Neonatal Resuscitation: the Inverted Pyramid, the Golden Minute, Positive-pressure Ventilation, and MR SOPA Practice Questions

25 multiple-choice questions on Neonatal resuscitation: the inverted pyramid, the golden minute, positive-pressure ventilation, and MR SOPA 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. The neonatal resuscitation pyramid shows that the interventions needed by the largest number of newborns are:

   1. A. Supplemental oxygen given by a blow-by mask
   2. B. Chest compressions coordinated with ventilation
   3. C. Epinephrine and volume expansion by IV
   4. D. Warming, drying, positioning, and stimulation
   Show answer

   Answer: D. Warming, drying, positioning, and stimulation

   The broad base of the pyramid is the basic care nearly every newborn needs, and each higher level is needed by fewer infants. Medications sit at the narrow top because very few newborns require them.

2. Which intervention sits at the narrow top of the neonatal resuscitation pyramid, needed by the fewest newborns?

   1. A. Positive-pressure ventilation by mask
   2. B. Medications such as epinephrine
   3. C. Endotracheal intubation
   4. D. Drying and stimulation
   Show answer

   Answer: B. Medications such as epinephrine

   Only a tiny fraction of newborns, roughly 1 in 1,000, need epinephrine or volume. Positive-pressure ventilation is near the middle of the pyramid and is the single most important skill in newborn resuscitation.

3. The single most important and effective action in resuscitating a compromised newborn is:

   1. A. Early, high-quality chest compressions
   2. B. Effective ventilation of the lungs
   3. C. Early epinephrine by IV or IO
   4. D. Rapid volume expansion with saline
   Show answer

   Answer: B. Effective ventilation of the lungs

   Most newborn bradycardia and arrest is caused by failure to establish breathing, so ventilating the lungs fixes the underlying problem. Compressions and drugs help only if ventilation is already effective.

4. The 'golden minute' refers to the goal of:

   1. A. Clamping and cutting the cord within the first 60 seconds
   2. B. Assigning the first Apgar score within 60 seconds
   3. C. Reaching a preductal SpO2 of 90% within 60 seconds
   4. D. Starting ventilation within 60 seconds of birth if needed
   Show answer

   Answer: D. Starting ventilation within 60 seconds of birth if needed

   The initial steps should be finished and positive-pressure ventilation begun within about 60 seconds for an infant who is apneic, gasping, or bradycardic. The Apgar score at 1 minute is a record, not a deadline for care. Cord clamping is not what the golden minute measures, and a preductal saturation of 90% is not expected at 1 minute; normal values are much lower in the first minutes.

5. After the initial steps, a newborn is gasping with a heart rate of 90 beats/min. You should:

   1. A. Give blow-by oxygen and reassess
   2. B. Begin chest compressions at once
   3. C. Begin positive-pressure ventilation
   4. D. Continue stimulating for 30 seconds
   Show answer

   Answer: C. Begin positive-pressure ventilation

   Apnea, gasping, or a heart rate below 100 after the initial steps is an indication for positive-pressure ventilation. Gasping is not effective breathing, and blow-by oxygen does nothing for an infant who is not moving air.

6. After drying, a newborn is breathing with grunting and retractions, and the heart rate is 130. The next step is to consider:

   1. A. Pulse oximetry and CPAP
   2. B. Chest compressions
   3. C. Endotracheal intubation
   4. D. Epinephrine by ET tube
   Show answer

   Answer: A. Pulse oximetry and CPAP

   An infant with labored breathing and a heart rate above 100 is monitored with preductal pulse oximetry, and CPAP or supplemental oxygen is considered for distress or low saturation. Intubation is not the first step for an infant who is breathing with a good heart rate.

7. The recommended rate for positive-pressure ventilation of a newborn is:

   1. A. 12 to 20 breaths/min
   2. B. 80 to 100 breaths/min
   3. C. 30 to 60 breaths/min
   4. D. 100 to 120 breaths/min
   Show answer

   Answer: C. 30 to 60 breaths/min

   The NRP 9th edition, which reflects the 2025 AHA/AAP guidelines, widened the newborn ventilation rate to 30 to 60 breaths/min (it was 40 to 60). Counting 'breathe, two, three' gives about 40 per minute, and 30 per minute matches the breaths given during 3:1 compressions, so ventilation can continue at that rate when compressions stop. Twelve to 20 is an adult rate and under-ventilates a newborn. Rates of 80 to 100 leave too little time to exhale and risk air trapping and a pneumothorax. One hundred to 120 per minute is the compression rate for infant and adult CPR, not a breathing rate. (AHA/AAP 2025; NRP 9th ed.)

8. When starting positive-pressure ventilation of a term newborn, the usual initial inflation pressure is about:

   1. A. 5 to 10 cm H2O
   2. B. 20 to 25 cm H2O
   3. C. 40 to 50 cm H2O
   4. D. 60 to 70 cm H2O
   Show answer

   Answer: B. 20 to 25 cm H2O

   An initial peak pressure of 20 to 25 cm H2O is usually enough, and some term infants need 30 to 40 cm H2O for the first breaths if the chest does not rise. Starting at 40 to 50 risks pneumothorax in most infants.

9. For a newborn of 35 weeks' gestation or more, positive-pressure ventilation should be started with:

   1. A. 100% oxygen, then wean
   2. B. 60% oxygen by blender
   3. C. 50% oxygen, then titrate
   4. D. Room air, 21% oxygen
   Show answer

   Answer: D. Room air, 21% oxygen

   Term and late-preterm infants are resuscitated starting with 21% oxygen, and oxygen is then titrated to preductal saturation targets. Starting with 100% oxygen increases oxidative injury and has been linked to higher mortality.

10. A newborn born at 28 weeks' gestation needs positive-pressure ventilation. Under the 2025 AHA/AAP guidelines, the initial oxygen concentration should be:

    1. A. 30% or higher, then titrated to SpO2
    2. B. 21% (room air), then titrated to SpO2
    3. C. 100%, held there throughout transport
    4. D. Whatever level makes the skin pink
    Show answer

    Answer: A. 30% or higher, then titrated to SpO2

    For infants born before 32 weeks, the 2025 AHA/AAP guidelines and the NRP 9th edition advise starting resuscitation with at least 30% oxygen (a range of 30% to 100%) and then adjusting it to the preductal SpO2 targets. This replaced the older advice of 21% to 30% for every infant under 35 weeks; 21% to 30% now applies at 32 to 34 6/7 weeks, and infants of 35 weeks or more still start in room air. Room air is no longer advised for very preterm infants, because many fail to reach their saturation targets on it. Holding 100% without titration exposes the immature lungs, eyes, and brain to hyperoxia. Skin color is a poor guide to oxygenation; use a pulse oximeter on the right hand or wrist. (AHA/AAP 2025; ILCOR 2025; NRP 9th ed.)

11. Pulse oximetry during newborn resuscitation should be measured on the:

    1. A. Right hand or wrist
    2. B. Left foot or ankle
    3. C. Left hand or wrist
    4. D. Right foot or ankle
    Show answer

    Answer: A. Right hand or wrist

    The right upper extremity is preductal, so it reflects oxygen delivered to the brain and heart. The feet and left hand may receive blood mixed through the ductus arteriosus and read lower.

12. Under the NRP 9th edition, the target preductal SpO2 table begins at 2 minutes of age. The target at 2 minutes is about:

    1. A. 90% to 95%
    2. B. 80% to 85%
    3. C. 50% to 55%
    4. D. 65% to 70%
    Show answer

    Answer: D. 65% to 70%

    Healthy newborns start with low saturations that climb gradually over the first 10 minutes. The 9th edition table now begins at 2 minutes, at 65% to 70%, because with cord clamping deferred for at least 60 seconds a reliable oximeter reading is rarely available in the first minute. Expecting 90% to 95% this early leads to unneeded oxygen and hyperoxia. Eighty to 85% is a target reached only several minutes later. Fifty to 55% is below the target at any minute and, in an infant being ventilated, calls for checking the ventilation and adjusting the oxygen. (NRP 9th ed. SpO2 table; AHA/AAP 2025.)

13. The target preductal SpO2 at 5 minutes of age is about:

    1. A. 60% to 65%
    2. B. 80% to 85%
    3. C. 70% to 75%
    4. D. 95% to 100%
    Show answer

    Answer: B. 80% to 85%

    At 5 minutes the target range is 80% to 85%, reaching 85% to 95% by 10 minutes. Seventy to 75% is the 3-minute target, so it would be too low at 5 minutes.

14. A newborn receiving blow-by oxygen at 10 minutes has a preductal SpO2 of 99%. You should:

    1. A. Maintain the oxygen at the same flow
    2. B. Increase oxygen to keep 100%
    3. C. Reduce the oxygen to keep 85% to 95%
    4. D. Begin positive-pressure ventilation
    Show answer

    Answer: C. Reduce the oxygen to keep 85% to 95%

    The 10-minute target is 85% to 95%, so a saturation of 99% suggests too much oxygen, and the concentration should be weaned. Hyperoxia causes oxidative injury and offers no benefit over a normal saturation.

15. The best sign that positive-pressure ventilation of a newborn is effective is:

    1. A. A rising blood pressure
    2. B. Movement of the abdomen
    3. C. Pink hands and feet
    4. D. A rising heart rate
    Show answer

    Answer: D. A rising heart rate

    A prompt rise in heart rate is the most important indicator of effective ventilation, along with chest rise and improving saturation. Blood pressure is not measured during the initial resuscitation, and abdominal movement suggests air going into the stomach rather than the lungs. Acrocyanosis may persist for hours and is not a guide to ventilation.

16. You begin ventilating a newborn, but the chest does not rise and the heart rate is not improving. The mnemonic for corrective steps is:

    1. A. SAMPLE
    2. B. AEIOU-TIPS
    3. C. MR SOPA
    4. D. DOPE
    Show answer

    Answer: C. MR SOPA

    MR SOPA stands for Mask adjustment, Reposition the airway, Suction mouth and nose, Open the mouth, Pressure increase, and Alternative airway. DOPE troubleshoots an intubated patient who deteriorates, not a failing mask seal.

17. In the MR SOPA mnemonic, the first two steps, M and R, are:

    1. A. Mask adjustment and reposition the head
    2. B. Monitor rhythm and reassess the pulse
    3. C. Mouth suction and reposition the head
    4. D. Mask adjustment and raising the pressure
    Show answer

    Answer: A. Mask adjustment and reposition the head

    The first corrective steps fix the most common causes of ineffective mask ventilation: a poor seal and a malpositioned head. Suctioning the mouth and nose is S, and raising the pressure is P, later steps used if the first two do not produce chest rise. Medications are never part of the ventilation corrective sequence.

18. In MR SOPA, the P step means you should:

    1. A. Pause ventilation and check a pulse
    2. B. Raise the inflation pressure gradually
    3. C. Place an IO needle in the tibia
    4. D. Push epinephrine through the tube
    Show answer

    Answer: B. Raise the inflation pressure gradually

    If the mask seal and airway are corrected and the chest still does not rise, inflation pressure is raised in small increments up to about 40 cm H2O in a term infant. Pausing ventilation for a pulse check delays the fix and worsens hypoxia.

19. You have completed MR SOPA steps through pressure, and there is still no chest movement with the mask. The final step is to:

    1. A. Start chest compressions at a 15:2 ratio for two minutes
    2. B. Switch to blow-by oxygen at 10 L/min for one minute
    3. C. Stop ventilation and wait for spontaneous breathing
    4. D. Insert an alternative airway such as an ET tube
    Show answer

    Answer: D. Insert an alternative airway such as an ET tube

    The A in MR SOPA is an alternative airway, either an endotracheal tube or laryngeal mask, when mask ventilation fails despite corrective steps. Compressions do not help an infant whose lungs are not yet being ventilated.

20. After 30 seconds of positive-pressure ventilation that moves the chest, a newborn's heart rate is 80 beats/min. You should:

    1. A. Begin chest compressions at a 3:1 ratio
    2. B. Continue ventilation and reassess
    3. C. Give epinephrine IV or IO
    4. D. Stop and give blow-by oxygen
    Show answer

    Answer: B. Continue ventilation and reassess

    A heart rate of 60 to 99 after effective ventilation means the infant still needs ventilation, so you keep ventilating, run MR SOPA if needed, and reassess. Compressions begin only if the rate stays below 60 after 30 seconds of ventilation that moves the chest.

21. During ventilation, a newborn's heart rate rises to 120 beats/min and the infant begins breathing on its own. You should:

    1. A. Taper ventilation and monitor closely
    2. B. Begin chest compressions
    3. C. Continue full ventilation at 60 per minute
    4. D. Give a fluid bolus of 10 mL/kg
    Show answer

    Answer: A. Taper ventilation and monitor closely

    When the heart rate exceeds 100 and spontaneous breathing is adequate, positive-pressure ventilation is gradually stopped while the infant is monitored for recurrent apnea. Continuing full ventilation is unnecessary once the infant breathes effectively on its own.

22. When positive-pressure ventilation continues for more than several minutes, you should consider inserting an orogastric tube to:

    1. A. Prevent meconium aspiration
    2. B. Feed during transport
    3. C. Relieve gastric distension
    4. D. Confirm placement of the ET tube
    Show answer

    Answer: C. Relieve gastric distension

    Air forced into the stomach during mask ventilation distends the abdomen, pushes up the diaphragm, and limits lung expansion. An orogastric tube does not reach the airway, so it neither prevents meconium aspiration nor confirms ET tube placement, and nothing is fed through it during resuscitation.

23. Positive end-expiratory pressure of about 5 cm H2O is recommended during newborn ventilation because it:

    1. A. Raises venous return to the heart
    2. B. Helps keep the alveoli from collapsing
    3. C. Increases the tidal volume of each breath
    4. D. Prevents gastric inflation with air
    Show answer

    Answer: B. Helps keep the alveoli from collapsing

    PEEP helps establish and maintain functional residual capacity in fluid-filled lungs, especially in preterm infants with little surfactant. It does not prevent gastric inflation, and with the peak pressure unchanged it narrows rather than increases the pressure swing of each breath. Raised intrathoracic pressure tends to lower, not raise, venous return.

24. A bag-mask device for newborn ventilation should have a volume of about:

    1. A. 200 to 750 mL
    2. B. 1,000 to 1,600 mL
    3. C. 50 to 100 mL
    4. D. 2,000 to 3,000 mL
    Show answer

    Answer: A. 200 to 750 mL

    A neonatal bag of about 200 to 750 mL lets you deliver small breaths with control, using only enough volume to raise the chest. An adult bag of 1,000 to 1,600 mL makes it easy to overinflate and injure the lungs.

25. A newborn mask for positive-pressure ventilation is correctly sized when it:

    1. A. Covers only the mouth, leaving the nose free to breathe
    2. B. Covers the eyes, nose, and mouth completely
    3. C. Rests on the forehead and covers the nose
    4. D. Covers the chin, mouth, and nose, but not the eyes
    Show answer

    Answer: D. Covers the chin, mouth, and nose, but not the eyes

    A properly sized round or anatomic mask covers the tip of the chin, the mouth, and the nose without pressing on the eyes. Pressure on the eyes can cause injury and a vagal bradycardia, and a mask that leaves the nose open will not seal.