Initial Newborn Assessment and Care: the First Questions, Warm-dry-stimulate, Apgar, and Thermoregulation Practice Questions

25 multiple-choice questions on Initial newborn assessment and care: the first questions, warm-dry-stimulate, Apgar, and thermoregulation for paramedic and EMT students, from Chapter 43 (Neonatal Care). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. Immediately after birth, the three rapid questions that decide whether a newborn needs resuscitation steps are:

   1. A. Pink color? Heart rate above 100? Apgar above 7?
   2. B. Term gestation? Good tone? Breathing or crying?
   3. C. Meconium? Cord pulsing? Placenta delivered?
   4. D. Birth weight? Fontanelle? Capillary refill?
   Show answer

   Answer: B. Term gestation? Good tone? Breathing or crying?

   If the infant is term, has good tone, and is breathing or crying, it can stay with the mother for routine care. Color and the Apgar score are not used to decide whether to begin resuscitation, because waiting for them delays the first steps.

2. A term newborn cries vigorously at birth and has good flexed tone. The best place for this infant is:

   1. A. On a warmed stretcher away from the mother
   2. B. Wrapped and held by a crew member
   3. C. In an isolette until the placenta delivers
   4. D. Skin-to-skin on the mother's chest
   Show answer

   Answer: D. Skin-to-skin on the mother's chest

   A vigorous term infant can be dried and placed skin-to-skin with the mother, covered with a dry blanket, which keeps it warm and supports bonding and breastfeeding. Moving a healthy infant away to a stretcher, an isolette, or a crew member's arms separates it from the mother without any benefit and adds steps that risk heat loss.

3. The initial steps of newborn care, done within the first 30 seconds or so, are:

   1. A. Warm, dry, position, clear the airway, and stimulate
   2. B. Suction deeply, give oxygen, and check a glucose level
   3. C. Clamp the cord, weigh the infant, and assign an Apgar score
   4. D. Ventilate with a mask, then dry and stimulate the infant
   Show answer

   Answer: A. Warm, dry, position, clear the airway, and stimulate

   The initial steps provide warmth, dry the infant, position the airway, clear secretions if needed, and stimulate breathing. Ventilation comes after these steps if the infant remains apneic, gasping, or bradycardic, not before them.

4. When drying a newborn, you should remove the wet towel and replace it with a dry one because:

   1. A. Wet towels can transmit infection to the infant
   2. B. A dry towel stimulates breathing more strongly
   3. C. The wet towel can hide signs of a birth injury
   4. D. Evaporation from wet skin causes rapid heat loss
   Show answer

   Answer: D. Evaporation from wet skin causes rapid heat loss

   Evaporative loss from amniotic fluid on the skin is a major source of cooling in the first minutes. Infection is not the reason; a soaked towel simply keeps the infant wet and cold.

5. A newborn placed on a cold metal stretcher loses heat mainly by:

   1. A. Convection
   2. B. Radiation
   3. C. Conduction
   4. D. Evaporation
   Show answer

   Answer: C. Conduction

   Conduction is direct transfer to a cooler surface in contact with the skin, prevented by a warm blanket underneath. Convection is loss to moving air, such as a draft from an open door.

6. You are delivering in an apartment with an air conditioner blowing across the bed. Turning it off and closing the door mainly prevents heat loss by:

   1. A. Convection
   2. B. Conduction
   3. C. Evaporation
   4. D. Radiation
   Show answer

   Answer: A. Convection

   Convection is loss to moving air currents, so stopping drafts reduces it. Radiation is loss to cooler nearby objects without contact, such as cold windows or walls.

7. Heat loss from a newborn to a cold ambulance wall that the infant is not touching occurs by:

   1. A. Conduction
   2. B. Radiation
   3. C. Convection
   4. D. Evaporation
   Show answer

   Answer: B. Radiation

   Radiant heat moves from the warm infant to cooler objects nearby even without contact, which is why the patient compartment should be warmed before the infant arrives. Conduction requires direct contact with the cold surface.

8. The normal axillary temperature range for a newborn, and the target during care, is:

   1. A. 35.0 to 36.0 °C (95.0 to 96.8 °F)
   2. B. 37.5 to 38.5 °C (99.5 to 101.3 °F)
   3. C. 36.5 to 37.5 °C (97.7 to 99.5 °F)
   4. D. 34.0 to 35.0 °C (93.2 to 95.0 °F)
   Show answer

   Answer: C. 36.5 to 37.5 °C (97.7 to 99.5 °F)

   Guidelines aim to keep newborn temperature between 36.5 and 37.5 °C, avoiding both hypothermia and hyperthermia. A range of 37.5 to 38.5 °C is overheating, which also worsens outcomes, particularly after a hypoxic event.

9. As a cold newborn burns energy to make heat, which pair of problems should you anticipate?

   1. A. Hypoglycemia and alkalosis
   2. B. Hypoglycemia and hypoxia
   3. C. Hypoxia and hyperglycemia
   4. D. Hyperglycemia and alkalosis
   Show answer

   Answer: B. Hypoglycemia and hypoxia

   Nonshivering thermogenesis burns glucose and oxygen, so a cold infant becomes hypoglycemic, hypoxic, and acidotic. Glucose falls rather than rises as stores are used up, and alkalosis is the wrong direction; anaerobic metabolism produces acidosis.

10. To stimulate a newborn that has been dried but is not yet breathing well, you should:

    1. A. Rub the back or flick the soles of the feet
    2. B. Slap the buttocks firmly several times in a row
    3. C. Squeeze the chest to start breathing
    4. D. Blow cold air across the infant's face
    Show answer

    Answer: A. Rub the back or flick the soles of the feet

    Gently rubbing the back, trunk, or extremities or flicking the soles provides adequate tactile stimulation. Vigorous slapping or squeezing is harmful, and if brief stimulation does not work the infant needs ventilation, not stronger stimulation.

11. A newborn remains apneic after 10 to 15 seconds of drying and gentle stimulation. The reason not to continue stimulating is that the infant may be in:

    1. A. Primary apnea, which will end on its own
    2. B. Breath-holding, which needs no action
    3. C. Postictal apnea, which needs glucose
    4. D. Secondary apnea, which needs ventilation
    Show answer

    Answer: D. Secondary apnea, which needs ventilation

    In primary apnea, stimulation may restart breathing, but in secondary apnea it will not, and the two look alike. An apneic infant is therefore assumed to be in secondary apnea, and positive-pressure ventilation is started without further delay.

12. To open the airway of a newborn lying supine, you should place the head in:

    1. A. Full extension with the chin pointed toward the ceiling
    2. B. A neutral sniffing position with a shoulder roll
    3. C. Flexion with the chin resting on the chest
    4. D. A lateral position with the face turned to the floor
    Show answer

    Answer: B. A neutral sniffing position with a shoulder roll

    A small towel under the shoulders offsets the large occiput and aligns the airway. Both hyperextension and flexion can kink the soft trachea and obstruct airflow.

13. When suctioning a newborn with secretions, you should suction:

    1. A. The mouth first, then the nose
    2. B. The nose first, then the mouth
    3. C. Deep into the pharynx first
    4. D. The nose and the mouth together
    Show answer

    Answer: A. The mouth first, then the nose

    Clearing the mouth first prevents aspiration if suctioning the nose triggers a gasp. Deep pharyngeal suctioning is avoided because it can cause a vagal bradycardia and apnea.

14. You are suctioning a newborn's oropharynx with a catheter, and the heart rate drops from 140 to 80 beats/min. The likely cause is:

    1. A. Cold stress from being undressed for care
    2. B. Airway obstruction from mucus
    3. C. Pain from the catheter tip
    4. D. Vagal stimulation from the suction
    Show answer

    Answer: D. Vagal stimulation from the suction

    Stimulation of the posterior pharynx can trigger a vagal response with bradycardia and apnea, so suctioning is brief, gentle, and only as deep as needed. Mucus obstruction would cause hypoxia but not a sudden drop tied to the act of suctioning. Cold stress develops over minutes rather than at the moment of suctioning, and pain tends to speed the heart rather than slow it.

15. The Apgar score is assessed at:

    1. A. Birth and 30 minutes after birth
    2. B. Only at 1 minute after birth
    3. C. 1 and 5 minutes after birth
    4. D. Every 30 seconds for 5 minutes
    Show answer

    Answer: C. 1 and 5 minutes after birth

    Apgar scores are recorded at 1 and 5 minutes, and every 5 minutes after that up to 20 minutes if the 5-minute score is below 7. A single 1-minute score misses the infant's response to care.

16. The Apgar score is best described as a tool that:

    1. A. Decides when to begin resuscitation
    2. B. Records the infant's condition and response
    3. C. Predicts the infant's long-term neurologic outcome
    4. D. Measures the mother's labor progress
    Show answer

    Answer: B. Records the infant's condition and response

    The Apgar score documents how the infant is doing and how it responds to resuscitation. It should not be used to decide whether to start resuscitation; ventilation is started based on breathing and heart rate long before a 1-minute score is assigned.

17. In the Apgar score, the letter G for grimace refers to the infant's:

    1. A. Overall muscle tone and flexion
    2. B. Skin color of the trunk and limbs
    3. C. Reflex response to stimulation
    4. D. Effort and rate of breathing
    Show answer

    Answer: C. Reflex response to stimulation

    Grimace scores reflex irritability, such as a cry or pulling away when the soles are flicked or the nose is suctioned. Muscle tone is scored under A for activity.

18. At 1 minute, a newborn has a pink body with blue extremities, a heart rate of 110 beats/min, a grimace to stimulation, some flexion, and slow, irregular breathing. The Apgar score is:

    1. A. 6
    2. B. 5
    3. C. 7
    4. D. 4
    Show answer

    Answer: A. 6

    Appearance 1 (pink body, blue extremities), pulse 2 (any rate of 100 or more), grimace 1 (a grimace without a cry), activity 1 (some flexion), and respiration 1 (slow, irregular breathing) add up to 6. A score of 5 comes from wrongly giving the heart rate only 1 point; any rate of 100 or more earns the full 2. A score of 7 would need full credit for a sign this infant does not earn, such as a strong cry or active motion. A score of 4 undercounts two of the five signs. The Apgar score records the infant's condition; it does not decide whether to start resuscitation. (ACOG/AAP, The Apgar Score.)

19. At 5 minutes, an infant is completely pink, has a heart rate of 140, cries and pulls away, actively moves, and has a strong cry. The Apgar score is:

    1. A. 9
    2. B. 8
    3. C. 7
    4. D. 10
    Show answer

    Answer: D. 10

    Each of the five components scores 2, for a total of 10. Many healthy infants score 9 because of acrocyanosis, but a completely pink infant earns the full point for appearance.

20. A newborn has a heart rate of 80 beats/min. In the Apgar score, the pulse component is scored as:

    1. A. 0
    2. B. 1
    3. C. 2
    4. D. 3
    Show answer

    Answer: B. 1

    Pulse scores 0 if absent, 1 if below 100, and 2 if 100 or more, so a rate of 80 earns 1 point. No component scores 3; the maximum per item is 2.

21. A newborn's 5-minute Apgar score is 5. According to current practice, you should:

    1. A. Stop scoring once you start care
    2. B. Wait until 30 minutes to rescore
    3. C. Repeat the score every 5 minutes
    4. D. Rescore only if the infant cries
    Show answer

    Answer: C. Repeat the score every 5 minutes

    When the 5-minute score is below 7, scores are repeated every 5 minutes up to 20 minutes to document the response to resuscitation. Scoring does not stop when care begins; it records how the infant responds to it.

22. You have just delivered a term infant in a cold vehicle. Besides drying and skin-to-skin care, the most effective way to reduce heat loss from the head is to:

    1. A. Leave the head damp
    2. B. Wrap the body tightly, leaving the head out
    3. C. Wipe the vernix off with a wet cloth
    4. D. Cover the head with a cap
    Show answer

    Answer: D. Cover the head with a cap

    The head is a large share of the newborn's surface area and loses much heat, so it is dried and covered with a cap or a dry blanket, a simple, effective step. Leaving the head wet or uncovered while the body is dried and wrapped leaves the biggest source of heat loss untreated, and wiping the skin with a wet cloth adds evaporative cooling.

23. You are caring for a vigorous newborn on a 40-minute transport. The patient compartment should be:

    1. A. Warmed before and during transport
    2. B. Kept cool to prevent hyperthermia
    3. C. Kept at the usual cabin temperature setting
    4. D. Ventilated with outside air
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    Answer: A. Warmed before and during transport

    Warming the compartment before the infant arrives, and keeping it warm throughout, reduces radiant and convective losses; set it as warm as the crew can tolerate and check the infant's temperature so you avoid overheating. Keeping the cabin cool to prevent hyperthermia gets the priority backward, because cold stress is by far the more common danger. Usual cabin settings are comfortable for clothed adults but chill a newborn quickly. Outside air brings drafts and cold, increasing convective loss. (WHO thermal protection of the newborn; NRP 9th ed.)

24. A newborn is breathing well and has a heart rate of 130, but the lips and trunk appear blue at 5 minutes. The best next step is to:

    1. A. Check a preductal pulse oximetry reading
    2. B. Begin positive-pressure ventilation
    3. C. Assign an Apgar score and begin transport
    4. D. Begin chest compressions at once
    Show answer

    Answer: A. Check a preductal pulse oximetry reading

    Persistent central cyanosis in a breathing infant with a good heart rate is evaluated with a preductal SpO2 on the right hand, and supplemental oxygen is titrated to the target for the minute of life. Ventilation is for apnea, gasping, or a heart rate under 100, which this infant does not have.

25. When estimating the gestational age of a newborn in the field, a sign that suggests a preterm infant is:

    1. A. Deep creases across the whole sole
    2. B. Cracked, peeling skin with little vernix
    3. C. Thin, translucent skin with visible veins
    4. D. Firm ear cartilage that recoils quickly
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    Answer: C. Thin, translucent skin with visible veins

    Preterm infants have thin, gelatinous skin with visible vessels, few sole creases, soft ears, and more lanugo. Cracked, peeling skin with little vernix is typical of a postterm infant.