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.