Common NRP exam mistakes and how to avoid them
Most missed NRP questions aren't missed for lack of knowledge. They're missed because the question is built around a detail that's easy to get almost right. These are the mistakes that show up again and again.
Treating heart rate assessment as a pulse ox reading
Pulse oximetry takes time to pick up a signal and lags behind the true heart rate, especially in the first minute. Exam questions frequently hinge on this exact gap.
Do this instead: the fastest, most reliable initial heart rate assessment is auscultation, with ECG monitoring added for an ongoing, continuous reading once available. Pulse ox confirms oxygenation, not a fast, reliable initial heart rate.
Running MR. SOPA as a rigid, unskippable sequence
Test-takers often apply M through A in strict order even when the clinical picture points elsewhere, for example, an obviously obstructed airway from thick secretions.
Do this instead: MR. SOPA is situational troubleshooting. When the presentation suggests a specific problem (visible obstruction, known craniofacial anomaly), start with the step that addresses it.
Confusing epinephrine's IV/IO dose with its ETT dose
These are different numbers, not the same dose given two ways: 0.01-0.03 mg/kg IV/IO versus 0.05-0.1 mg/kg via ETT, roughly three to five times higher for the less reliable route.
Do this instead: anchor the IV/IO number first (0.02 mg/kg is the commonly cited starting point), then remember ETT dosing is meaningfully higher, not the same number given differently.
Starting compressions before ventilation is confirmed effective
The trigger for compressions is a heart rate under 60 despite 30 seconds of ventilation that is visibly moving the chest, not just 30 seconds of attempted PPV.
Do this instead: if the chest isn't moving, the problem is ventilation, not the heart rate. Troubleshoot with MR. SOPA before escalating to compressions.
Jumping to 100% FiO₂ too early
Outside of chest compressions, oxygen is titrated to preductal SpO₂ targets by minute of life, not maximized by default.
Do this instead: know the target range for each minute, and reserve 100% FiO₂ specifically for once chest compressions have started.
Applying the old meconium-suctioning rule
Routine tracheal suctioning for non-vigorous infants born through meconium was dropped years ago, but it remains one of the most commonly missed "current guideline" questions.
Do this instead: treat meconium-stained deliveries like any other delivery. Assess and proceed to PPV if indicated, without a mandatory suction step first.
Misjudging "vigorous"
Vigorous means strong respiratory effort, good muscle tone, and a heart rate over 100, all three, not just one reassuring sign.
Do this instead: check all three criteria before calling an infant vigorous. One good sign doesn't override the other two.
Running out of time on scenario-based questions
Long stem questions with several vitals and a timeline reward a specific reading habit, not raw knowledge, and test-takers who read too fast miss the one detail the question is actually testing.
Do this instead: read the full stem once for the timeline before jumping to the answer choices. The detail that changes the answer is usually a time marker or a specific vital sign value.
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- American Academy of Pediatrics, American Heart Association. Textbook of Neonatal Resuscitation. 9th ed. Itasca, IL: American Academy of Pediatrics; 2025.
- Lee HC, Strand ML, Finan E, et al. Part 5: Neonatal Resuscitation: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(16 Suppl 2):S385–S423. doi:10.1161/CIR.0000000000001367