Free NBRC NPS Practice Test

B is correct. The right hand is preductal and the foot is postductal. This confirmed 11-percentage-point gap suggests desaturated blood is reaching the lower body through right-to-left ductal shunting. Persistent pulmonary hypertension of the newborn (PPHN) and certain congenital heart lesions can produce this pattern; echocardiography helps identify the cause.

• A: A left-to-right shunt would not desaturate the foot.
• C: Probe error happens, but the reliable waveforms and checked probe placement make it less likely here.
• D: A gap this large is abnormal and needs prompt evaluation.

Review point: Know which sites are preductal (right hand) and postductal (either foot), and why a confirmed saturation gap needs evaluation.

Source: Lakshminrusimha and Keszler, NeoReviews 2015 (Etiology and Pathophysiology; Figure 2; Diagnosis).

A is correct. PaCO2 is 20 mm Hg above normal, so the primary problem is respiratory acidosis. In an acute rise, bicarbonate climbs only about 1 mEq/L for every 10 mm Hg, so you'd expect an HCO3− of about 26. That's exactly what's here.

• B: In a chronic process the kidneys raise HCO3− by roughly 3.5–4 mEq/L per 10 mm Hg (to about 31–32), and the pH sits closer to normal.
• C: A metabolic acidosis would show a low HCO3−.
• D: Nothing here is alkalotic.

Review point: Use the expected HCO3− change to tell acute from chronic respiratory acidosis.

Source: StatPearls: Respiratory Acidosis (Evaluation).

C is correct. Cesarean delivery without labor, a term baby, fast breathing with a modest oxygen need, and a film showing retained lung fluid all point to transient tachypnea of the newborn (TTN). It usually clears within 24–72 hours.

• A: Respiratory distress syndrome (RDS) is most common in premature infants with surfactant deficiency and typically produces low lung volumes and a ground-glass pattern.
• B: Meconium aspiration needs meconium-stained fluid and shows patchy infiltrates with air trapping.
• D: A diaphragmatic hernia shows bowel loops in the chest and a shifted heart.

Review point: Match the delivery history and the lung-volume pattern on the film to TTN, RDS, or meconium aspiration.

Source: StatPearls: Transient Tachypnea of the Newborn (Etiology; Evaluation; Prognosis).

D is correct. Wheezing needs airflow. When a child in distress gets quieter while becoming drowsy and more hypoxemic, airflow is falling, not improving. This "silent chest" is a red flag for impending respiratory failure. It calls for immediate escalation and a blood gas.

• A and B: Less wheeze plus drowsiness and falling SpO2 is not improvement.
• C: There's no stridor; the picture fits worsening lower-airway obstruction.

Review point: List the signs that a severe asthma attack is turning into respiratory failure.

Source: NAEPP EPR-3 summary, Camargo et al., Proc Am Thorac Soc 2009 (Table 2, p. 359).

B is correct. Viral croup swells the subglottic airway. That produces the barking cough, inspiratory stridor, and the tapered "steeple" on an AP film.

• A: Epiglottitis is above the vocal cords and presents with high fever, drooling, a toxic look, and a "thumb sign" on the lateral film.
• C: A mainstem foreign body causes one-sided wheeze or decreased breath sounds.
• D: Bacterial tracheitis looks sicker, with high fever and a poor response to croup treatment.

Review point: Separate croup, epiglottitis, and bacterial tracheitis by fever, appearance, and film.

Source: AAFP: Croup — Diagnosis and Management (2018) (Diagnosis); Canadian Paediatric Society: Acute management of croup (Etiology and pathophysiology; Differential diagnosis).

A is correct. Mutations in the CFTR gene impair chloride (and bicarbonate) movement across airway cells. The airway surface liquid dries out, mucus thickens, clearance fails, and chronic infection follows.

• B: Immotile cilia from dynein-arm defects describe primary ciliary dyskinesia, a different disease.
• C and D: Neither is the CF mechanism.

Review point: Link the CFTR defect to dehydrated secretions and impaired clearance.

Source: Cystic Fibrosis Foundation: Basics of the CFTR Protein (How Does the CFTR Protein Work?); CF Foundation disease overview (p. 4).

C is correct. Progressive muscle weakness makes his cough too weak to clear secretions. A peak cough flow below about 160 L/min is linked with ineffective airway clearance. Assisted cough, usually mechanical insufflation-exsufflation, is recommended once peak cough flow drops below about 270 L/min.

• A, B, and D: Nothing in the stem suggests asthma, a surfactant problem, or a cardiac shunt.

Review point: Interpret the 270 and 160 L/min thresholds in an adolescent with DMD.

Source: ATS Consensus Statement: Respiratory Care of the Patient with Duchenne Muscular Dystrophy (2004) (Management — Airway Clearance); DMD Care Considerations, part 2 (2018) (Respiratory care, late non-ambulatory stage, p. 3; Figure 1).

C is correct. OI = (mean airway pressure × FiO2 × 100) ÷ PaO2 = (18 × 0.70 × 100) ÷ 45 = 1,260 ÷ 45 = 28. A higher OI means worse oxygenation for the support given.

• A, B, and D: None equals (18 × 0.70 × 100) ÷ 45. Use FiO2 as a decimal when the formula includes ×100; forgetting that factor gives 0.28.

Review point: Write the OI formula from memory and practice it with FiO2 as a decimal.

Source: PALICC-2 executive summary, Pediatr Crit Care Med 2023 (Table 4, oxygenation-index formula).

B is correct. The NRP 9th-edition table recommends a 3.0-mm internal-diameter tube for infants weighing 1,201–2,200 g or at 29–34 weeks of gestation. At 1.8 kg and 32 weeks, 3.0 mm fits.

• A: 2.5 mm is the initial size listed for smaller or less mature infants; a tube that is too small increases resistance and leak.
• C and D: These are larger than the recommended initial size for this infant and may increase airway trauma.

Review point: Use the current neonatal tube-size table: 3.0 mm for 1,201–2,200 g or 29–34 weeks, then assess clinical fit.

Source: AAP: NRP 9th Edition Practice Changes (p. 2, endotracheal tube-size table).

B is correct. Cuffed tube internal diameter (mm) = (age in years ÷ 4) + 3.5 = (4 ÷ 4) + 3.5 = 4.5 mm. Keep a half-size smaller and a half-size larger tube ready.

• C: 5.0 mm comes from the uncuffed formula, (age ÷ 4) + 4.
• A and D: Neither matches either formula for a 4-year-old.

Review point: Keep the cuffed (+3.5) and uncuffed (+4) formulas separate.

Source: ERC Paediatric Life Support guidelines (2025) (Airway, p. 32); Royal Children’s Hospital: Airway management (Endotracheal tube).

D is correct. If a suction catheter won't pass after these initial checks in a child who is deteriorating, the tube may be blocked or displaced: remove and replace it now. If the same-size tube won't go in, try a half-size smaller.

• A: More oxygen can't get past an obstruction.
• B: Repeated saline and suction attempts waste critical time.
• C: Oral intubation is a later step if the stoma can't be recannulated and the child can't be oxygenated another way.

Review point: Walk through the emergency tracheostomy algorithm: suction test, tube change, then a smaller tube.

Source: NTSP emergency paediatric tracheostomy algorithm, reproduced by Resuscitation Council UK (p. 15, initial response and emergency tube change).

A is correct. Bubbling shows gas escaping through the water seal. In this infant, the open mouth is the most likely source of a leak that prevents pressure from being maintained. Displaced prongs or a disconnection do the same thing. Fix the interface and check the circuit, gas flow, and measured pressure; bubbling alone does not confirm the prescribed pressure at the patient.

• B: The set level alone does not explain the obvious mouth leak.
• C: Stability does not make loss of bubbling acceptable; check that support is still being delivered.
• D: Compliance changes don't stop the bubbling.

Review point: Know what bubbling tells you and the common leak sources to check first.

Source: Sydney Children’s Hospitals Network bubble CPAP guideline, v3.0 (effective January 2025) (§4.2, p. 10; §5.5, p. 11); Fisher & Paykel BC151/BC161 user instructions, Rev V (May 2024) (English warnings, PDF pp. 3–4; Checks During Operation, PDF p. 5).

C is correct. A pulse rate that doesn't match the ECG, plus a poor waveform, means the SpO2 can't be trusted. Here it's most likely motion artifact. Re-site the probe and reassess the patient before acting on the number.

• A and B: Treating an artifact with FiO2 1.0 or an intubation workup risks harm.
• D: Ignoring the alarm is unsafe; the reading still has to be confirmed.

Review point: Check waveform quality and heart-rate agreement before believing any SpO2.

Source: Masimo Rad-G operator’s manual (Performance warnings, printed p. 12; Signal IQ, printed p. 22; Troubleshooting Measurements, printed p. 53).

B is correct. An MDI with a valved holding chamber reduces the need to coordinate actuation with inhalation. A properly fitted face mask is appropriate when the child cannot use a mouthpiece.

• A: An MDI alone requires coordination that this toddler has not demonstrated.
• C: A holding chamber helps with coordination, but its mouthpiece still requires a seal this child cannot maintain.
• D: A dry-powder inhaler requires sufficient inspiratory flow and a different technique; it is not the prescribed MDI delivery setup.

Review point: Match inhaler devices to age and ability.

Source: AARC: Aerosol Delivery Device Selection for Spontaneously Breathing Patients (2012) (recommendations 1–4, p. 613; Description, pp. 613–614).

C is correct. Capillary samples track arterial pH and PCO2 reasonably well. Capillary PO2 does not stand in for arterial PO2, so judge oxygenation with pulse oximetry or an arterial sample. Heel warming is common, but the 2022 AARC guideline found no proven accuracy benefit; choose a well-perfused site and avoid burns.

• A and B: These are the useful values from a capillary sample.
• D: Bicarbonate is calculated from pH and PCO2, so it's as reliable as those values.

Review point: Separate ventilation and acid–base values from oxygenation values on a capillary gas.

Source: AARC Clinical Practice Guideline: Capillary Blood Gas Sampling for Neonatal and Pediatric Patients (2022) (Table 2; Summary).

D is correct. Racemic epinephrine works fast, but its effect wanes after 1–2 hours, and stridor can come back. Observe for at least 2 hours while the dexamethasone takes effect.

• A: Going home now risks a return of stridor at home as epinephrine wears off.
• B: Scheduled doses regardless of symptoms aren't indicated.
• C: Intubating a child who responded isn't appropriate.

Review point: Know the onset and duration of racemic epinephrine and why observation follows it.

Source: Canadian Paediatric Society: Acute management of croup in the emergency department (updated March 6, 2026; Epinephrine).

B is correct. Caffeine is a methylxanthine. Its effects are attributed largely to blocking adenosine receptors, and stimulation of the brain's respiratory center is one proposed mechanism. It's used to treat apnea of prematurity.

• A: It isn't a beta-2 agonist.
• C: It isn't a surfactant.
• D: It's a stimulant, not a sedative.

Review point: Know caffeine's drug class and what it treats.

Source: Caffeine citrate prescribing information (Mechanism of Action; Indications and Usage).

A is correct. GINA guidance supports considering IV magnesium sulfate when a severe attack does not respond to initial treatment and hypoxemia persists. It relaxes bronchial smooth muscle.

• B, C, and D: Inhaled steroids, leukotriene blockers, and cromolyn are long-term controllers. They are not the best next escalation for this persistently severe attack.

Review point: Know the escalation order in a severe pediatric asthma exacerbation.

Source: GINA 2026 Strategy Report (printed p. 188 / PDF p. 189, Magnesium and Inhaled corticosteroids); Magnesium and airway smooth-muscle relaxation (Gourgoulianis et al., 2001) (Abstract; experimental mechanism study).

D is correct. A sweat chloride of 60 mmol/L or higher is consistent with CF.

• A: After a positive newborn screen, a result below 30 mmol/L makes CF unlikely; 64 does not.
• B: The intermediate range is 30–59 and needs further evaluation.
• C: Sweat testing is routinely done in young infants after a positive newborn screen.

Review point: Memorize the three sweat chloride bands.

Source: Cystic Fibrosis Foundation diagnosis guidelines (Farrell et al., 2017) (Recommendations 2–3, 6, and 8–10).

C is correct. The thumb sign is a swollen epiglottis. The image is already available in this case; do not delay airway care to obtain imaging when epiglottitis is strongly suspected. Keep the child calm in a position of comfort, and secure the airway in a controlled setting, often the operating room, with the most experienced airway team.

• A and B: Agitation, a tongue blade, or forcing the child flat can trigger complete obstruction.
• D: Treating this presentation as croup and discharging the child is unsafe.

Review point: Know what not to do before the airway is secured in suspected epiglottitis.

Source: Kojima et al., Case 3: Sore Throat and Fever in a 4-year-old Boy, Pediatrics in Review 2016 (printed p. 398 / PDF p. 2, Diagnosis and Treatment).

A is correct. The film shows respiratory distress syndrome from surfactant deficiency, and the oxygen need is climbing on CPAP. The 2025 European consensus guideline recommends early surfactant during noninvasive respiratory support; in infants under 28 weeks, consideration begins with early signs of RDS after stabilization. In a baby who is breathing on CPAP, the preferred route is a thin catheter (less invasive surfactant administration, or LISA).

• B and C: Neither treats surfactant deficiency.
• D: Low-flow cannula removes the distending pressure this baby needs.

Review point: Recognize worsening RDS on CPAP and the need for early surfactant.

Source: European Consensus Guidelines on the Management of RDS: 2025 (published 2026; Surfactant Therapy, Recommendations 1 and 4).

B is correct. Lung size tracks height, not fat mass. PALICC-2 says to use the lower of predicted and actual body weight, which in severe obesity is the predicted weight.

• A: Actual weight can overestimate the appropriate breath size in severe obesity.
• C and D: Neither is the standard approach.

Review point: Set tidal volume from predicted body weight in obese patients.

Source: PALICC-2 executive summary, Pediatric Critical Care Medicine 2023 (Good Practice Statement 6.1.2 and Remarks).

D is correct. A heart rate below 60/min despite at least 30 seconds of ventilation that inflates the lungs, ideally through an endotracheal tube, calls for chest compressions. Use a 3:1 ratio (90 compressions and 30 breaths per minute) and raise the oxygen to 100%.

• A: Continuing PPV alone delays the circulation this baby needs.
• B: Epinephrine comes later, if the heart rate stays below 60 after compressions with ventilation.
• C: 15:2 is the two-rescuer pediatric ratio, not the newborn ratio.

Review point: Know the heart-rate triggers for each step of newborn resuscitation.

Source: AHA/AAP Neonatal Resuscitation Guidelines (2025) (Sections 13.1–13.2; Epinephrine synopsis).

C is correct. CDC guidance puts RSV under contact precautions (gown and gloves) on top of standard precautions. It spreads easily by hands and surfaces.

• A: CDC's RSV entry does not call for Airborne Precautions.
• B: Droplet-only precautions omit the Contact Precautions specified for RSV.
• D: Standard precautions alone aren't enough.

Review point: Know the isolation category for the common pediatric respiratory infections.

Source: CDC Isolation Precautions Guideline, Appendix A (RSV entry; page updated September 11, 2026).

A is correct. PaCO2 is often low during an asthma attack. A rising PaCO2 with drowsiness is a warning of respiratory failure, especially with persistent hypoxemia. Escalate now and get ready for ventilatory support.

• B: Waiting 4 hours is dangerous.
• C: Sedation can suppress the breathing she's depending on.
• D: Cutting the bronchodilator treats the wrong problem.

Review point: Recognize when a "normal-looking" PaCO2 is actually a warning sign.

Source: GINA 2026 Strategy Report (printed p. 185 / PDF p. 186, Arterial blood gas measurements).

D is correct. Extremely preterm babies are hurt by both too little and too much oxygen. In the oxygen-targeting trials, a low target (85–89%) raised the risk of death compared with 91–95%, and too much oxygen raises the risk of retinopathy of prematurity. Titrate in small steps to the ordered range, and explain the reason to the nurse.

• A: Jumping to 1.0 invites hyperoxia.
• B: 88% is below the ordered range; leaving it is under-treatment.
• C: Removing monitoring is unsafe.

Review point: Know why preterm SpO2 targets have both a floor and a ceiling.

Source: European Consensus Guidelines on the Management of RDS: 2025 (published 2026; Oxygen Supplementation beyond Stabilisation).

B is correct. Teach-back means asking the caregiver to show the technique and explain it in their own words. It's how you confirm they understood.

• A: Yes/no questions invite polite agreement.
• C and D: Handouts and videos are teaching tools, not ways to check that learning happened.

Review point: Use teach-back to confirm understanding at discharge.

Source: AHRQ Health Literacy Universal Precautions Toolkit, Tool 5: Teach-Back.

C is correct. Each sign scores 0–2:

• Heart rate below 100: 1
• Slow, irregular breathing: 1
• Some flexion: 1
• Grimace: 1
• Pink body with blue extremities (acrocyanosis): 1

The total is 5. A, B, and D come from scoring one or more signs as 0 or 2.

Resuscitation decisions are made in real time from heart rate, breathing, and tone. Nobody waits for the Apgar score to act.

Review point: Score all five Apgar signs quickly and accurately.

Source: Merck Manual: Apgar Score table (five score-1 criteria); AHA/AAP Neonatal Resuscitation Guidelines (2025) (Initial Steps; Ventilation and Continuous Positive Airway Pressure).

A is correct. Fetal lungs need amniotic fluid to grow. Early, prolonged oligohydramnios can impair lung growth and cause pulmonary hypoplasia, with small lungs, high oxygen requirements, and pulmonary hypertension.

• B: Meconium aspiration is mainly a term or post-term problem.
• C: TTN is a mild retained-fluid condition.
• D: Nothing suggests maternal opioid exposure.

Review point: Connect maternal and fetal history to what you should prepare for at delivery.

Source: RCOG Scientific Impact Paper No. 76 (2025) (Section 2.3.1, Prediction of Pulmonary Hypoplasia).

D is correct. Stopping iNO suddenly can cause rebound pulmonary hypertension and a sharp drop in oxygenation, so the FDA label calls for weaning in steps. The U.S. label advises pausing for several hours at each reduction to monitor oxygenation. If rebound occurs, reinstate therapy promptly and reassess with the neonatal team.

• A: Stopping abruptly risks rebound.
• B: A higher dose has no purpose when the baby has already responded, and the U.S. label doesn't recommend doses above 20 ppm.
• C: Heliox has no role in PPHN.

Review point: Know why iNO is weaned in steps and what rebound looks like.

Source: INOmax prescribing information (Sections 2.1–2.2 and 5.1; label text revised April 2023, current DailyMed record December 2025).

D is correct. Heliox is less dense than oxygen, so an oxygen flowmeter under-reads it. For 80:20 heliox, multiply the reading by about 1.8: 10 × 1.8 = 18 L/min.

• A, B, and C: Each ignores or under-corrects for the density difference.

The density advantage decreases as the oxygen fraction rises. The selected blend still has to meet the patient's oxygen needs. Use a heliox-calibrated flowmeter when available, and follow the device's instructions rather than applying this correction twice.

Review point: Apply the correction factor to an oxygen-calibrated flowmeter, and check which gas the meter is calibrated for.

Source: AARC: The Pros and Cons of Heliox Therapy (Application).

A is correct. On HFOV, CO2 removal depends mainly on the delivered tidal volume, which goes up with amplitude. Oxygenation and lung volume are already fine, so raise the ΔP.

• B and D: Mean airway pressure and FiO2 control oxygenation, and the lungs are already well inflated at 9 ribs.
• C: At the same amplitude without volume guarantee, raising frequency usually reduces the oscillatory tidal volume and can reduce CO2 clearance.

Review point: Sort the HFOV controls into oxygenation knobs and CO2 knobs.

Source: West of Scotland Neonatology: HFOV in the neonate (October 25, 2024) (Sections 2.4–2.5 and adjustment table, pp. 4–6).

B is correct. The lungs are under-inflated (the usual target is 8–9 posterior ribs) and the baby is hypoxemic, so the lung needs recruiting. Mean airway pressure sets lung volume on HFOV and is the main oxygenation control. Increase it carefully while reassessing oxygenation and blood pressure; both underinflation and overinflation can impair gas exchange.

• A and C: Amplitude and frequency mostly change CO2, which is already normal.
• D: Lowering FiO2 would deepen the hypoxemia.

Review point: Use the film together with oxygenation and hemodynamics to assess lung recruitment on HFOV.

Source: West of Scotland Neonatology: HFOV in the neonate (October 25, 2024) (Sections 2.3, 2.5 and 2.7, pp. 4–6).

B is correct. 4.5 mL is 5 mL/kg for a 0.9-kg baby, the approximate starting target described in the current European RDS consensus. Adjust the target to blood gases, work of breathing, and lung mechanics. Compared with pressure-limited ventilation, volume-targeted modes reduce the combined outcome of death or bronchopulmonary dysplasia (BPD), as well as pneumothorax and low CO2.

• A: 2 mL is about 2.2 mL/kg, which risks atelectasis and CO2 retention.
• C: 9 mL is 10 mL/kg, which risks volutrauma.
• D: 13.5 mL is 15 mL/kg, far too large.

Review point: Convert mL/kg targets to milliliters quickly for very small babies.

Source: European Consensus Guidelines on RDS: 2025, published 2026 (Mechanical Ventilation Strategies → Volume-Targeted Ventilation); Cochrane: Volume-targeted vs pressure-limited ventilation in the neonate (Klingenberg 2017) (Main results; Authors’ conclusions).

C is correct. The tidal volume is 8 mL/kg (160 ÷ 20). With normal chest-wall compliance, the plateau pressure of 34 cm H2O is above PALICC-2’s suggested ceiling of 28 cm H2O. Static driving pressure is plateau pressure minus total PEEP: 34 − 10 = 24 cm H2O, above its suggested 15 cm H2O limit. PALICC-2 suggests 6–8 mL/kg when pressures allow, and 4–6 mL/kg when needed to meet pressure limits. Lower the tidal volume and recheck both pressures.

• A: A bigger volume worsens overdistension.
• B: PEEP should be titrated to oxygenation, hemodynamics, and compliance. An arbitrary increase without reassessing the pressure and volume limits is not the appropriate correction here.
• D: Raising the rate alone doesn't fix the injurious pressure.

Review point: Calculate mL/kg and driving pressure, then compare them with the PALICC-2 limits.

Source: PALICC-2 executive summary, Pediatr Crit Care Med 2023 (Recommendations 3.2, 3.3.1–3.3.2 and 3.4.1; GPS 6.1.2); AARC: Patient–Ventilator Assessment (2024) (Driving Pressure, p. 1046 / PDF p. 5).

A is correct. For PARDS, PALICC-2 suggests allowing a higher PaCO2 down to a pH of 7.20 when needed to stay within lung-protective pressure and volume limits. This child has none of the listed contraindications; continue monitoring rather than raising tidal volume just to normalize PaCO2.

• B: Going back to the injurious volume defeats the strategy.
• C: Routine bicarbonate isn't recommended.
• D: A pH of 7.25 alone doesn't call for a mode change.

Review point: Know the pH floor for permissive hypercapnia and its exceptions.

Source: PALICC-2 executive summary, Pediatr Crit Care Med 2023 (Recommendations 3.10.1–3.10.2 and remarks).

B is correct. Restore effective oxygenation and ventilation while identifying the cause. Manual ventilation with oxygen removes the ventilator and circuit as possible causes and lets the team assess chest rise and resistance. Rapidly check capnography, tube position and patency, breath sounds, and equipment; suction if a plug is suspected. Displacement, obstruction, pneumothorax, and equipment failure are the DOPE checks, not a rigid order that delays treating an obvious cause.

• A and D: Changing PEEP or FiO2 and observing does not promptly establish effective ventilation or correct a blocked or displaced tube.
• C: Waiting for a film delays treatment.

Review point: Use DOPE to troubleshoot while supporting ventilation and treating the cause you find.

Source: Sydney Children’s Hospitals Network: Ventilated Patient—Patient Care in CICU (v4.1, March 2026) (Complications, p. 10); Fosse et al.: Can intubate, cannot ventilate (2025) (Abstract, Results; proposed troubleshooting algorithm).

D is correct. Preterm babies often need distending pressure after extubation. The 2023 Cochrane review found that NIPPV likely reduces extubation failure and reintubation compared with nasal CPAP in infants born at 28 weeks or later; ventilator-generated NIPPV performed better than bilevel devices.

• A: Room air provides no respiratory support.
• B and C: These provide oxygen without reliable distending pressure.

Review point: Distinguish oxygen delivery from post-extubation pressure support, and match the evidence to gestational age.

Source: Cochrane: NIPPV versus NCPAP after extubation in preterm infants (Lemyre 2023) (Authors’ conclusions; device subgroup).

C is correct. Water sloshing in the circuit creates flow changes the ventilator reads as a breath attempt. That's auto-triggering. Drain the condensate away from the patient and check for leaks.

• A: Sedation won't stop breaths the machine is triggering itself.
• B: Raising the rate just accepts the error.
• D: CPAP pulls away support the baby needs.

Review point: List the common causes of auto-triggering and how to fix each one.

Source: France et al., Respiratory Care 2012 (Abstract, causes of inadvertent triggering); CDC/HICPAC: Guidelines for Preventing Health-Care-Associated Pneumonia (Part II, II.B.3.a.(2), p. 58).

A is correct. This infant has respiratory alkalosis and marked hypocapnia. The current European RDS consensus advises avoiding PaCO2 below 35 mm Hg during mechanical ventilation to reduce brain-injury risk. Cut the ventilation back promptly and reassess the blood gas.

• B: These values aren't acceptable.
• C: More ventilation makes the problem worse.
• D: PEEP mainly affects oxygenation and lung volume.

Review point: Know why overventilation is dangerous for a preterm baby's brain.

Source: European Consensus Guidelines on RDS: 2025, published 2026 (Mechanical Ventilation Strategies, recommendations on pH and PaCO2).

C is correct. For infants with moderate to severe bronchiolitis, the AARC guideline rates high-flow nasal cannula (HFNC) as safe and more effective than low-flow oxygen. Watch closely after starting. Rising work of breathing, heart rate, or oxygen need despite high flow means escalation.

• A: A simple mask at 2 L/min allows CO2 rebreathing and does nothing for work of breathing.
• B: Intubation is premature in an awake infant without apnea or exhaustion.
• D: Lowering oxygen ignores an SpO2 below the AARC bronchiolitis target range of 90–97%.

Review point: Know when to step up from low-flow oxygen in bronchiolitis and what to watch for after starting HFNC.

Source: AARC Clinical Practice Guideline: Management of Pediatric Patients With Oxygen in the Acute Care Setting (2021) (High-Flow Oxygen Versus Low-Flow Oxygen; Table 2, p. 1219 / PDF p. 6).

B is correct. Infants born at 36 weeks or later with moderate to severe hypoxic-ischemic encephalopathy (HIE) should be assessed promptly for therapeutic hypothermia. For eligible infants, treatment begins within 6 hours and continues for 72 hours at a protocol-specified target in the 33.5–34.5 °C range. This requires a unit able to provide the necessary monitoring and multidisciplinary care.

• A and C: Waiting 12 hours, or waiting for seizures, delays the recommended treatment in an infant who already has concerning findings.
• D: 30 °C is below the recommended treatment range.

Review point: Know the eligibility, timing window, temperature, and duration for therapeutic hypothermia.

Source: AAP Clinical Report: Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy (2026) (Abstract); AHA/AAP Neonatal Resuscitation Guidelines (2025) (Section 17, Postresuscitation Care).

A is correct. This is a tension pneumothorax in an unstable baby. Transillumination supports the diagnosis at the bedside. Needle decompression should not wait for imaging; a tension pneumothorax is likely to need an intercostal drain after the initial aspiration.

• B: Higher PIP enlarges the leak.
• C: Waiting for a film is reasonable only when the baby is stable.
• D: Extubation removes support from a collapsing patient.

Review point: Know when to treat a pneumothorax before an X-ray.

Source: Child and Adolescent Health Service neonatal guideline: Pneumothorax (Diagnosis, pp. 2–3; Management, p. 4).

D is correct. By Boyle's law, gas expands as the surrounding pressure falls. A small pneumothorax may enlarge enough to cause clinical compromise. The retrieval team should decide whether drainage is needed and plan cabin pressure, monitoring, and emergency equipment before flight. Current NETS guidance allows conservative management of selected small pneumothoraces; drainage is not automatic for every infant. The same physics can raise pressure in an air-filled endotracheal tube cuff.

• A: Gas expands at altitude; it doesn't contract.
• B: Trapped gas is affected too.
• C: Positive-pressure ventilation makes expansion more dangerous.

Review point: Apply Boyle's law to every gas-filled space before air transport.

Source: NETS WA: Pneumothorax, reviewed August 2026 (Management, pp. 2–3); NETS WA: Special Features of Air Transport (Gas Expansion and Management, pp. 2–3).

B is correct. Post-extubation stridor can come from swelling at or below the vocal cords. Nebulized epinephrine is used for temporary relief of that swelling; pediatric expert consensus includes it among treatment options, although outcome evidence is limited. Watch closely and escalate if the child gets worse or fails to improve.

• A: Albuterol targets lower-airway bronchospasm.
• C: A stable child with mild distress doesn't need reintubation now.
• D: Chest physiotherapy has no role here.

Review point: Recognize post-extubation upper-airway swelling and reassess after treatment; persistent stridor needs further airway evaluation.

Source: Pazinatto et al.: Position paper on post-extubation laryngitis in children (2024) (Clinical treatment; Discussion; Table 1).

C is correct. The preferred umbilical artery catheter (UAC) tip position is high: T6–T9, above the celiac and mesenteric arteries. A low position (L3–L4, below the renal arteries) is an alternative used with caution when a high position cannot be obtained. Avoid T12–L2. T8 is a correct high position. Remember that UAC blood gases are postductal.

• A: T8 is already in the preferred zone.
• B: A catheter placed through the umbilical artery runs into the aorta.
• D: The aortic arch sits well above T6.

Review point: Know the high and low UAC positions and the zone to avoid.

Source: Child and Adolescent Health Service: Umbilical Arterial Catheter, reviewed September 2026 (Post Procedure Management, pp. 9–10; Anatomy and Position, Appendix 1, p. 13).

A is correct. Surfactant can improve compliance within minutes, and the label calls for frequent reassessment and adjustment of oxygen and ventilator support. On pressure control, the same PIP is now delivering twice the volume, which risks volutrauma and pneumothorax. An SpO2 of 99% while receiving supplemental oxygen is above the target range used for this preterm population. Reduce PIP and titrate FiO2 to the prescribed target, with close reassessment.

• B: Increasing PEEP does not address the excessive delivered tidal volume; PEEP is adjusted separately according to lung recruitment and oxygenation.
• C: Waiting invites injury.
• D: A second dose isn't indicated in a baby who is improving.

Review point: Know what to watch and adjust in the first hour after surfactant.

Source: Poractant alfa prescribing information, DailyMed, revised May 2022 (Section 5.1); European Consensus Guidelines on RDS: 2025, published 2026 (Oxygen Supplementation beyond Stabilisation).

D is correct. Neuromuscular blockers paralyze but don't sedate or relieve pain. A surge in heart rate and blood pressure during something painful may mean the child is in pain or aware. Check and optimize sedation and pain control.

• A: Vecuronium gives no sedation.
• B: More paralysis just hides the problem.
• C: Reversal isn't indicated.

Review point: Know what neuromuscular blockers do and don't do.

Source: Vecuronium bromide prescribing information, DailyMed (Precautions → CNS); SCCM PANDEM Guidelines for Infants and Children (2022) (Neuromuscular Blockade: adequate sedation and analgesia).

B is correct. The 2023 brain death guideline for adults and children requires the PaCO2 to reach at least 60 mm Hg and rise at least 20 mm Hg above baseline, with an arterial pH below 7.30, while no breathing effort occurs. At 55 mm Hg, a 15-point rise, neither PaCO2 target is met. This finding does not establish brain death; the qualified team manages further testing according to the protocol and the child’s stability.

• A and C: Neither PaCO2 target has been reached, so the test isn't complete.
• D: Apnea testing is part of brain death determination in children.

Review point: Know both PaCO2 targets and the pH requirement; distinguish an apnea-test endpoint from the full determination.

Source: AAN/AAP/CNS/SCCM Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline (2023) (Recommendations 24a, 25f and 25h–25m).

C is correct. Neuromuscular blockers don't relieve pain or breathlessness. They can hide signs of distress. They should never be started at withdrawal. If they're already running, the ideal is to stop them and let them wear off first, so the team can see and treat discomfort. If reversal or recovery would cause an unacceptable delay, the guideline calls for individualized planning and continued comfort treatment; it does not make waiting an absolute rule.

• A and D: Continuing or increasing paralysis masks suffering.
• B: Comfort medications are continued and adjusted, not stopped.

Review point: Know the role of paralytics and comfort medications at withdrawal of support.

Source: ACCM/SCCM recommendations for end-of-life care in the ICU (Truog et al. 2008) (Pharmacologic Paralysis and End-of-Life Care, p. 957 / PDF p. 5); SCCM Pediatric and Neonatal End-of-Life Guideline (2026) (Symptom management).