Neonatal Emergencies: Apnea, Bradycardia, Respiratory Distress, Airway Anomalies, Diaphragmatic Hernia, Pneumothorax, and Congenital Heart Disease Practice Questions

25 multiple-choice questions on Neonatal emergencies: apnea, bradycardia, respiratory distress, airway anomalies, diaphragmatic hernia, pneumothorax, and congenital heart disease 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. In a newborn, apnea is generally defined as a pause in breathing lasting longer than:

   1. A. 20 seconds, or shorter with bradycardia or cyanosis
   2. B. 5 seconds, even with a normal heart rate and color
   3. C. 60 seconds, if the heart rate and color stay normal
   4. D. 10 seconds, if the pause happens during deep sleep
   Show answer

   Answer: A. 20 seconds, or shorter with bradycardia or cyanosis

   A respiratory pause of more than 20 seconds, or a shorter pause with bradycardia, cyanosis, or pallor, is apnea. Brief pauses of 5 to 10 seconds are normal periodic breathing in newborns.

2. A 2-day-old infant born at 33 weeks has repeated episodes of apnea with the heart rate falling to 70. Initial treatment is:

   1. A. Atropine 0.02 mg/kg IV, repeated once
   2. B. Stimulation, then ventilation
   3. C. Naloxone 0.1 mg/kg IV or IM at once
   4. D. Transcutaneous pacing at 100 beats/min
   Show answer

   Answer: B. Stimulation, then ventilation

   Apnea with bradycardia in a preterm infant is treated by gentle stimulation and, if breathing does not resume, bag-mask ventilation. Atropine and pacing do not treat the cause, which is hypoxia from inadequate breathing.

3. The most common cause of bradycardia in a newborn is:

   1. A. Hypothermia
   2. B. Hypoglycemia
   3. C. Hypoxia
   4. D. Heart block
   Show answer

   Answer: C. Hypoxia

   Newborn bradycardia almost always reflects inadequate oxygenation and ventilation, so the treatment is ventilation. Congenital heart block exists but is rare and still requires ventilation first.

4. Compared with a self-inflating bag, a T-piece resuscitator for newborn ventilation:

   1. A. Runs without an oxygen or air source
   2. B. Delivers a set peak pressure and PEEP
   3. C. Gives a larger tidal volume with each breath
   4. D. Lets you feel lung stiffness through the bag
   Show answer

   Answer: B. Delivers a set peak pressure and PEEP

   A T-piece device uses a gas source to give a preset peak inflation pressure and consistent PEEP each time the opening is covered, which helps preterm lungs. It needs compressed gas to work, unlike a self-inflating bag, and it does not let you feel changes in compliance the way a bag does.

5. An infant delivered by cesarean section at 38 weeks has a respiratory rate of 80 with mild retractions but good saturations and color. This most likely represents:

   1. A. Congenital diaphragmatic hernia on the left
   2. B. Tension pneumothorax
   3. C. Transient tachypnea of the newborn
   4. D. Hypoplastic left heart
   Show answer

   Answer: C. Transient tachypnea of the newborn

   Retained lung fluid, more common after cesarean delivery without labor, causes tachypnea that usually resolves within 24 to 72 hours. A diaphragmatic hernia would cause severe distress, a scaphoid abdomen, and shifted heart sounds.

6. A newborn has severe respiratory distress, a scaphoid (sunken) abdomen, and bowel sounds heard in the left chest. You should suspect:

   1. A. Tracheoesophageal fistula with atresia
   2. B. Meconium aspiration
   3. C. Pyloric stenosis
   4. D. Congenital diaphragmatic hernia
   Show answer

   Answer: D. Congenital diaphragmatic hernia

   Abdominal contents herniating through a defect, usually on the left, leave the abdomen sunken and compress the developing lung. Meconium aspiration causes distress but not a scaphoid abdomen or bowel sounds in the chest.

7. A newborn with a suspected diaphragmatic hernia needs ventilation. You should avoid prolonged bag-mask ventilation because it:

   1. A. Fills the bowel in the chest with air
   2. B. Pushes the bowel back into the belly
   3. C. Causes the diaphragm defect to tear wider
   4. D. Raises the risk of meconium aspiration
   Show answer

   Answer: A. Fills the bowel in the chest with air

   Mask ventilation pushes air into the stomach and intestines that lie in the chest, further compressing the lungs. Positive pressure does not push the bowel back down or enlarge the diaphragmatic defect; the herniated bowel stays in the chest until surgery. Prompt intubation and an orogastric tube to decompress the stomach are preferred.

8. After intubating a newborn with a diaphragmatic hernia, you should also:

   1. A. Press on the abdomen to reduce the hernia
   2. B. Give a fluid bolus of 20 mL/kg before transport
   3. C. Place an orogastric tube to vent the stomach
   4. D. Ventilate at high pressures to expand the lung
   Show answer

   Answer: C. Place an orogastric tube to vent the stomach

   An orogastric tube on low suction keeps the herniated stomach and bowel from filling with air and further compressing the lungs and heart. Pressing on the abdomen cannot push the bowel back through the diaphragm and only raises pressure on the chest. A rapid 20 mL/kg bolus is not routine; volume is given only for signs of shock, at 10 mL/kg. High ventilating pressures injure the underdeveloped lungs and cause pneumothorax, so use the lowest pressure that moves the chest. Transport with the head and chest elevated. (NRP 9th ed.; Caroline, diaphragmatic hernia.)

9. A newborn is cyanotic and struggling while quiet, but becomes pink when crying. The most likely cause is:

   1. A. A cyanotic congenital heart defect
   2. B. Choanal atresia blocking the nose
   3. C. Pneumothorax on the right side
   4. D. Transient tachypnea of the newborn
   Show answer

   Answer: B. Choanal atresia blocking the nose

   Because newborns breathe mainly through the nose, bony or membranous blockage of the posterior nares causes distress at rest that improves when the infant cries and breathes through the mouth. Cyanotic heart disease would not improve with crying.

10. A newborn with choanal atresia is in respiratory distress. The best initial airway management is:

    1. A. An oral airway to keep the mouth open
    2. B. A nasal airway through the blocked naris
    3. C. Deep suctioning through both nostrils
    4. D. Covering the mouth to force nose breathing
    Show answer

    Answer: A. An oral airway to keep the mouth open

    An oral airway or a cut nipple keeps the mouth open so the infant can breathe around the blocked nose. A nasopharyngeal airway cannot pass the atretic choana.

11. A newborn has a very small lower jaw, a tongue that falls back into the throat, and noisy, obstructed breathing. This suggests:

    1. A. Trisomy 21 (Down syndrome)
    2. B. Choanal atresia
    3. C. Croup
    4. D. Pierre Robin sequence
    Show answer

    Answer: D. Pierre Robin sequence

    Pierre Robin sequence combines a small mandible, a tongue displaced toward the back of the throat, and often a cleft palate, causing upper airway obstruction from birth. Trisomy 21 causes a large tongue relative to a small midface and low tone, not a tiny jaw. Choanal atresia blocks the back of the nose and improves when the infant cries and breathes through the mouth. Croup is a viral illness of older infants and toddlers, not a congenital jaw anomaly. (Caroline, neonatal airway anomalies.)

12. The position that most often relieves airway obstruction in an infant with Pierre Robin sequence is:

    1. A. Prone, so the tongue falls forward
    2. B. Supine, with the neck hyperextended
    3. C. Supine, with the head flexed forward
    4. D. Upright, with the head tilted back
    Show answer

    Answer: A. Prone, so the tongue falls forward

    Gravity pulls the tongue and jaw forward when the infant lies prone, opening the airway. Supine positioning lets the tongue fall back and worsens obstruction.

13. During positive-pressure ventilation, a newborn suddenly deteriorates. Breath sounds are diminished on the right, the heart rate is falling, and saturations are dropping. You should suspect:

    1. A. A diaphragmatic hernia
    2. B. A tension pneumothorax
    3. C. Choanal atresia
    4. D. Hypoglycemia
    Show answer

    Answer: B. A tension pneumothorax

    Sudden deterioration with unilateral decreased breath sounds during ventilation suggests a pneumothorax, a known complication of meconium aspiration and high pressures. A diaphragmatic hernia is present from birth and does not appear suddenly during care.

14. A newborn on positive-pressure ventilation develops a suspected tension pneumothorax and is deteriorating rapidly. If allowed by protocol, you should:

    1. A. Increase the inflation pressure to 50 cm H2O or more
    2. B. Give epinephrine 0.1 mg/kg by the ET tube
    3. C. Stop ventilation and give blow-by oxygen
    4. D. Perform needle decompression of the affected side
    Show answer

    Answer: D. Perform needle decompression of the affected side

    A tension pneumothorax compromising circulation is relieved by needle decompression, typically in the fourth intercostal space at the anterior axillary line or second space at the midclavicular line in newborns. Raising the pressure enlarges the air leak.

15. A newborn has a scaphoid abdomen, and breath sounds are absent on the left. The heart sounds are loudest on the right side of the chest. This finding means:

    1. A. The heart is in its normal left position
    2. B. The left lung is fully expanded
    3. C. The mediastinum is shifted to the right
    4. D. The infant has isolated dextrocardia
    Show answer

    Answer: C. The mediastinum is shifted to the right

    Herniated bowel in the left chest pushes the heart and mediastinum to the right, so heart sounds are heard best on the right. Isolated dextrocardia would not explain the absent breath sounds and scaphoid abdomen.

16. A term newborn born after an uneventful labor is breathing comfortably with clear, equal breath sounds, but the lips and trunk stay blue and the SpO2 stays near 75% despite 100% oxygen. This most suggests:

    1. A. A cyanotic congenital heart defect
    2. B. Transient tachypnea of the newborn
    3. C. Acrocyanosis of the hands and feet
    4. D. Meconium aspiration syndrome
    Show answer

    Answer: A. A cyanotic congenital heart defect

    Central cyanosis that barely changes with 100% oxygen points to blood bypassing the lungs. When the infant is breathing comfortably with clear lungs after an uneventful birth, a fixed right-to-left shunt inside the heart is the likely cause; persistent pulmonary hypertension can look similar, but it usually follows meconium aspiration, asphyxia, or sepsis and comes with respiratory distress, and both are confirmed in the hospital by echocardiography. Transient tachypnea causes fast breathing and usually responds to modest oxygen. Acrocyanosis involves only the hands and feet, with a pink trunk and a normal saturation. Meconium aspiration needs a history of meconium and causes obvious distress. (NRP 9th ed., congenital heart disease lesson; AHA/AAP 2025.)

17. A 6-day-old infant is brought in for poor feeding, gray color, cool extremities, and fast breathing. Femoral pulses are weak. The most likely cause is:

    1. A. Bronchiolitis from RSV
    2. B. Transient tachypnea of the newborn
    3. C. Pyloric stenosis with dehydration
    4. D. A ductal-dependent heart lesion
    Show answer

    Answer: D. A ductal-dependent heart lesion

    Lesions such as coarctation or hypoplastic left heart depend on the ductus arteriosus for systemic flow, and they present with shock when it closes in the first days to 2 weeks of life. Weak femoral pulses suggest obstruction to aortic flow. Bronchiolitis causes cough and wheeze without weak femoral pulses, pyloric stenosis usually appears at 3 to 6 weeks with projectile vomiting, and transient tachypnea settles in the first day or two.

18. The hospital medication used to keep the ductus arteriosus open in an infant with a ductal-dependent heart lesion is:

    1. A. Indomethacin IV
    2. B. Prostaglandin E1
    3. C. Epinephrine infusion
    4. D. Adenosine
    Show answer

    Answer: B. Prostaglandin E1

    Prostaglandin E1 (alprostadil) reopens and maintains the ductus to restore flow; apnea is a common side effect, so airway support must be ready. Indomethacin does the opposite and is used to close a patent ductus.

19. An infant with a known cyanotic heart defect whose baseline SpO2 is 78% is breathing comfortably and feeding well. You should:

    1. A. Give 100% oxygen to bring the SpO2 to 100%
    2. B. Begin positive-pressure ventilation
    3. C. Avoid raising the SpO2 far above baseline
    4. D. Begin chest compressions immediately
    Show answer

    Answer: C. Avoid raising the SpO2 far above baseline

    Some infants with cyanotic lesions normally saturate in the 70s or 80s, and high oxygen can close the ductus or upset the balance of pulmonary and systemic flow. Care is guided by the cardiologist's baseline and the infant's comfort.

20. A 2-week-old has an SVT with a heart rate of 260 beats/min, is alert, and has good perfusion. The first intervention to consider, per protocol, is:

    1. A. Synchronized cardioversion
    2. B. Ice applied to the face
    3. C. Procainamide IV infusion
    4. D. Carotid massage in the neck
    Show answer

    Answer: B. Ice applied to the face

    In a stable infant, a vagal maneuver with ice or ice water applied to the face can terminate SVT, followed by adenosine if needed. Carotid massage is not used in infants, and cardioversion is reserved for poor perfusion.

21. A newborn's heart rate is 50 beats/min after 60 seconds of coordinated compressions and ventilation with 100% oxygen through an ET tube. You should next:

    1. A. Stop compressions and observe
    2. B. Give atropine 0.02 mg/kg
    3. C. Give epinephrine IV or IO
    4. D. Change to a laryngeal mask
    Show answer

    Answer: C. Give epinephrine IV or IO

    A heart rate below 60 after 60 seconds of coordinated compressions and ventilation through an airway is the indication for epinephrine, preferably by umbilical vein or IO, while compressions and ventilation continue. Stopping compressions at a rate of 50 removes the circulation the infant depends on. Atropine has no role, because newborn bradycardia is caused by hypoxia, not vagal tone. Changing a working ET tube to a laryngeal mask wastes time and risks losing the airway. (AHA/AAP 2025; NRP 9th ed.)

22. Respiratory distress syndrome in a preterm infant typically worsens over the first hours of life because:

    1. A. Lung fluid clears too quickly after birth
    2. B. The alveoli fill with blood from fragile vessels
    3. C. Weak respiratory drive slows breathing over time
    4. D. Alveoli keep collapsing without surfactant
    Show answer

    Answer: D. Alveoli keep collapsing without surfactant

    Without enough surfactant, alveoli collapse at the end of each breath, so the work of breathing rises and the infant tires. CPAP or ventilation with PEEP helps hold the alveoli open until surfactant is given in the hospital. Lung fluid clearance is delayed rather than too fast, the alveoli do not fill with blood, and the problem is stiff, collapsing lungs rather than a fading respiratory drive, which is the mechanism of apnea of prematurity.

23. A newborn's mouth fills with frothy secretions, and the infant chokes and becomes cyanotic with the first feeding. A suction catheter cannot be passed into the stomach. You should suspect:

    1. A. Esophageal atresia with a fistula
    2. B. Choanal atresia of both nares
    3. C. Pyloric stenosis from birth
    4. D. Diaphragmatic hernia on the right
    Show answer

    Answer: A. Esophageal atresia with a fistula

    Esophageal atresia, usually with a tracheoesophageal fistula, causes drooling, choking, and aspiration with feeding, and a tube stops short of the stomach. The infant is kept head up with the upper pouch suctioned to prevent aspiration.

24. A full-term newborn remains cyanotic with an SpO2 of 70% despite effective ventilation with 100% oxygen. Breath sounds are equal and the chest rises well. Which hospital diagnosis do you suspect?

    1. A. Transient tachypnea of the newborn
    2. B. Choanal atresia of both nares
    3. C. Simple acrocyanosis of the hands
    4. D. Persistent pulmonary hypertension
    Show answer

    Answer: D. Persistent pulmonary hypertension

    Persistent pulmonary hypertension keeps blood shunting right to left through fetal pathways despite good ventilation, often after meconium aspiration, asphyxia, or sepsis. Acrocyanosis involves only the hands and feet with a normal saturation.

25. A newborn's preductal (right hand) SpO2 is 97%, but the SpO2 on a foot is 88%. This difference most suggests:

    1. A. A heart defect with shunting across the ductus
    2. B. A faulty probe, since readings should not differ
    3. C. Normal transition that needs no further workup
    4. D. Hypothermia lowering blood flow to both feet
    Show answer

    Answer: A. A heart defect with shunting across the ductus

    Blood to the right hand leaves the aorta before the ductus arteriosus, while blood to the legs comes after it. A lower postductal reading means deoxygenated blood is crossing the ductus into the aorta, as in critical congenital heart disease or pulmonary hypertension. Newborn screening flags a difference of more than about 3%.