During neonatal resuscitation in the delivery room, a term infant born through meconium-stained amniotic fluid is not vigorous (limp, HR <100, apneic). According to current NRP guidelines (2021), the recommended immediate next step is:
- A Immediate endotracheal intubation and tracheal suctioning before positive pressure ventilation
- B Oral suctioning of meconium under direct laryngoscopy before any other intervention
- C Initial steps (dry, stimulate, suction mouth and nose) then assess — start PPV if not breathing or HR <100 ✓
- D Immediate IV epinephrine without waiting for pulse check
Correct answer: C. Initial steps (dry, stimulate, suction mouth and nose) then assess — start PPV if not breathing or HR <100
Explanation
The 2015/2021 NRP guidelines removed routine endotracheal intubation and tracheal suctioning for non-vigorous meconium-stained neonates because evidence did not show benefit over standard resuscitation. Instead, initial steps (drying, warming, stimulating, clearing airway if necessary) are performed and PPV is initiated if the infant is apneic or HR <100 bpm. Routine pre-PPV intubation for tracheal suctioning is no longer recommended. Epinephrine is indicated only in cardiac arrest with HR <60 despite adequate PPV and chest compressions.
Reference: Ghai Essential Pediatrics, 10th ed.
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Written and medically reviewed by the StethoPrep medical team.