10 free Paramedic practice questions: Advanced Obstetric and Neonatal Emergencies

A new seizure disorder unmasked by the demands of pregnancy: A first seizure in an adult needs a broad list of possible causes, and pregnancy does stress the body. This seizure came after 20 weeks, in a patient with a headache and blurred vision. A seizure like this is eclampsia until something else explains it.

Preeclampsia with severe features, since the pressure is above 160 systolic: A systolic of 168 is in the severe range, and severe features do make the call more urgent. Severe features describe how bad the preeclampsia is. Once a seizure happens, the diagnosis is eclampsia, no matter how high or low the pressure is.

Gestational hypertension, since the pressure rose only late in pregnancy: Gestational hypertension is high blood pressure that shows up late in pregnancy, so the timing fits. Gestational hypertension has no end organ findings. This patient has a headache, blurred vision, and now a seizure.

Hold gentle pressure against the head to keep it back until arrival at the hospital: A flat palm on the head during crowning is a real technique. The palm slows an explosive delivery and helps prevent a tear of the perineum. Holding the head back to stop the birth is a different act, and it is never done.

Move the patient to the ambulance and transport her on her left side instead: Transport on the left side is right for a patient in labor who is not crowning yet. This head is already visible at the opening. Moving this patient means carrying her down the stairs in the middle of the delivery.

Perform a digital vaginal examination to confirm that the cervix is fully dilated: A head visible at the opening already tells you the cervix is fully dilated. A digital exam would only confirm what you can already see. In the field, gloved fingers go into the vagina for only two reasons. One is to lift the presenting part off a prolapsed cord. The other is to hold the vaginal wall off the face of a breech newborn.

Give blow by oxygen until the saturation reaches the adult normal range: A saturation of 74% would need oxygen right away in any other patient. A newborn in the first minutes of life is the exception. Blow by oxygen aimed at an adult target over treats a transition that is going normally.

Move the oximeter to a foot, since a hand reading underestimates the true value: Probe site does matter on a newborn. The right hand and wrist are preductal, and that is the correct site. A foot reads postductal, and postductal readings run lower in the first minutes. Moving the probe to a foot would make the number look worse, not more accurate.

Begin positive pressure ventilation, since the saturation is below 90%: Positive pressure ventilation is the right call for a newborn who needs it. A newborn needs ventilation for apnea, poor breathing effort, or a heart rate below 100. This newborn has a strong cry and a heart rate of 150.

After 2 minutes, matching the rhythm check interval used in older children: Two minutes is the check interval for older children and adults. Newborn resuscitation checks much more often than that. Waiting two minutes would leave this newborn on the wrong step of the algorithm for too long.

After 15 seconds, since a newborn tolerates almost no time at that rate: Checking quickly makes sense when a newborn is this sick, and a short pause can seem harmless. Fifteen seconds is not long enough for compressions to change the heart rate. Every check stops the compressions that are doing the work.

After 30 seconds, the same interval used before compressions were started: Thirty seconds is a real interval in the newborn algorithm. That interval belongs to ventilation alone, before compressions start. Once compressions are running, the wait doubles to 60 seconds.

Suction the mouth and nose repeatedly until the returning fluid runs clear: Clearing visible fluid from the mouth and nose once is part of the initial steps. Suctioning over and over chases fluid that is already below the cords. Repeated suctioning also stimulates the vagus nerve, which can slow the heart even more. Each pass puts off the ventilation this newborn needs.

Suction the trachea through an endotracheal tube before ventilating: Suctioning the trachea through an endotracheal tube was taught for years for meconium. Tracheal suctioning is no longer part of newborn resuscitation, whether the newborn is vigorous or not. Setting up for tracheal suctioning delays the ventilation this newborn needs now.

Stimulate the newborn again and recheck the heart rate in 30 seconds: Stimulation gets most newborns breathing, and stimulation is part of the initial steps. This newborn already had the initial steps and is still apneic. Stimulating again will not work, so ventilation starts now.

50% dextrose at 1 mL per kilogram through a vascular line: 50% dextrose is the adult preparation. The small volume of 1 mL per kilogram makes the dose look safe. The concentration is what hurts a newborn, not the volume. 50% is the most concentrated option on the list.

25% dextrose at 2 mL per kilogram through a vascular line: 25% dextrose is what older children get, and 2 mL per kilogram is the right dose for a child. A newborn is not just a small child. For the first weeks of life, the concentration drops to 10%.

Glucose gel rubbed into the cheek, then a repeat glucose check: Glucose gel in the cheek works in an older patient who can protect the airway. This newborn has poor tone and a weak cry and may not swallow reliably. Gel absorbs through the cheek slowly and unpredictably. A glucose of 28 needs to come up now.

Administer a normal saline fluid bolus: A saline bolus is for low blood pressure caused by too little volume, like bleeding, dehydration, or sepsis. This patient's pressure is high at 178/112. Preeclampsia makes the capillaries leak fluid out into the tissues. Extra fluid pushes her toward pulmonary edema and does nothing for the seizure.

Administer furosemide to reduce the blood pressure: Furosemide only has a role in pregnancy for pulmonary edema, not for lowering the blood pressure in preeclampsia. The capillary leak has already left her blood vessels low on volume. Pulling off more fluid drops blood flow to the placenta and hurts the baby. The blood pressure is also not what is causing the seizure. Even when she does need a blood pressure drug, magnesium still goes first to control the seizure.

Administer 50% dextrose intravenously: Dextrose is the answer when a seizure is caused by low blood sugar, and checking a glucose on any seizing patient is a good idea. Nothing here points to low blood sugar. The 2 days of headache, the blurred vision, the high blood pressure, and the 34 weeks of pregnancy all point to eclampsia. Dextrose treats a problem she does not have while the eclampsia goes untreated.

Administer glucagon intramuscularly: Glucagon is the backup when you cannot get vascular access. Glucagon works by making the liver release the sugar it has stored. A newborn with symptoms of low sugar is treated with IV dextrose, and dextrose is the better choice whenever you can get access.

Administer 50% dextrose intravenously: 50% dextrose is the strength used in older children and adults. This patient is a newborn, only 45 minutes old. In a newborn, 50% dextrose can injure the small vein and can cause bleeding in the brain.

Administer oral glucose gel: Oral glucose gel is for a patient who can protect the airway and swallow. This newborn has poor tone and a weak cry, so you cannot count on the newborn to swallow. Gel in the mouth of a newborn who cannot swallow can block the airway or be aspirated.

Wait for the placenta to deliver before the second newborn: With twins, the second baby delivers before the placenta does. The placenta will not come until both babies are out. Waiting for the placenta wastes the time you should be using to clamp and cut the first cord.

Apply firm downward pressure on the abdomen: Pushing down hard on the abdomen, also called fundal pressure, is not a field technique for delivering a second twin. Fundal pressure can injure the uterus, separate the placenta, and make a bad position worse. The second twin is often not head down.

Pull gently on the first cord to deliver the placenta: Pulling on the cord to deliver the placenta is dangerous at any delivery. Cord traction can pull the uterus inside out. Pulling is even more dangerous here, because the placenta is still supporting the second twin who has not delivered yet.

Peripheral cyanosis by itself means more supplemental oxygen is needed: Blue hands and feet can look like a reason to give more oxygen. This newborn's trunk is already pink, so the blue color is only a peripheral finding. The heart rate response, not the color of the hands and feet, tells you whether the support is enough.

A heart rate above 100 means the paramedic can stop reassessing heart rate: A heart rate above 100 does not mean you stop checking the heart rate. This newborn has not cried or started breathing well on its own. Support continues, and you keep watching the heart rate trend.

Peripheral cyanosis after ventilation means chest compressions are indicated: Chest compressions are for a heart rate below 60 that is not responding to ventilation. This heart rate is 150. Peripheral cyanosis by itself is not a reason to start compressions.