramen ovale allows oxygenated blood returning from the placenta via the umbilical vein and inferior vena cava to bypass the pulmonary circulation by shunting from the right atrium to the left atrium.

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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