Neonatal Resuscitation — MCQs
Which of the following is NOT included in the resuscitation of a neonate with HR < 60/min?
A preterm infant with poor respiration at birth starts throwing seizures at 10 hours after birth. Antiepileptic of choice shall be:
In a newborn, chest compressions should be started if the heart rate is less than?
IV dose of 1:10,000 concentration of epinephrine in a 2 kg preterm baby is:
According to neonatal resuscitation protocol, how much oxygen to give in a term neonate with apnea and bradycardia initially?
A term neonate, with a birth weight of 2700 g, who is otherwise well, and is exclusively breastfed, presents for routine evaluation. His total serum bilirubin is found to be 14mg/dl on day 5. What is the management?
Most common cause of neonatal diarrhea worldwide is:
Erythematous blotchy rash is seen on the abdomen, trunk, and face of a 3-day-old child along with yellowish papules. The child appears well. What is the appropriate management?
A neonate with micrognathia has episodes of cyanosis while feeding. Best management is:
What is the average weight gain of the neonate per day after the initial weight loss period?
Neonatal Resuscitation Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is NOT included in the resuscitation of a neonate with HR < 60/min?
- A. Endotracheal tube intubation
- B. Chest compression
- C. Adrenaline
- D. None of the above (Correct Answer)
Explanation: ***None of the above*** - All listed interventions—**endotracheal tube intubation**, **chest compressions**, and **adrenaline administration**—are standard components of neonatal resuscitation when the heart rate remains below 60 beats/min despite initial steps. - This question asks which is *NOT* included, implying that all options are, in fact, appropriate interventions in this critical scenario. *Endotracheal tube intubation* - This is a critical step in **securing the airway** and ensuring effective positive pressure ventilation when other methods fail or prolonged mechanical ventilation is anticipated. - It's indicated if the heart rate remains below 60 bpm despite adequate bag-mask ventilation and chest compressions. *Chest compression* - **Chest compressions** are initiated when the heart rate is less than 60 bpm *after* 30 seconds of effective positive pressure ventilation. - They are used in conjunction with positive pressure ventilation to improve cardiac output and myocardial perfusion. *Adrenaline* - **Adrenaline** is administered if the heart rate remains below 60 bpm *despite* adequate ventilation and chest compressions. - It acts as a potent **vasopressor** and **cardiac stimulant**, increasing heart rate and contractility.
Question 2: A preterm infant with poor respiration at birth starts throwing seizures at 10 hours after birth. Antiepileptic of choice shall be:
- A. Phenobarbitone (Correct Answer)
- B. Lorazepam
- C. Levetiracetam
- D. Phenytoin
Explanation: ***Phenobarbitone*** - **Phenobarbitone** is the **first-line antiepileptic drug** recommended for neonatal seizures due to its established efficacy and safety profile in this population. - It acts primarily by **potentiating GABAA receptor-mediated chloride currents**, leading to central nervous system depression and seizure control. *Lorazepam* - While **benzodiazepines** like lorazepam can be used for acute seizure cessation, especially status epilepticus, they are generally **not the first-line choice for maintenance therapy** due to potential sedation and respiratory depression in neonates. - Its short duration of action and risk of rebound seizures make it less suitable as a sole agent for ongoing seizure control. *Levetiracetam* - **Levetiracetam** is an increasingly common antiepileptic in neonates, but its long-term efficacy and safety, particularly regarding neurodevelopmental outcomes, are **still under investigation** compared to phenobarbitone. - While it may be used as a second-line agent or in specific situations, it is **not universally considered the first-line drug of choice** for neonatal seizures. *Phenytoin* - **Phenytoin** is typically considered a **second-line or third-line antiepileptic** for neonatal seizures, primarily used if phenobarbitone is ineffective. - Its use is limited by potential side effects such as **cardiac arrhythmias, hypotension, and infiltration at the injection site**, which can be particularly concerning in premature infants.
Question 3: In a newborn, chest compressions should be started if the heart rate is less than?
- A. < 40/min
- B. < 60/min (Correct Answer)
- C. < 120/min
- D. < 100/min
Explanation: ***< 60/min*** - According to **Neonatal Resuscitation Program (NRP)** guidelines, chest compressions are initiated in newborns if the heart rate remains **below 60 beats per minute** despite 30 seconds of effective positive pressure ventilation. - This threshold indicates severe bradycardia and inadequate cardiac output, necessitating direct cardiac support. *< 120/min* - A heart rate of **120 beats per minute** is within the normal range for a newborn and does not warrant chest compressions. - Interventions like positive pressure ventilation are usually sufficient for heart rates below normal but above 60 bpm. *< 100/min* - If the newborn's heart rate is **below 100 beats per minute** but **above 60 bpm**, the primary intervention is to continue and optimize **positive pressure ventilation (PPV)**. - Chest compressions are not typically initiated unless the heart rate drops further and remains below 60 bpm despite effective ventilation. *< 40/min* - A heart rate of **less than 40 beats per minute** in a newborn is a critical finding that would certainly warrant chest compressions, but it is not the **threshold for initiation**. - Chest compressions should have already been started once the heart rate fell below 60 bpm.
Question 4: IV dose of 1:10,000 concentration of epinephrine in a 2 kg preterm baby is:
- A. 0.1 ml
- B. 0.3 ml
- C. 0.2 ml (Correct Answer)
- D. 0.4 ml
Explanation: ***0.2 ml*** - The recommended **IV dose of 1:10,000 epinephrine** for neonatal resuscitation is **0.01 to 0.03 mg/kg**. - For a 2 kg baby: dose range = 0.02 to 0.06 mg - Since 1:10,000 epinephrine contains **0.1 mg/mL**, a dose of **0.2 mL delivers 0.02 mg** (0.01 mg/kg) - This represents the **recommended starting dose** at the lower end of the therapeutic range, which is preferred in neonatal resuscitation to minimize adverse effects while ensuring efficacy. *0.1 ml* - This volume delivers **0.01 mg** (0.005 mg/kg for a 2 kg infant) - This is **below the recommended minimum dose** of 0.01 mg/kg and would be **sub-therapeutic** - Insufficient for effective neonatal resuscitation *0.3 ml* - This volume delivers **0.03 mg** (0.015 mg/kg for a 2 kg infant) - This falls **within the recommended range** but is at the **mid-range** dose - While acceptable, the lower starting dose (0.2 mL) is typically preferred initially, with subsequent doses adjusted based on response *0.4 ml* - This volume delivers **0.04 mg** (0.02 mg/kg for a 2 kg infant) - This falls **within the recommended range** (0.01-0.03 mg/kg) and represents an appropriate therapeutic dose - However, **0.2 mL (0.01 mg/kg) is the standard initial dose** recommended by NRP (Neonatal Resuscitation Program) guidelines, making it the preferred answer for initial administration
Question 5: According to neonatal resuscitation protocol, how much oxygen to give in a term neonate with apnea and bradycardia initially?
- A. 100%
- B. 21% (Correct Answer)
- C. 50%
- D. 30%
Explanation: ***21%*** - According to **NRP (Neonatal Resuscitation Program) 2020 guidelines**, for **term neonates (≥35 weeks gestation)** requiring resuscitation, the initial recommendation is to use **room air (21% oxygen)** to minimize the risk of hyperoxia and oxidative injury. - Multiple randomized controlled trials have demonstrated that room air is as effective as 100% oxygen for initial resuscitation. - Supplemental oxygen is only added if **oxygen saturation targets** are not met despite adequate ventilation, and should be titrated using **pulse oximetry**. *30%* - This concentration is **higher than room air** and is not the initial recommendation for term neonates needing resuscitation. - Starting with a higher oxygen concentration can lead to **oxidative stress** without immediate benefit. - Higher initial concentrations (21-30%) are reserved for **preterm neonates (<35 weeks)**. *100%* - Administering **100% oxygen** can be harmful to a neonate, potentially causing **oxidative injury** to developing organs, including the lungs, brain, and retina. - This was the old practice but has been **discontinued** based on evidence showing increased mortality and morbidity. - High concentrations are no longer recommended even in severe cases; oxygen should be titrated to saturation targets. *50%* - While lower than 100%, 50% oxygen is still **not the initial recommended concentration** for term neonates in resuscitation protocols. - The goal is to start with **21% oxygen** and gradually increase based on **pulse oximetry monitoring** and target saturation ranges if 21% is insufficient.
Question 6: A term neonate, with a birth weight of 2700 g, who is otherwise well, and is exclusively breastfed, presents for routine evaluation. His total serum bilirubin is found to be 14mg/dl on day 5. What is the management?
- A. No active treatment required (Correct Answer)
- B. Stop breastfeeding for 2 days
- C. Phototherapy
- D. Exchange transfusion
Explanation: ***No active treatment required*** - A total serum bilirubin of **14 mg/dL** on day 5 in an otherwise well, exclusively breastfed term neonate (birth weight 2700g, which is >2500g) falls within the **physiologic jaundice range** and below thresholds for intervention. - This level is considered **normal for breastfed infants** at this age and does not warrant medical intervention as per current guidelines. *Stop breastfeeding for 2 days* - This intervention, known as **breast milk jaundice interruption**, is usually reserved for higher bilirubin levels or if there is concern for significant breast milk jaundice, which is not indicated here. - Temporarily stopping breastfeeding can disrupt the establishment of breastfeeding and is generally discouraged unless strictly necessary. *Phototherapy* - **Phototherapy** is indicated for bilirubin levels typically >15-18 mg/dL in a healthy term neonate on day 5, depending on risk factors, which this infant does not meet. - It works by converting unconjugated bilirubin into water-soluble isomers that can be excreted more easily. *Exchange transfusion* - **Exchange transfusion** is reserved for severe hyperbilirubinemia, usually with bilirubin levels approaching or exceeding 20-25 mg/dL, especially if there are signs of **acute bilirubin encephalopathy**. - This level is far below the threshold for such an invasive procedure.
Question 7: Most common cause of neonatal diarrhea worldwide is:
- A. E. coli
- B. Salmonella
- C. Rotavirus (Correct Answer)
- D. Shigella
Explanation: ***Rotavirus*** - **Rotavirus** is the **most common cause of severe acute diarrhea in infants and young children worldwide**, including the neonatal period. - It is responsible for significant morbidity and mortality, particularly in **developing countries** with limited access to clean water and sanitation. - The virus causes **watery diarrhea, vomiting, and dehydration**, which can be life-threatening in neonates. - **WHO** recognizes Rotavirus as the leading cause of severe diarrheal disease in children under 5 years globally. - Vaccination programs (Rotavac, Rotarix) have reduced incidence but it remains the predominant pathogen. *E. coli* - **Enteropathogenic E. coli (EPEC)** and **Enterotoxigenic E. coli (ETEC)** are important causes of neonatal diarrhea, especially in resource-limited settings. - EPEC causes diarrhea through attachment and effacement of intestinal mucosa. - ETEC is a major cause of traveler's diarrhea and endemic diarrhea in developing countries. - While significant, E. coli is the **most common bacterial cause** but not the overall most common cause when viruses are included. *Salmonella* - **Salmonella** causes gastroenteritis but is more common in **older infants and children**. - Often associated with **foodborne outbreaks**, fever, and sometimes bloody diarrhea. - Less frequent as a primary cause of neonatal diarrhea compared to Rotavirus or E. coli. *Shigella* - **Shigella** typically causes **dysentery (bloody diarrhea)** and is more common in **children over 6 months**. - Requires a lower infectious dose but is less prevalent in the immediate neonatal period. - Associated with poor hygiene and fecal-oral transmission in older children.
Question 8: Erythematous blotchy rash is seen on the abdomen, trunk, and face of a 3-day-old child along with yellowish papules. The child appears well. What is the appropriate management?
- A. Topical steroid and antibiotic lotion
- B. Topical steroid cream
- C. Intravenous antibiotics
- D. No treatment (Correct Answer)
Explanation: ***No treatment (Correct Answer)*** The described symptoms—erythematous blotchy rash with yellowish papules on the abdomen, trunk, and face in a well-appearing 3-day-old neonate—are **classic for erythema toxicum neonatorum**. **Key Features:** - **Benign, self-limiting rash** of unknown etiology - Affects **50-70% of term newborns** - Typically appears on **days 2-5** of life - Characterized by **erythematous macules/patches** with overlying **yellowish-white papules/pustules** - Infant appears **well and thriving** - **Resolves spontaneously** within 1-2 weeks without treatment - Histology shows **eosinophils** in pustules **Management:** Reassurance to parents; no medical intervention required. --- *Topical steroid and antibiotic lotion (Incorrect)* This approach is inappropriate because erythema toxicum neonatorum is: - **Not an infection** (no bacterial or fungal cause) - **Not an inflammatory condition** requiring steroids - Misdiagnosis and overtreatment could lead to unnecessary side effects, antibiotic resistance, and mask other conditions --- *Topical steroid cream (Incorrect)* Topical steroids are: - **Unnecessary** for this benign, self-resolving condition - **Potentially harmful** in neonates (can cause skin atrophy, increased absorption) - Provide **no therapeutic benefit** for erythema toxicum neonatorum --- *Intravenous antibiotics (Incorrect)* Systemic antibiotics are: - **Entirely unwarranted** as this is a non-infectious, benign rash - Would represent **gross overtreatment** with significant risks - Contribute to **antibiotic resistance** - Carry risks of adverse reactions, disruption of normal flora, and unnecessary hospitalization **Differentials to consider (but not present here):** - Transient neonatal pustular melanosis (present at birth) - Neonatal acne (appears later, at 2-4 weeks) - Miliaria (smaller, clear vesicles) - Infectious causes (infant appears ill, requires septic workup)
Question 9: A neonate with micrognathia has episodes of cyanosis while feeding. Best management is:
- A. CPAP
- B. Tracheostomy
- C. Prone positioning (Correct Answer)
- D. Tongue-lip adhesion
Explanation: ***Prone positioning*** - **Prone positioning** helps move the tongue forward, preventing it from obstructing the airway in neonates with **micrognathia** and glossoptosis. - This simple maneuver can alleviate symptoms like **cyanosis during feeding** by improving respiratory airflow. *CPAP* - **Continuous Positive Airway Pressure (CPAP)** is primarily used for newborns with respiratory distress syndrome or severe apnea. - While it can help maintain airway patency, it is generally considered a more invasive intervention than positioning for **isolated glossoptosis** due to micrognathia. *Tracheostomy* - **Tracheostomy** is an invasive surgical procedure reserved for severe, persistent airway obstruction that cannot be managed by less invasive means. - It is not the first-line treatment for a neonate with **feeding-related cyanosis** due to micrognathia unless other interventions have failed. *Tongue-lip adhesion* - **Tongue-lip adhesion** is a surgical procedure to physically secure the tongue forward, typically used for more severe cases of **glossoptosis** that do not respond to conservative measures. - It is a more permanent and invasive solution than prone positioning and would not be the initial management choice.
Question 10: What is the average weight gain of the neonate per day after the initial weight loss period?
- A. 5-10 g
- B. 25-30 g (Correct Answer)
- C. 50-60 g
- D. 100-150 g
Explanation: ***25-30 g*** - After the initial physiological weight loss (typically 5-10% of birth weight in the first few days), healthy term neonates should gain approximately **25-30 grams per day**. - This consistent weight gain indicates adequate feeding and healthy development in the first month of life. *5-10 g* - This range is too low for the average daily weight gain after the initial weight loss period. - A gain of only **5-10 g per day** would suggest inadequate feeding or an underlying medical issue. *50-60 g* - This rate of weight gain is typically seen in **older infants** (e.g., 2-3 months of age) or in cases of catch-up growth, not usually in the immediate neonatal period after initial weight loss. - While rapid growth can occur, 50-60 g/day is above the average for a neonate. *100-150 g* - This is an **excessively high** rate of daily weight gain for a neonate. - Such rapid weight gain is not typical and could potentially indicate measurement error or an unusual metabolic state.
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