APGAR Newborn Assessment NCLEX Review

This NCLEX review will discuss APGAR newborn assessment scoring.

As a nursing student, you need to know how to evaluate a scenario and calculate the APGAR score or what type of nursing interventions to provide based on an APGAR score. These questions may be found on NCLEX and definitely on nursing lecture exams in maternity.

After you review these notes on APGAR, don’t forget to take the APGAR review quiz.

Lecture on APGAR Newborn Assessment

APGAR Newborn Assessment NCLEX Review

What is APGAR? an easy and quick assessment tool used to assess the status of a newborn baby after birth.

APGAR is a mnemonic that stands for:

Appearance (skin color)

Pulse (heart rate)

Grimace (reflex irritability)

Activity (muscle tone)

Respiration (effort)

*APGAR scoring is performed at 1 minute and 5 minutes after birth and may be reassessed at 10 minutes (5 minutes later) after birth, if the score is 6 or less.

Each category is scored 0-2 and added up for a score 0-10. The higher the score the better the baby is doing. It is rare to have a perfect 10 because most babies have acrocyanosis after birth where the feet and hands will be blue.

Appearance:

• 0: pallor or blue all over
• 1: body pink but extremities blue (hands and feet)…acrocyanosis
• 2: Body and extremities all pink

Pulse:

• 0: absent
• 1: <100 bpm
• 2: >100 bpm

Grimace:

• 0: not response to stimulation
• 1: grimace to stimulation (no cry)
• 2: cry and active movement to stimulation

Activity:

• 0: none, flaccid
• 1: some flexion of arms and legs,
• 2: arms and leg flexed

Respiratory:

• 0: absent
• 1: weak cry, irregular
• 2: strong cry

Interventions based on the APGAR Score:

Score 7-10: no interventions, baby doing good just needs routine post-delivery care
Score 4-6: some resuscitation assistance required. Oxygen, suction…. stimulate the baby, rub baby’s back
Score 0-3: need full resuscitation

APGAR Practice questions:

Question 1: You’re collecting the 1 minute APGAR on a male newborn. You note the heart rate to be 140 bpm. The baby’s cry is strong and regular and the body is pink with slightly blue hands. There is some flexion of arms and legs. While assessing the newborn it moves and cries. What is the newborn’s APGAR score?

• A: 1
• P: 2
• G: 2
• A: 1
• R: 2

Answer: APGAR: 8

Question 2: You’re assessing the five minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 97, no response to stimulation, flaccid, absent respirations, cyanotic throughout. What is your patient’s APGAR score and what nursing interventions who perform based on the APGAR score?

• A: 0
• P: 1
• G: 0
• A: 0
• R: 0

Answer: APGAR 1; full resuscitation measures

More NCLEX Review for Maternity

References:

1. Your baby’s first hours of life | womenshealth.gov. (2017). womenshealth.gov. Retrieved 01 January 2017, from https://www.womenshealth.gov/pregnancy/childbirth-and-beyond/your-babys-first-hours-life/