NRP Neonatal Resuscitation Program Exam — Questions and Answers

Question 1: Hyperthermia (temperature >38°C) during or after neonatal resuscitation is associated with which outcome?

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

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 2: What clinical sign distinguishes a newborn with primary apnea from one with secondary apnea?

Secondary apnea responds to stimulation; primary apnea requires PPV
Primary apnea responds to stimulation; secondary apnea does not and requires PPV (Correct answer)
Only laboratory tests can distinguish them
Both respond equally to stimulation

Correct answer: Primary apnea responds to stimulation; secondary apnea does not and requires PPV

Primary apnea responds to stimulation and increased oxygen, whereas secondary apnea will not resume with stimulation and requires PPV.

Question 3: What should be done if cardiac monitoring (ECG) is unavailable during compressions?

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

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 4: A newborn with a large omphalocele requires which modification to the initial resuscitation setup?

Applying compression to reduce the hernia before PPV
Covering the defect with a sterile, moist dressing and avoiding compression (Correct answer)
Placing the infant prone to protect the defect
Immediate surgical repair before initiating resuscitation

Correct answer: Covering the defect with a sterile, moist dressing and avoiding compression

The exposed viscera must be covered with a warm, moist sterile dressing to prevent desiccation and heat loss during resuscitation.

Question 5: What is the role of CO₂ detectors in the presence of extremely poor cardiac output?

They are more reliable than in normal perfusion states
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 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 6: What is 'gentle' chest rise in the context of PPV for preterm infants, and why is it important?

Slight, visible chest rise described as a gentle movement of the chest — indicates appropriate tidal volume without overdistension (Correct answer)
Chest rise equivalent to that seen in a normal adult breath
Vigorous chest expansion to ensure adequate tidal volume delivery
Chest movement barely perceptible — any visible movement indicates excessive tidal volume

Correct answer: Slight, visible chest rise described as a gentle movement of the chest — indicates appropriate tidal volume without overdistension

NRP recommends aiming for slight, visible chest rise ('a gentle wiggle') during PPV for preterm infants. Excessive chest rise indicates high tidal volumes that risk volutrauma and BPD.

Question 7: In the context of NRP ethics, 'futility' generally refers to interventions that:

Cannot achieve the intended physiological goal or desired outcome (Correct answer)
Are unavailable at the delivery facility
Are too expensive to justify
Have not been tested in clinical trials

Correct answer: Cannot achieve the intended physiological goal or desired outcome

Medical futility applies when an intervention cannot achieve its intended goal, making continued attempts ethically unjustifiable.

Question 8: What is the purpose of the MRSOPA step 'Airway alternative' in the context of a failed mask?

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

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 9: What is the target preductal SpO2 at 5 minutes of life for a newborn undergoing resuscitation, according to NRP guidelines?

95–100%
80–85% (Correct answer)
60–65%
70–75%

Correct answer: 80–85%

The NRP target SpO2 at 5 minutes of life is 80–85%, reflecting the normal physiological rise from the fetal baseline as the pulmonary circulation opens and ventilation is established.

Question 10: A gastric tube should be inserted during prolonged PPV primarily to:

Decompress the lungs
Provide a route for medication delivery
Monitor gastric pH during resuscitation
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 11: What is the approximate combined rate of compressions and ventilations per minute during 3:1 CPR?

100 events per minute
80 events per minute
120 events per minute (90 compressions + 30 ventilations) (Correct answer)
150 events per minute

Correct answer: 120 events per minute (90 compressions + 30 ventilations)

The 3:1 ratio at the correct pace delivers 90 compressions and 30 ventilations, totaling 120 coordinated events per minute.

Question 12: What is the recommended insertion depth for a UVC in a 3 kg term newborn for emergency delivery room resuscitation?

Exactly 8 cm from the skin level
Calculated using birth weight formula for central placement
Just until blood is freely aspirated (~2–4 cm from the skin) (Correct answer)
Until resistance is met

Correct answer: Just until blood is freely aspirated (~2–4 cm from the skin)

For emergency delivery room use, insert the UVC just until blood can be freely aspirated (~2–4 cm), regardless of birth weight. Precise depth calculation is for elective NICU placement, not emergency access.

Question 13: How deep should sternal compressions be in a newborn?

1–2 cm regardless of chest size
One-half the anterior-posterior diameter
One-third the anterior-posterior diameter of the chest (Correct answer)
Until rib resistance is felt

Correct answer: One-third the anterior-posterior diameter of the chest

Compressions should depress the sternum approximately one-third the anterior-posterior (AP) diameter of the chest.

Question 14: What does the ethical principle of 'non-maleficence' require in neonatal resuscitation?

Distributing resources equally among all neonates
Always attempting resuscitation regardless of outcome
Respecting parental autonomy above all else
Avoiding interventions that cause more harm than benefit (Correct answer)

Correct answer: Avoiding interventions that cause more harm than benefit

Non-maleficence requires that clinicians avoid interventions whose burdens outweigh their benefits, which is central to decisions about resuscitation.

Question 15: Which of the following best describes a 'time-limited trial' in neonatal resuscitation ethics?

Resuscitation is attempted for a fixed duration to assess response before deciding to continue or stop (Correct answer)
A trial of medications is given before intubation
Resuscitation is withheld for a set period before initiating
Comfort care is provided for a fixed time before resuscitation

Correct answer: Resuscitation is attempted for a fixed duration to assess response before deciding to continue or stop

A time-limited trial involves providing resuscitation for a defined period to evaluate response and gather information before making a final decision.

Question 16: Which mechanism of heat loss is MOST significant immediately after birth when an infant is wet from amniotic fluid?

Evaporation (Correct answer)
Radiation
Conduction
Convection

Correct answer: Evaporation

Evaporation of amniotic fluid from the skin surface is the primary and most rapid mechanism of heat loss immediately after birth.

Question 17: Which of the following is NOT an indication for volume expansion during neonatal resuscitation?

Pale skin color with poor pulse volume unresponsive to resuscitation
Suspected cord avulsion with fetal hemorrhage
Suspected blood loss from placenta previa
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 18: 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 19: What is the consequence of a failure to clear lung fluid adequately at birth?

Respiratory alkalosis due to excessive CO2 exhalation
Persistent pulmonary hypertension due to excess oxygen exposure
Immediate cardiac arrest due to hypoxia
Transient tachypnea of the newborn (TTN) or respiratory distress requiring positive pressure support (Correct answer)

Correct answer: Transient tachypnea of the newborn (TTN) or respiratory distress requiring positive pressure support

Retained lung fluid interferes with gas exchange and causes respiratory distress, most commonly presenting as transient tachypnea of the newborn (TTN) in term infants, or requiring PPV in those who cannot clear fluid independently.

Question 20: What is the correct technique for holding the laryngoscope during neonatal intubation?

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

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 21: What role does surfactant play in neonatal lung transition at birth?

Surfactant primarily transports oxygen across the alveolar membrane
Surfactant is produced only after the first breath
Surfactant increases alveolar surface tension to promote drainage of lung fluid
Surfactant reduces alveolar surface tension, preventing alveolar collapse and facilitating FRC (Correct answer)

Correct answer: Surfactant reduces alveolar surface tension, preventing alveolar collapse and facilitating FRC

Surfactant, produced by type II pneumocytes, reduces alveolar surface tension, preventing alveolar collapse (atelectasis) at end-expiration and reducing the work of breathing needed to establish and maintain FRC.

Question 22: What should the resuscitation team do if a newborn's SpO2 is consistently above the NRP target range during resuscitation?

Do nothing — SpO2 above target is always beneficial
Increase the respiratory rate to remove the excess oxygen
Add PEEP to the ventilation circuit
Wean the supplemental oxygen (FiO2) to bring SpO2 back into the target range (Correct answer)

Correct answer: Wean the supplemental oxygen (FiO2) to bring SpO2 back into the target range

If SpO2 exceeds the NRP target range, supplemental oxygen should be decreased (FiO2 weaned), since hyperoxia is harmful. The goal is to maintain SpO2 within the physiological target range, not maximize it.

Question 23: What is the role of catecholamines (epinephrine, norepinephrine) released during the birth process in neonatal transition?

They cause pulmonary vasoconstriction to maintain fetal circulation longer
They promote lung fluid clearance, surfactant release, and cardiovascular adaptation to extrauterine life (Correct answer)
They suppress respiratory drive to prevent hyperventilation at birth
They stimulate the foramen ovale to close more rapidly

Correct answer: They promote lung fluid clearance, surfactant release, and cardiovascular adaptation to extrauterine life

The catecholamine surge during labor and delivery promotes lung fluid absorption, stimulates surfactant secretion from type II pneumocytes, increases heart rate and cardiac output, and mobilizes fuel substrates to support the transition to extrauterine life.

Question 24: What is the T-piece resuscitator's main advantage over a self-inflating bag?

Provides higher maximum pressures
Does not require a gas source
Automatically adjusts oxygen concentration
Delivers consistent, adjustable PIP and PEEP with less provider fatigue (Correct answer)

Correct answer: Delivers consistent, adjustable PIP and PEEP with less provider fatigue

The T-piece resuscitator delivers consistent, preset PIP and PEEP with each breath, reducing variability caused by hand fatigue.

Question 25: What initial PEEP (positive end-expiratory pressure) is recommended when providing positive-pressure ventilation to a preterm infant?

10 cmH2O
5 cmH2O (Correct answer)
0 cmH2O (no PEEP)
15 cmH2O

Correct answer: 5 cmH2O

NRP recommends providing PEEP of 5 cmH2O during PPV for preterm infants to maintain alveolar recruitment and functional residual capacity, given their surfactant deficiency and tendency for atelectasis.

Question 26: What is the correct landmark for intraosseous needle insertion in a neonate?

The iliac crest, just posterior to the anterior superior iliac spine
The lateral surface of the femur, 1 cm above the lateral condyle
The flat, medial surface of the proximal tibia, approximately 1–2 cm below the tibial tuberosity (Correct answer)
The posterior surface of the calcaneus at the heel

Correct answer: The flat, medial surface of the proximal tibia, approximately 1–2 cm below the tibial tuberosity

The preferred site for IO insertion in neonates is the flat, medial surface of the proximal tibia, approximately 1–2 cm distal (below) to the tibial tuberosity — a site with minimal overlying tissue and a broad, flat marrow cavity.

Question 27: When can free-flow oxygen be delivered with a self-inflating bag?

By holding the mask loosely over the face
By opening the inlet valve
It cannot deliver free-flow oxygen reliably (Correct answer)
Only when attached to a reservoir bag

Correct answer: It cannot deliver free-flow oxygen reliably

A self-inflating bag does not deliver reliable free-flow oxygen because the inlet valve remains closed unless the bag is squeezed.

Question 28: Which of the following methods can help prevent cold stress in a preterm infant less than 32 weeks in the delivery room?

Oral glucose to prevent metabolic cold response
Polyethylene wrap, prewarmed delivery room (25–26°C), prewarmed radiant warmer, and chemical warming mattress (Correct answer)
Immediate intubation to allow warming via heated humidified gases
Vigorous drying followed by warm blankets

Correct answer: Polyethylene wrap, prewarmed delivery room (25–26°C), prewarmed radiant warmer, and chemical warming mattress

A bundle of interventions is recommended: polyethylene wrap/bag (without drying), prewarmed radiant warmer, room temperature ≥25–26°C, and a chemical warming mattress for the most premature infants.

Question 29: 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
Gestational age, tone, and breathing/crying (Correct answer)
Heart rate, color, and temperature

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

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

Correct answer: 40–60 breaths per minute

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

Question 31: Five minutes after birth, what is the targeted pre-ductal SPO2 level?

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

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 32: 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 followed by a brief pause for one ventilation, repeated continuously (Correct answer)
Three compressions while simultaneously delivering a breath

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

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

Correct answer: A small shoulder roll

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

Question 34: A newborn receives 30 seconds of PPV with no improvement in heart rate. What is the next step?

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

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

Routine airway for all preterm infants
Alternative airway when intubation fails or is not feasible in ≥34-week infants (Correct answer)
Airway for infants requiring chest compressions
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.

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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