Appearance (color): 0 = blue/pale, 1 = body pink with blue extremities (acrocyanosis), 2 = completely pink.
Before you read
Test yourself first: 3 questions
Question 1 of 3
A nurse assesses a newborn at 1 minute of life: heart rate 110, slow irregular respirations with a weak cry, some flexion of extremities, grimace with suctioning, and a pink body with blue hands and feet. What is this newborn's Apgar score?
Answer: B. Apgar scores each of 5 signs 0-2. HR over 100 = 2; slow irregular weak cry = 1; some flexion = 1; grimace = 1; acrocyanosis (blue extremities, pink body) = 1, for a total of 6. A score of 4-6 is moderately depressed and warrants continued support; 7-10 is reassuring.
Question 2 of 3
A client who uses heroin is brought to the emergency department with a respiratory rate of 6 per minute, pinpoint pupils, and decreased level of consciousness. What is the nurse's FIRST priority action?
Answer: B. Opioid overdose causes respiratory depression, which is the immediate life threat. Supporting the airway and breathing comes first; naloxone is given to reverse the opioid effect. While naloxone administration is the targeted antidote and follows closely, ensuring oxygenation and ventilation addresses the airway-breathing priority. Restraints and withdrawal scoring are not priorities in an unresponsive, hypoventilating client.
Question 3 of 3
A nurse assesses a newborn at 1 minute of life: heart rate 110, slow irregular respirations, some flexion of extremities, grimace to suction, and pink body with blue extremities. What is the Apgar score?
Answer: A. Heart rate over 100 = 2, slow/irregular respirations = 1, some flexion = 1, grimace = 1, and acrocyanosis (pink body, blue extremities) = 1. The total is 6. Scores of 7 to 10 are reassuring; 4 to 6 indicate moderate distress needing intervention.
Keep the streak going with more questions like these, each with a full rationale.
What is apgar scoring?
Five parameters are each scored 0, 1, or 2 for a maximum of 10. The acronym is Appearance, Pulse, Grimace, Activity, Respiration.
Key points to remember
- Appearance (color): 0 = blue/pale, 1 = body pink with blue extremities (acrocyanosis), 2 = completely pink.
- Pulse (heart rate): 0 = absent, 1 = below 100, 2 = above 100 bpm; heart rate is the most important indicator for resuscitation decisions.
- Grimace (reflex irritability): 0 = no response, 1 = grimace, 2 = vigorous cry or cough/sneeze.
- Activity (muscle tone): 0 = limp, 1 = some flexion, 2 = active motion; Respiration: 0 = absent, 1 = slow/irregular, 2 = strong cry.
- Scores 7 to 10 are normal, 4 to 6 indicate moderate distress, and 0 to 3 indicate severe distress requiring resuscitation.
Nursing priorities
- Assign and document the APGAR score at exactly 1 and 5 minutes; do not delay resuscitation to score.
- For a low score, provide warmth, dry and stimulate, position the airway, and suction mouth then nose.
- Initiate positive pressure ventilation if heart rate is below 100 bpm and the newborn is not breathing.
- Continue scoring every 5 minutes up to 20 minutes when the 5-minute score is below 7.
Patient teaching
- The Apgar is a quick check of how your baby is adjusting to life outside the womb, not a measure of long-term intelligence or health.
Red flags: report now
- A heart rate under 100 bpm or absent respirations requires immediate resuscitation, not just observation.
- A 5-minute score under 7 mandates continued scoring and escalation of support.
- Acrocyanosis (blue hands and feet) is normal in the first 24 hours; central cyanosis of the trunk and lips is never normal.
References
Clinical references for this topic
