Nursing Measurements Guide
A Guide to Deep Tendon Reflexes
APGAR scoring is an important topic concerning OBGYN and newborn nursing. But what does APGAR stand for, and how does it work?
As a nurse, you have to efficiently and accurately classify the characteristics of the newborn; such as appearance and vitals. Therefore, APGAR is a scoring chart to identify the health status of a newborn baby.
Just like everything else, there’s good, bad, and worse – some newborns will need more attention than others. The APGAR scoring system helps prioritize which newborns need urgent care.
What is APGAR?
APGAR is a scoring technique that helps medical professionals, especially nurses, to do a quick head-to-toe assessment of newborns.
APGAR stands for:
Appearance or how the baby looks
For example, you get this test question (or possibly on the NCLEX):
A nurse assesses a newborn with a heart rate of 198, a strong cry that resists when touched, and has blue hands and feet. What is the APGAR score and condition of the client?
Think about this scenario, and we’ll get back to it later in this post. But first, let’s dive into the scoring system itself.
Taking the NCLEX after this school year? Read about priority questions here.
In each category, a nurse can only score a maximum of two and a minimum of zero. Here, the higher the score, the better. The overall score is ten points.
Let’s review each category and what their scoring stands for:
If you have a blue core, you always have to equate that with low oxygen or cyanosis; therefore, it’s not a good appearance, so it gets a zero on the score sheet.
Blue arms and legs or extremities are a bit better than a blue core, so it gets a score of one. A pink baby is the most desired appearance, so it will get a score of two.
Appearance Assessment Summary:
0 – Blue core (cyanotic)
1 – Blue arms and legs
2 – Pink (entire)
Without a pulse, that’s a zero and is not a good sign. If the pulse is less than a hundred, the score is one. If the pulse is greater than a hundred, it doesn’t matter if it reaches 200, the score would be two.
Pulse Assessment Summary:
0 – No pulse
1 – Less than 100
2 – More than 100
Check out this nursing mnemonic for fetal heart rate monitoring.
Is the newborn moving? Do they automatically cry and pull away when touched?
When a newborn is stimulated, the normal reaction would be extending, retracting, or pulling away. If the newborn you’re assessing is not doing any of these reactions naturally, there is a need for stimulation.
- If the baby does not react at all, that’s a zero.
- If the baby cries with stimuli, the score is one.
- For a baby to score a two, they should cry and pull away automatically (even without stimuli).
Stimuli can be in the form of feet or back rubbing.
Grimace Assessment Summary:
0 – No normal reactions
1 – Cry with stimuli
2 – Cry and pull away automatically
No activity is a zero on the scoreboard. If you have a baby showing no sign of activity, a code blue will take place because the baby is deteriorating. Minor flexion will get a score of one.
Minor flexion means that the baby will not have full-on flexion-extension, and they will not move around that much; there is also some sluggishness. Flexion and extension, when the baby is normal moving up and about, will obtain a two on the scoreboard.
Activity Assessment Summary:
0 – No activity
1 – Minor flexion, slightly sluggish
2 – Flexion and extension
Does the baby have a strong or weak cry, like irregular gasps? With weak, irregular gasps, the nurse has to suction the baby because they might have aspirated some amniotic fluid while inside the uterus.
As a nurse, you want to suction all the amniotic fluid and meconium to prevent brain damage.
If the baby’s breathing is absent, that’s a zero. If the baby has weak, irregular gasps, that’s a one. But if the baby’s cry is strong, and they have a good respiratory rate, that would be a score of two.
Respiratory Rate Summary:
0 – No cry
1 – Weak irregular gasps
2 – Strong cry
APGAR Score Chart
So, how do you assess if the baby is bad or good, or is doing well? Here’s how to summarize APGAR scoring.
|10||Normal||Pink, >100 pulse, cries & pulls away, flexion & extension, strong cries|
|9||Normal||Likely pink, >100 pulse, cries & pulls away, flexion & extension, or strong cries|
|8||Normal||Likely pink, >100 pulse, cries & pulls away, flexion & extension, or strong cries|
|7||Normal||Likely pink, >100 pulse, cries & pulls away, flexion & extension, or strong cries|
|6||Abnormal||Likely blue arms & legs, <100 pulse, cries with stimuli, minor flexion, or weak gasps|
|5||Abnormal||Likely blue arms & legs, <100 pulse, cries with stimuli, minor flexion, or weak gasps|
|4||Abnormal||Likely blue arms & legs, <100 pulse, cries with stimuli, minor flexion, or weak gasps|
|3||Critical||Likely blue, no pulse, no reaction, no activity, or no crying|
|2||Critical||Likely blue, no pulse, no reaction, no activity, or no crying|
|1||Critical||Likely blue, no pulse, no reaction, no activity, or no crying|
|0||Critical||Blue, no pulse, no reaction, no activity, no crying|
Nursing Interventions After APGAR Scoring
Nurses should understand that a score between 7-10 is normal. The first thing to do is to warm the baby up because everything’s fine, there is no need for reassessment.
A score between 4-6 is abnormal and will need reevaluation as the infant does require monitoring for 5 minutes. The newborn can undergo changes very quickly.
But, if the newborn’s APGAR score is three, what is the FIRST nursing intervention?
Call for help – doctor, and code blue team. This infant is critical.
APGAR Example Question
So, going back to the test question mentioned above – the newborn in question has:
- A heart rate of 198
- A strong cry
- Resistance with staff
- Flexion and extension when touched
- Blue hands and feet
Answering with your APGAR scoring:
A – blue hands and feet (1 point)
P – more than 100 (2 points)
G – resists staff when touched (2 points)
A – flexion and extension (2 points)
R – Strong cry (2 points)
APGAR total score: 9 points
Remember that APGAR scoring is done a minute after giving birth. If the score is below seven, you have to do it again in five minutes until the client gets a good score or is normal.
And it’s a good thing to write this APGAR scoring down like a chart so you can carry it around with you.
Get the Most Out of Nursing School
APGAR scoring is just one part of OBGYN and newborn learning, and you’ll come across plenty of related questions on your next test.
To pass your classes, exams, and clinicals, it helps to go beyond the classroom lecture. SimpleNursing offers comprehensive study guides, quizzes, covering every nursing topic including OBGYN and newborns.
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