1. A new nurse in the delivery room for newborn care asks the senior
nurse about the purpose of Apgar scoring. How should the senior
nurse reply?
A. “It is a good predictor of neurologic status in preterm newborns.”
B. “It is necessary for deciding whether a newborn needs
resuscitation.”
C. “It is a tool to communicate the newborn’s general status and
response to resuscitation efforts.”
D. “It assists in identifying anomalies in a newborn.”
Rationale: The Apgar score is a quick assessment tool used to
indicate the newborn’s response to resuscitation and general status.
The Apgar score cannot be used to predict future neurologic status
because many newborns with low Apgar scores at birth will function
normally. A nurse or practitioner should not wait for a 1-minute Apgar
score to determine whether the newborn needs resuscitation.
However, the Apgar score may be used to evaluate the effectiveness
of resuscitation interventions in assisting the newborn through the
transition period. The score should not be used to assist in identifying
anomalies, which should be determined with physical examination and
radiologic and laboratory studies.
2. A newborn whose respirations are being assisted has a weak cry.
What should the nurse document as the Apgar score for respiratory
effort?
A. 0 for needing respiratory assistance
B. 1 for respiratory effort
C. 1.5 for crying effort
D. 2 for crying effort
Rationale: The Apgar score for respiratory effort should be 1 because
the newborn requires assistance breathing and has only a weak cry.
Crying effort is not a category within the Apgar score, but it may be
used to evaluate breathing effort or the response to stimulation. The
newborn would receive 0 for respiratory effort only if there were no
respiratory effort at all. Only whole numbers are used to calculate
Apgar scores.
3. A newborn has an Apgar score of 6 at 5 minutes. What are the
most appropriate actions for the nurse?
A. Continue resuscitation for 30 minutes to ensure full transition;
repeat Apgar assessment every 15 minutes until the score is 7 or
higher.
B. Swaddle the newborn and allow the family to bond.
C. Discontinue resuscitation and closely monitor the newborn.
D. Continue resuscitation measures and repeat Apgar assessment
every 5 minutes until the Apgar score is 7 or higher or until 20 minutes
of life.
Rationale: An Apgar score of 6 is not within the reassuring range of 7
to 10. Current neonatal resuscitation guidelines recommend repeating
the assessment every 5 minutes for 20 minutes during resuscitation
until the score is 7 or higher. An Apgar score of 6 indicates that the
newborn has not completely transitioned to extrauterine life; swaddling
is not appropriate because health care team members need to
observe the newborn. The newborn should be closely monitored, but
resuscitation should also be continued as needed. Resuscitation for
longer than 20 minutes may indicate the need for advanced care, and
the newborn should be transferred to an appropriate critical care unit
for evaluation by an experienced practitioner.
4. A newborn delivered at 37 weeks’ gestation was placed on the
prewarmed newborn warmer bed for the nurse to evaluate. What
should the nurse do next?
A. Start the Apgar timer and dry and stimulate the newborn.
B. Obtain the Apgar score and perform cord care.
C. Apply a nonrebreather mask to the newborn and obtain an Apgar
score.
D. Weigh and measure the newborn while evaluating the Apgar score.
Rationale: Upon the birth of a newborn, the nurse should start the
Apgar timer and begin warming, drying, and stimulating the newborn
per neonatal resuscitation guidelines. Cord care is not a priority
immediately after birth unless the newborn has active bleeding caused
by an improperly applied cord clamp. Nonrebreather masks are
inappropriate for neonatal use and inhibit the practitioner from
adequately observing respiratory effort. The Apgar score should be
completed before other assessments (e.g., measuring weight and
length) so the respiratory and heart rates can be accurately assessed.
5. Which technique may the nurse use to evaluate the newborn’s
heart rate for the Apgar score?
A. Obtaining a heart rate reading from the pulse oximeter
B. Palpating bilateral pedal pulses
C. Palpating the radial pulses
D. Auscultating an apical pulse
Rationale: The heart rate for the Apgar score should be obtained via
auscultation an apical pulse with a stethoscope or by palpating an
umbilical pulse. Radial and pedal pulses and pulse oximeter rates may
be difficult to obtain and may be inaccurate because of variances in
circulation quality.
6. An experienced nurse is explaining to a new nurse the components
of the Apgar score used in the immediate postdelivery period. What
are the components of the Apgar score?
A. Newborn’s heart rate, respiratory effort, muscle tone, reflex
irritability, and color
B. Newborn’s color, heart rate, cyanosis, muscle tone, and respiratory
effort
C. Newborn’s movement, heart rate, respiratory effort, muscle tone,
and reflex irritability
D. Newborn’s movement, heart rate, respiratory effort, color, and
reflex irritability
Rationale: The components of the Apgar score used in the immediate
postdelivery period are the newborn’s heart rate, respiratory effort,
muscle tone, reflex irritability, and color. Assessing the newborn for
cyanosis is a part of the color assessment and is not an independent
component. Assessing newborn movement is a part of the muscle
tone assessment and is not an independent component.
7. A full-term newborn was born 1 minute ago. The newborn’s heart
rate is 90 beats per minute. How many points does the newborn
receive for the heart rate assessment portion of the Apgar score?
A. 2 points
B. 0 points
C. 1 point
D. 1.5 points
Rationale: A maximum of 2 points is assigned to each of the five
components of the Apgar score. For the heart rate component:
0 = Absent heart rate
1 = Rate less than 100 beats per minute
2 = Rate greater than 100 beats per minute
A heart rate of 90 beats per minute is assigned a score of 1. Two
points are assigned if the heart rate is greater than 100 beats per
minute. Zero points are assigned if the heart rate is absent. Only
whole numbers are used to calculate Apgar scores, so a score of 1.5
would not be appropriate.
8. A newborn has a heart rate of 70 beats per minute after being
placed under the warmer, dried, and stimulated. Only 30 seconds
have passed since delivery. What should the newborn resuscitation
team do next?
A. Continue to stimulate the newborn until the 1-minute Apgar score
can be assigned.
B. Start resuscitation as appropriate before the 1-minute Apgar score
is assigned.
C. Start chest compressions before the 1-minute Apgar score is
assigned.
D. Ensure the accuracy of the heart rate with an ECG.
Rationale: Trained health care team members should begin
resuscitation measures immediately after delivery for depressed
newborns and should not wait for a 1-minute Apgar score to intervene.
Waiting would only delay resuscitative efforts and could lead to
metabolic or respiratory acidosis, making resuscitation more difficult.
The sooner the measures are initiated, the more likely they will be
successful. Chest compressions should not be started before positive
pressure ventilation is initiated. Although an ECG provides a more
accurate heart rate in the first 3 minutes of life, no evidence indicates
that actions based on that more accurate information affect outcomes;
thus, obtaining an ECG before initiating resuscitative measures would
be inappropriate.
9. Following labor induction, a mother with gestational diabetes
delivers a term newborn. One minute after birth, the heart rate is 120
beats per minute, respiratory effort is adequate with a good cry, reflex
irritability shows a good cry response to stimulation, some flexion of
the extremities is noted, and the newborn has bluish extremities
(acrocyanosis). Based on these findings, what is the 1-minute Apgar
score?
A. 7
B. 6
C. 8
D. 9
Rationale: A heart rate of 120 beats per minute is a score of 2; a
respiratory effort with a good cry is a score of 2; reflex irritability with a
good cry response is a score of 2; muscle tone of the extremities with
some flexion is a score of 1; and bluish extremities is a score of 1 for a
total 1-minute Apgar score of 8.
10. After delivery, a term newborn is placed in skin-to-skin contact with
the mother. The 1-minute Apgar is 9 with 1 point lost for color. The
mother expresses concern over the bluish tinge of her newborn’s
hands and feet. How does the nurse respond?
A. The nurse explains that this is a normal finding after delivery.
B. The nurse tells the mother that the practitioner will be called to
assess her newborn.
C. The nurse tells the mother not to worry and that the newborn is
fine.
D. The nurse explains that this may be an indication of a serious
circulation problem.
Rationale: The nurse should explain to the mother that this bluish
tinge in the extremities (peripheral cyanosis) is a common finding after
delivery. The practitioner does not need to assess the newborn
because the finding is normal. Telling the mother not to worry without
telling her that the bluish tinge is normal would be inappropriate.
Telling the mother that the bluish tinge may indicate a serious
circulation problem would be inaccurate.