Neonatal Resuscitation 2025

You are the only doctor at a CHC. A 24-year-old at 39 weeks, third pregnancy, entirely uncomplicated antenatal course, clear liquor, normal fetal heart rate, is about to deliver vaginally. The staff nurse asks whether she should stay for the baby or go and set up the mother's oxytocin. What is the correct answer, and why?

1. She may set up the oxytocin — with no risk factors this baby is very unlikely to need help, and the mother's third stage is the greater danger.
2. She must stay, with the baby as her only responsibility, because a qualified person dedicated solely to the newborn is required at every birth regardless of risk assessment.
3. She may leave, provided she is within calling distance and can return within a minute if the baby does not cry.
4. She should stay only if the delivery becomes instrumental or the liquor turns meconium-stained.

A hospital administrator proposes that, to save money, only the two senior neonatal nurses be trained in chest compressions and drug administration, while everyone else is trained "just in bag-and-mask". Which single fact makes this partly defensible, and which makes it dangerous as stated?

1. It is defensible because compressions are rare; it is dangerous because bag-and-mask skills decay within weeks without refreshers.
2. It is defensible because only about 1–3 per 1000 newborns need compressions or drugs; it is dangerous because a team with full resuscitation skills must be immediately available to every birth, not merely rostered somewhere in the hospital.
3. It is defensible because ventilation resolves almost all cases; it is dangerous because intubation would then never be available.
4. It is defensible on cost grounds alone; it is dangerous because the nurses might be on leave simultaneously.

A term baby is born limp and makes occasional deep, shuddering single inspirations about every eight seconds. The obstetrician says "she's breathing, just slowly" and continues to rub her back. At 55 seconds she is unchanged. What is the physiological state, and what does it require?

1. Primary apnoea — continue vigorous tactile stimulation, which is sufficient in this phase.
2. Irregular neonatal breathing, a normal variant at this age — observe for a further 60 seconds.
3. Gasping, which is a terminal sign equivalent to apnoea — start positive-pressure ventilation now, within the first minute.
4. Secondary apnoea — start chest compressions, since stimulation has already failed.

You are ventilating a 27-week infant with a T-piece. Your assistant reports "I can't see the chest moving." The heart rate, which was 60/min, is now 95/min and climbing, and the colorimetric CO₂ detector is turning yellow with each breath. What should you do?

1. Increase the peak inflation pressure in 5 cm H₂O steps until chest movement is visible.
2. Continue ventilation at the current settings — the rising heart rate and detected CO₂ show the lungs are being ventilated, and visible chest movement is an unreliable sign at this gestation.
3. Stop and intubate, since face-mask ventilation has failed to produce chest movement.
4. Perform the full sequence of ventilation corrective steps before reassessing.

A term baby is apnoeic. PPV was started at 50 seconds. At 80 seconds the heart rate is 45/min, the assistant reports no chest movement, and the CO₂ detector is still purple. The registrar says "heart rate under 60 — start compressions." What is the correct action, and what principle is the registrar violating?

1. Start compressions as instructed; a heart rate below 60 is the threshold and 30 seconds of PPV have now elapsed.
2. Do not start compressions. Perform the ventilation corrective steps until the lungs are actually being inflated — compressions require ≥30 s of ventilation that inflates the lungs, not merely 30 s of attempted ventilation.
3. Give endotracheal epinephrine first, since the heart rate is profoundly low and vascular access will take time.
4. Increase the ventilation rate to 80 breaths/min to compensate for the poor chest movement, then reassess in 30 seconds.

A colleague trained on the previous edition tells you: "At one minute the saturation should be 60 to 65%, so if it's 62% at one minute we're fine." How should you correct this, using the 2025 target table?

1. She is right; the 1-minute row is unchanged, and 62% is within target.
2. The 2025 table has no 1-minute row — it begins at 2 minutes (65–70%). At one minute you should not be titrating oxygen to a saturation at all; you should be asking whether ventilation is indicated.
3. The 1-minute target has been raised to 70–75%, so 62% would now mandate supplemental oxygen.
4. The table now starts at 3 minutes, so both the 1- and 2-minute values have been withdrawn.

You are called to a birth. The obstetric provider says: "Term, clear liquor, no risk factors, she's pushing now." You have time for one more question before the head delivers. Which one adds the most value, and why?

1. "What was the last fetal heart rate?" — because a Category II or III trace is the commonest reason a term baby needs help.
2. "What is the umbilical cord management plan?" — because it is the only one of the four questions that requires the obstetric and neonatal teams to coordinate an action in the first 60 seconds, and it cannot be resolved after the birth without losing time.
3. "Has she had opioids?" — because maternal opioid exposure is a specific, reversible cause of neonatal apnoea.
4. "How many previous deliveries?" — because grand multiparity predicts precipitate birth and postpartum haemorrhage.

You take over a CHC labour room. The emergency trolley contains: a 500 mL self-inflating bag, masks in two sizes, a bulb syringe, an oxygen cylinder at one-eighth full, epinephrine ampoules labelled 1 mg/mL, and a laryngoscope whose bulb flickers. Which single change should you make first?

1. Replace the laryngoscope bulb — a failed intubation in a baby needing compressions is immediately lethal.
2. Refill the oxygen cylinder — without oxygen you cannot resuscitate a depressed newborn.
3. Remove the 1 mg/mL epinephrine from the neonatal trolley and replace it with the 0.1 mg/mL preparation, or a written, pre-calculated dilution — a ten-fold overdose is the highest-consequence, hardest-to-detect error on this trolley.
4. Replace the 500 mL bag with a 240 mL bag, which is the correct size for a newborn.

A baby is born at 39 weeks through clear liquor. At birth she is limp and does not cry. The obstetrician dries and rubs her back with the cord intact. At 60 seconds she is still apnoeic and the auscultated heart rate is 70/min. The obstetrician says, "Let's give the cord another 30 seconds, the evidence favours deferring." What do you do?

1. Agree — 90 seconds of deferral is within the evidence base and the placental transfusion will support her circulation.
2. Ask for the cord to be clamped now and move her to the warmer to begin positive-pressure ventilation — she meets the indication for PPV, and cord management must never delay it.
3. Ask for intact cord milking, three passes, then clamp — this delivers the placental transfusion quickly without delaying ventilation.
4. Begin bag-and-mask ventilation at the delivery table with the cord still attached, and clamp when the heart rate exceeds 100/min.

Four preterm births occur on the same night. In which one would intact umbilical cord milking be contraindicated?

1. A vigorous 33-week infant in whom deferred clamping could not be performed because the mother required immediate transfer to theatre.
2. A 26-week infant delivering precipitously, in whom deferred clamping is not feasible.
3. A non-vigorous 36-week infant who has not responded to 30 seconds of drying and stimulation.
4. A vigorous 30-week infant delivered by caesarean section where the surgeon cannot wait 60 seconds.

A 27-week infant is delivered. Your colleague dries her thoroughly with two warm towels, then places her in polyethylene wrap, puts on a cap, and lays her on an activated thermal mattress under the radiant warmer. Which part of this sequence is wrong, and why does it matter?

1. The thermal mattress — it should not be used together with polyethylene wrap because of the risk of overheating.
2. The drying — below 32 weeks the infant should be placed directly into polyethylene wrap without drying, because the wrap prevents evaporative loss more effectively while the drying itself costs time, handling and exposure.
3. The cap — a cap under a radiant warmer blocks radiant heat delivery to the largest surface area available.
4. Nothing is wrong; this is the correct thermal bundle for 27 weeks.

A term infant required three minutes of PPV after a cord prolapse and is now breathing but hypotonic, with a poor suck. Forty minutes after birth the axillary temperature is 38.1 °C on a radiant warmer set to manual maximum output. What is the most important immediate action and the reason?

1. Continue as is and recheck in 30 minutes — a mild rise in temperature after resuscitation is expected and self-limiting.
2. Reduce the warmer output and actively avoid further hyperthermia while urgently assessing this infant for hypoxic-ischaemic encephalopathy and eligibility for therapeutic hypothermia — hyperthermia worsens outcome in an injured brain.
3. Give paracetamol and take blood cultures, since intrapartum fever is the likeliest explanation.
4. Begin active surface cooling with ice packs immediately, since this infant probably has HIE.

A baby is born at term through thick meconium-stained liquor. She cries immediately, has good tone, and is pink. The senior nurse reaches for the laryngoscope. What is the correct management, and what is the single finding that decides it?

1. Intubate and suction the trachea before the first breath, because the meconium is thick.
2. Perform laryngoscopy to inspect the cords, and suction only if meconium is seen below them.
3. No laryngoscopy and no suction. She is vigorous — she stays with her parent for routine initial steps, exactly as any other baby would.
4. Suction the mouth and nose with a bulb syringe, then place her with her parent.

A term baby with a large caput is apnoeic at 45 seconds. You place him supine on the flat mattress of the warmer, apply a well-fitting mask and begin PPV. The heart rate does not rise and the chest does not move. Before changing any ventilator setting, what is the most likely problem and the quickest fix?

1. The mask is too small; change to a larger mask.
2. The prominent occiput has flexed the neck and obstructed the airway; reposition into the sniffing position and place a small shoulder roll.
3. The peak inflation pressure of 25 cm H₂O is too low for a term infant; increase it to 40 cm H₂O.
4. He has aspirated and needs immediate intubation and tracheal suction.

You are ventilating an apnoeic term baby. Your assistant auscultates for six seconds, counts 7 beats, and calls out "Heart rate 42." The oximeter has no signal. What is the actual heart rate, and what does it change?

1. 42/min — continue ventilation and prepare for compressions, since the rate is below 60.
2. 70/min — the count must be multiplied by 10, not by 6. The baby is above the compressions threshold; continue effective ventilation and reassess.
3. 7/min — the assistant should report the raw count; this baby is in asystole and needs compressions immediately.
4. The number cannot be determined without a cardiac monitor; attach leads before making any decision.

During a complex resuscitation, the cardiac monitor shows a regular complex at 80/min. However, the baby remains pale and flaccid, no pulse is palpable at the umbilical stump, no heart sounds are audible, and the pulse oximeter shows no signal. How should this be interpreted and managed?

1. The heart rate is 80/min, so chest compressions should be stopped and ventilation continued.
2. The monitor is faulty; disconnect it and rely on auscultation alone.
3. This is pulseless electrical activity. In the newborn it is treated the same as an absent heart rate — continue coordinated compressions and ventilation, give epinephrine, and actively look for a reversible cause such as hypovolaemia or pneumothorax.
4. This is likely ventricular tachycardia; prepare for defibrillation.

A 30-week infant is receiving PPV started in 30% oxygen. At 3 minutes the pre-ductal SpO₂ is 62% and the heart rate is 130/min and stable. What is the correct action?

1. Nothing — 62% is an acceptable saturation at 3 minutes for a preterm infant.
2. Increase the FiO₂ — 62% is below the 3-minute target of 70–75%. Raise it by roughly 20–30% and reassess in about 30 seconds.
3. Increase FiO₂ straight to 100%, as the saturation is well below target and preterm infants tolerate hypoxaemia poorly.
4. Reduce the FiO₂ to 21% — the same target table does not apply to preterm infants, who tolerate lower saturations.

A 34-week infant at 4 minutes of age is grunting with intercostal recession. The heart rate is 80/min and the SpO₂ is 72%. A colleague attaches a PEEP valve to the self-inflating bag and starts CPAP at 6 cm H₂O. Identify both errors.

1. The pressure is too high for 34 weeks, and CPAP should be given by nasal prongs rather than a mask.
2. CPAP is contraindicated because the heart rate is below 100/min — this baby needs positive-pressure ventilation; and a self-inflating bag cannot deliver CPAP even with a PEEP valve fitted.
3. The FiO₂ was not specified, and a self-inflating bag delivers 100% oxygen, which is excessive at 34 weeks.
4. CPAP should not be used before 35 weeks without surfactant cover, and 6 cm H₂O exceeds the recommended maximum.

A 33-week infant has completed the initial steps. At 55 seconds she is making shallow, irregular respiratory efforts and the auscultated heart rate is 90/min. Which of the following is correct?

1. Continue stimulation and reassess at 2 minutes; she is breathing, so the indication for PPV is not met.
2. Start CPAP at 5 cm H₂O with 30% oxygen, since she is breathing spontaneously.
3. Start PPV now, with FiO₂ 21–30%, rate 30–60/min, PIP 25 cm H₂O and PEEP 5 cm H₂O — a heart rate below 100/min is on its own an indication for ventilation.
4. Start PPV with FiO₂ 100%, since she is preterm and bradycardic.

You have ventilated a term infant for 30 seconds with clear chest movement. The heart rate is now 140/min, the SpO₂ is 88% at 6 minutes, and she is beginning to make spontaneous respiratory efforts against your breaths. What should you do next?

1. Stop ventilation immediately — the heart rate is above 100 and she is breathing.
2. Gradually reduce the rate and inflation pressure while stimulating gently, and discontinue only once she has a sustained heart rate above 100/min and sustained spontaneous breathing; then move to post-resuscitation care.
3. Continue at the same rate and pressure for a further 5 minutes to guarantee lung recruitment before weaning.
4. Switch to CPAP at 6 cm H₂O for 10 minutes before allowing her to breathe unassisted.

Your CHC has only self-inflating bags. Which three of the following can you not do with that equipment, and therefore must plan around?

1. Deliver PPV in room air; deliver PPV with supplemental oxygen; deliver PPV through an endotracheal tube.
2. Deliver CPAP; deliver free-flow oxygen through the mask; detect a mask leak from the device itself.
3. Deliver PEEP under any circumstances; control the ventilation rate; attach a CO₂ detector.
4. Ventilate a preterm infant; ventilate through a laryngeal mask; measure inflation pressure.

You test a T-piece resuscitator before a 30-week birth. With the outlet blocked and the cap opening left open, the manometer reads 0. When you occlude the cap, it rises to 25 cm H₂O. What is wrong, and why does it matter particularly for this baby?

1. Nothing is wrong — the manometer should read zero between breaths, and 25 cm H₂O on occlusion confirms the PIP is correct.
2. PEEP is not being delivered — it should read 5 cm H₂O with the cap open. Adjust the PEEP dial on the cap. Without PEEP, a surfactant-deficient 30-week lung will collapse at the end of every expiration and must be re-recruited with every breath.
3. The PIP is set too low for a 30-week infant and should be increased to 30–35 cm H₂O before use.
4. The gas flow is too high; reduce it to 5 L/min so that PEEP can be generated.

You are ventilating a term infant with a round, soft-membrane mask held by its stem. There is an audible leak. A colleague reaches over and presses firmly down on the rim of the mask. Name the four separate mechanisms by which this can make things worse.

1. It increases the delivered pressure, over-distends the lung, causes pneumothorax and triggers bradycardia.
2. It deforms the soft membrane so the mask leaks more; it flexes the neck and obstructs the airway; it presses on the eyes with risk of injury and vagal bradycardia; and it can occlude the mask against the face.
3. It dislodges the CO₂ detector, breaks the circuit, introduces a leak at the connector, and reduces PEEP.
4. It cools the infant, causes pain, raises oxygen consumption and worsens acidosis.

An infant is intubated. The tube was seen passing between the cords, the chest moves symmetrically and breath sounds are equal in both axillae — but the colorimetric CO₂ detector stays purple. The heart rate is 35/min. What is the most likely explanation, and what should you do?

1. The tube is in the oesophagus despite appearances; extubate and re-intubate immediately.
2. Cardiac output is too low to carry CO₂ to the lungs. Accept the clinical evidence of correct placement, and proceed to chest compressions — colour change may appear as cardiac output returns.
3. The detector is defective; replace it before taking any further action.
4. The tube is obstructed by secretions; suction it with a 5F catheter before continuing.

A 29-week infant is being ventilated by face mask. The heart rate is 55/min and not rising; the chest is not moving. You have performed mask adjustment, repositioning, suction and mouth opening without success. What is the correct pressure step, and what is the ceiling?

1. Increase to 40 cm H₂O in a single step — a bradycardic infant has no time for gradual increments.
2. Increase in 5 cm H₂O increments until the chest moves, up to a maximum of 30 cm H₂O for a preterm infant; if that fails, proceed to an alternative airway.
3. Increase in 5 cm H₂O increments up to a maximum of 40 cm H₂O, since the maximum is the same at all gestations.
4. Do not increase the pressure in a preterm infant; go straight to intubation, as raising pressure risks pneumothorax.

A term infant is being ventilated. Twenty seconds in, the heart rate has risen from 60 to 95/min but the assistant reports "I still can't see the chest moving much." The operator immediately begins MR SOPA. Is this correct?

1. Yes — absent chest movement is an indication for corrective steps regardless of the heart rate.
2. No — the corrective steps are indicated when the heart rate is not increasing AND there is no chest movement. Here the heart rate is rising, which is the most important indicator that ventilation is working. Continue and reassess at 30 seconds.
3. Yes, but only steps M and R should be performed, since the heart rate is partially responding.
4. No — the correct action is to increase the inflation pressure directly, bypassing the earlier steps, since the airway is evidently patent.

A 38-week infant has a laryngeal mask in place after two failed intubation attempts. Ventilation through it moves the chest well. The heart rate remains 45/min after 30 seconds, so compressions are started. Sixty seconds later the heart rate is still 45/min and no vascular access has been obtained. Which action is not appropriate?

1. Continue chest compressions with the laryngeal mask in place.
2. Give epinephrine down the laryngeal mask while vascular access is being obtained.
3. Insert an umbilical venous catheter and give epinephrine 0.02 mg/kg intravenously.
4. Insert an intraosseous needle if umbilical access proves difficult, and give epinephrine by that route.

You intubate a 26-week infant. The nasal-tragus length measures 4.5 cm. At what depth should the tube be secured at the gum, and which additional check should you perform before taping?

1. 4.5 cm; check the vocal cord guide lines sit at the cords.
2. 5.5 cm (NTL + 1 cm); auscultate for equal breath sounds in both axillae and absent air entry over the stomach, and obtain a chest radiograph if the tube is to remain.
3. 6.5 cm, using the gestational-age table, which overrides the NTL measurement.
4. 9.0 cm; check for a leak at the mouth.

Which single statement about compression technique is correct?

1. Compress at 120 per minute with 30 breaths per minute, giving 150 events per minute in total.
2. Compress the lower third of the sternum, just below the internipple line and in the midline, to one-third of the AP chest diameter, at 90 compressions with 30 breaths per minute, allowing full recoil while keeping the thumbs in contact with the chest.
3. Compress over the xiphoid process, which gives the most direct access to the heart, to one-half of the AP chest diameter.
4. Lift the thumbs completely off the chest between compressions to guarantee full recoil, and reassess the heart rate every 30 seconds.

A term infant has had 60 seconds of coordinated compressions and ventilation through an endotracheal tube with 100% oxygen. The heart rate remains 40/min. A team member says "It's been a minute, give epinephrine down the tube." Before doing anything else, what should the team leader do?

1. Give endotracheal epinephrine immediately — it is the fastest available route and the criteria have been met.
2. Run the five-question checklist out loud — airway secured, chest moving, 100% oxygen delivered, 3:1 every 2 seconds, depth one-third — while a team member simultaneously prepares umbilical venous access and epinephrine.
3. Stop compressions and give a 10 mL/kg normal saline bolus, since hypovolaemia is the commonest reversible cause.
4. Increase the compression rate to 120/min and continue for a further 60 seconds before any drug.

A term infant needs epinephrine. A colleague says: "The cord is very short and messy — let me put a cannula in the right hand, it'll be quicker." What are the two reasons to refuse, and what should be done instead?

1. Peripheral access is acceptable but slower; proceed with it while preparing a UVC as backup.
2. Peripheral cannulation in cardiovascular collapse is likely to fail and to delay lifesaving therapy, and extravasated epinephrine injures tissue. Insert an umbilical venous catheter; if that is unsuccessful or not feasible, use an intraosseous needle.
3. Peripheral access is contraindicated because epinephrine must be given centrally to be effective; a central line should be placed by the neonatologist.
4. Refuse, and give endotracheal epinephrine instead, which avoids the need for vascular access altogether.

Which single statement about emergency vascular access in the newborn is correct?

1. An emergency UVC should be advanced 10–12 cm to ensure the tip lies above the diaphragm before any drug is given.
2. An emergency UVC is advanced only until blood can be freely aspirated — typically 3–4 cm beyond the abdominal wall, and less in an extremely preterm infant — because inserting it further risks infusing drugs directly into the liver.
3. An intraosseous needle must be aspirated to confirm placement before any infusion; failure to aspirate marrow means the needle is misplaced.
4. The umbilical arteries are preferred to the umbilical vein for emergency drug administration because they are easier to identify.

A 3 kg infant needs epinephrine. A UVC is in place. Using the recommended concentration, what dose, volume and flush should be given?

1. 0.1 mg/kg = 3 mL of 0.1 mg/mL, given rapidly, followed by a 3 mL saline flush.
2. 0.02 mg/kg = 0.6 mL of 0.1 mg/mL, given rapidly, followed by a 3 mL normal saline flush, repeated every 3–5 minutes if the heart rate remains below 60/min.
3. 0.02 mg/kg = 0.06 mL of 1 mg/mL, given slowly over 1 minute, with no flush.
4. 0.01 mg/kg = 0.3 mL of 0.1 mg/mL, given rapidly with a 1 mL flush, repeated every 10 minutes.

A term infant born after a placental abruption is pale with weak pulses and a capillary refill of 5 seconds. Despite effective ventilation, compressions and two doses of intravenous epinephrine, the heart rate is 50/min. What should be given, and how?

1. Sodium bicarbonate 1–2 mEq/kg intravenously to correct the metabolic acidosis that is preventing a response to epinephrine.
2. Normal saline or emergency type O Rh-negative packed red cells, 10 mL/kg over 5–10 minutes through the UVC — there is a history of acute blood loss and clinical signs of shock.
3. Normal saline 20 mL/kg as a rapid push, since profound shock requires aggressive early volume replacement.
4. A third dose of epinephrine only; volume expanders are not indicated during active chest compressions.

A term infant has had no detectable heart rate for 18 minutes despite ventilation through a correctly placed endotracheal tube, coordinated compressions, 100% oxygen, three doses of intravenous epinephrine and a volume bolus. A registrar says: "The guideline says 20 minutes, so we carry on two more minutes and then stop." What is wrong with this reasoning?

1. Nothing — 20 minutes is the defined endpoint and the team should continue until then.
2. It treats a reasonable time frame for considering cessation as a rule. The decision must be individualised — and it requires confirming that all appropriate interventions have been performed and reversible causes excluded, and discussing it with the team and the family.
3. It is wrong because resuscitation should have been stopped at 10 minutes, after which survival without severe disability is not possible.
4. It is wrong because the decision belongs solely to the most senior clinician and should not involve the family.

A pregnancy is complicated by a lethal anomaly for which the responsible clinicians agree there is no chance of survival. A junior colleague proposes telling the parents: "We can attempt full resuscitation if you would like us to — it's entirely your choice." What is the ethical error?

1. There is no error; offering all options respects parental autonomy.
2. Where the responsible clinicians believe there is no chance of survival, initiating resuscitation is not an ethical treatment option and should not be offered. Offering it transfers to the parents the burden of a decision clinicians have already made, and it promises a possibility that does not exist.
3. The error is procedural: such a discussion must be led by the hospital ethics committee rather than the clinical team.
4. The error is that the parents should be told resuscitation will not be attempted, and that no discussion is required.

A 29-week infant is breathing spontaneously at 2 minutes with a heart rate of 150/min, but has marked recession and grunting, and the SpO₂ is 60%. Which initial respiratory strategy is most appropriate, and why?

1. Intubate and give prophylactic surfactant, as this is the standard of care below 30 weeks.
2. CPAP at 5–6 cm H₂O by mask with a T-piece or flow-inflating bag, titrating FiO₂ to the target table — early CPAP frequently avoids the need for intubation and mechanical ventilation.
3. Positive-pressure ventilation at 25/5 cm H₂O, since the saturation is well below target.
4. Free-flow oxygen at 100% through a self-inflating bag mask until the saturation reaches 90%.

A 26-week infant is being stabilised. Which action is most likely to increase the risk of intraventricular haemorrhage?

1. Placing the infant supine with the head in the midline and slightly elevated.
2. Giving a 20 mL/kg normal saline bolus as a rapid push for borderline blood pressure.
3. Using PEEP of 5 cm H₂O from the first inflations.
4. Titrating FiO₂ in 20–30% increments against pulse oximetry.

You work in a district hospital with no cooling facility. A 38-week infant born after a uterine rupture required 6 minutes of PPV and compressions. At 45 minutes she is lethargic and hypotonic with an absent suck; cord gas shows a severe metabolic acidosis. What is the single most important action now?

1. Complete a full standardised neurological examination, obtain an EEG if possible, and reassess at 3 hours before deciding whether to refer.
2. Contact the nearest cooling centre immediately and begin arranging transfer, while maintaining normothermia and actively avoiding hyperthermia — the window is 6 hours and the delay is almost always in recognition and referral, not diagnosis.
3. Begin passive cooling by switching off the radiant warmer and applying ice packs to the head while awaiting transport.
4. Give sodium bicarbonate to correct the metabolic acidosis, then reassess the neurological examination.

A term infant who needed 4 minutes of PPV is 3 hours old in the nursery. She is tachypnoeic with intermittent grunting and needs 35% oxygen. Which set of actions is most appropriate?

1. Commence full enteral feeds to prevent hypoglycaemia, bathe her to improve comfort, and suction her airway hourly to clear secretions.
2. Check blood glucose and repeat it serially; consider a chest radiograph and blood gas; consider blood culture and antibiotics; avoid unnecessary suctioning; cluster care to allow rest; delay bathing; and consider delaying feeds with intravenous fluids.
3. Give sodium bicarbonate for the presumed metabolic acidosis and increase oxygen to keep SpO₂ at 100%.
4. No specific action is needed; tachypnoea after resuscitation is expected and resolves spontaneously within 6 hours.

A term infant is born with a scaphoid abdomen and respiratory distress; breath sounds are reduced on the left. Congenital diaphragmatic hernia is suspected. What is the correct immediate management?

1. Begin face-mask ventilation at 25/5 cm H₂O and reassess in 30 seconds.
2. Avoid face-mask ventilation. Intubate the trachea promptly and insert an orogastric tube on continuous or intermittent suction to decompress the stomach and bowel.
3. Give CPAP at 6 cm H₂O to recruit the hypoplastic left lung.
4. Perform immediate needle thoracentesis on the left, since reduced breath sounds indicate a tension pneumothorax.

A term infant deteriorates suddenly during resuscitation: heart rate 50/min despite effective ventilation through a correctly placed tube, compressions and intravenous epinephrine. Breath sounds are absent on the right and transillumination is markedly brighter on that side. What do you do, and where?

1. Obtain an urgent chest radiograph to confirm before doing anything invasive.
2. Perform emergency needle/catheter aspiration on the right, at the 4th intercostal space in the anterior axillary line or the 2nd intercostal space in the midclavicular line, inserting just over the top of the rib.
3. Aspirate on the right at the 5th–6th intercostal space in the posterior axillary line, directing the catheter downward.
4. Increase the ventilation pressure and FiO₂ and continue compressions, since epinephrine may take several minutes to act.

An infant with antenatally diagnosed tetralogy of Fallot is born at term and is limp and apnoeic. What should the team do?

1. Withhold positive-pressure ventilation and give prostaglandin E first, because the underlying problem is cardiac.
2. Follow the standard algorithm — initial steps, then PPV if apnoeic, gasping, or heart rate <100/min — because most infants with CHD who need resuscitation need it for the usual reasons, and ventilation remains the most important and effective step.
3. Start chest compressions immediately, since infants with structural heart disease cannot respond to ventilation alone.
4. Ventilate with 100% oxygen from the outset to maximise pulmonary blood flow.

A 36-week infant with antenatally diagnosed hypoplastic left heart syndrome is vigorous at birth. At 4 minutes the pre-ductal SpO₂ is 62% and she has mild recession. The agreed plan specifies a target saturation of 75–85% by 10 minutes. A colleague suggests increasing FiO₂ to 100% to "bring her up to the normal 10-minute target of 85–95%". Why is that wrong?

1. It is not wrong; the standard target table applies to all infants, and 85–95% is correct at 10 minutes.
2. In duct-dependent systemic circulation, excess oxygen dilates the pulmonary vascular bed and diverts blood into the lungs at the expense of systemic perfusion. The pre-agreed lower target exists to keep the two circulations balanced; oxygen should be given judiciously to reach that target, not the standard one.
3. It is wrong only because 100% oxygen risks retinopathy of prematurity at 36 weeks.
4. It is wrong because oxygen is contraindicated in all forms of congenital heart disease.

A 4-day-old 25-week infant on a ventilator becomes acutely bradycardic at 50/min with SpO₂ falling to 40%. The capnography trace is flat. What is the correct first response?

1. Start chest compressions immediately, since the heart rate is below 60/min.
2. Work through DOPE — confirm the ventilator is cycling, check the position and patency of the endotracheal tube, consider pneumothorax and equipment failure — and hand-ventilate while calling for help.
3. Give a dose of intravenous epinephrine through the existing UVC, as vascular access is already available.
4. Increase the ventilator FiO₂ to 100% and the rate by 20 breaths/min, and observe for 2 minutes.

A 3-week-old ex-preterm infant in the NICU, with severe renal impairment, develops a wide-complex tachycardia and loses cardiac output. Which approach is most appropriate, and what principle decides it?

1. Use the neonatal 3:1 ratio at 120 events per minute, because the infant is still within the neonatal period.
2. Follow the PALS cardiac arrest algorithm, including defibrillation if the rhythm is VT or VF, and check urgently for severe hyperkalaemia — the choice of algorithm is decided by the aetiology of the arrest, not by the infant's age.
3. Use the neonatal algorithm, but with a 15:2 ratio as a compromise between the two programmes.
4. Give epinephrine 0.02 mg/kg intravenously and continue ventilation alone; defibrillation is never indicated in infants.

Your unit introduces a thermal bundle — polyethylene wrap, thermal mattress, cap — for infants under 32 weeks. Admission hypothermia falls from 40% to 15%. Which measure is most important to report alongside this, and why?

1. The proportion of preterm births attended by two or more staff — a process measure confirming adequate staffing.
2. The proportion of infants admitted with a temperature above 37.5 °C — a balancing measure, because combination warming is known to cause overheating and hyperthermia is itself associated with worse outcomes.
3. The proportion of infants who received plastic wrap — a process measure confirming the bundle was delivered.
4. The average length of stay, which is the outcome that matters most to families.

A colleague argues: "A large trial in South Asia found no benefit from therapeutic hypothermia and a signal of increased mortality, so cooling doesn't work and we should stop referring babies for it." What is the most defensible response?

1. Agree — a large trial in a comparable population is the strongest available evidence and should override earlier trials.
2. The trial is important and must not be dismissed, but it tests cooling as delivered within a particular system — the timing of the insult, the quality of intensive care and temperature control, and the population all differ. The honest conclusion is that the intervention cannot be separated from the system delivering it, and practice should follow current national guidance and local capability rather than any single trial in either direction.
3. Disagree — the trial must be methodologically flawed, because cooling has been proven effective in multiple high-income randomised trials.
4. It makes no difference to practice, since randomised trials rarely change what clinicians do.