Walsh: Perinatal and Pediatric Respiratory Care, 3rd Edition

Chapter 04: Neonatal Assessment and Resuscitation

Answers to Assessment Questions and Clinical Scenarios

1.	B
Rationale: Heart rate is a critical determinant of the resuscitation sequence and should be more than 100 beats/minute. If the heart rate is less than 100 beats/minute, positive-pressure ventilation should be started immediately. Frequently, effective positive-pressure ventilation alone will result in the heart rate accelerating to more than 100 beats/minute. If the heart rate is 60 beats/minute or less and adequate ventilation is being provided, chest compressions should be initiated immediately. In the case of a heart rate of 80 to 100 beats/minute, assisted ventilation is indicated only if the heart rate continues to be less than 100 beats/minute.
2.	A
Rationale: Immediately after delivery the first step in stabilizing the infant is to place the infant on a preheated radiant warmer before any other interactions.
3.	D
Rationale: Infants who are vigorous at birth (strong respiratory effort, heart rate >100 beats/min, good muscle tone) should not receive tracheal suctioning. Infants who are not vigorous (no or poor respiratory effort, heart rate <100 beats/min, poor muscle tone) may receive direct laryngotracheal suctioning.
4.	D 
Rationale: Heart rate is a critical determinant of the resuscitation sequence and should be more than 100 beats/minute. 
5.	B
Rationale: If the newborn does not respond to the extrauterine environment with a strong cry, good respiratory effort, and the movement of all extremities, the infant requires stimulation. Flicking the bottoms of the feet, gently rubbing the back, and drying with a towel are all acceptable methods of stimulation. Slapping, shaking, spanking, and holding the newborn upside down are contraindicated and potentially dangerous to the infant.
6.	B
Rationale: The Apgar score is an evaluation of newborns based on five factors: heart rate, respiratory effort, muscle tone, reflex irritability, and skin color (see Table 4-1).
7.	A
Rationale: The most important of the signs is heart rate, which indicates life or death. Failure of the heart rate to respond to resuscitation is an ominous prognostic sign. Heart rate appears to be least affected by developmental maturity but may still be inadequate because of developmental difficulties in establishing cardiorespiratory function at birth. In the immediate newborn period, skin color has the weakest correlation with the other four components of the Apgar score.
8.	C
Rationale: If the heart rate is 60 beats/minute or less and adequate ventilation is being provided, chest compressions should be initiated immediately.
9.	B
Rationale: The recommended ventilation rate is from 40 to 60 breaths/minute.
10.	D
Rationale: The flow-inflating (anesthesia) bag inflates only with pressure and flow from a compressed gas source of air, oxygen, or both. Successful use of this type of resuscitation bag requires appropriate gas flow (8 to 10 L/min), correct adjustment of the flow control valve, and careful attention to a tight seal at the face mask. To control all these factors, more training is required than with a self-inflating bag.
11.	C
Rationale: A nasogastric tube to decompress the bowel and allow the lungs to inflate should always be placed in these infants. During resuscitation endotracheal intubation should be performed to minimize overdistention of the stomach resulting from bag–mask ventilation if the infant is clearly unable to sustain adequate ventilation on its own with only the addition of supplemental oxygen.
12.	D
Rationale: Providing adequate ventilation is the primary factor in the effective resuscitation of a neonate. Most neonates will respond once ventilation is established. After 30 seconds of effective positive-pressure ventilation with 100% O2, if the heart rate remains less than 60 beats/minute, begin chest compressions.
13.	A
Rationale: Epinephrine is given either intravenously or through an endotracheal tube, although the intravenous route is strongly preferred.
14.	B
Rationale: Research shows that infants with no heart beat or respiratory effort after 10 minutes of resuscitative effort have high rates of mortality, or if they survive high rates of severe neurological damage and developmental delay. “After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life” (Kattwinkel J et al: Pediatrics 2006;117:E1029).