APGAR Scoring
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Physical examination
Perform at 1 minute and 5 minutes following delivery
Evaluate newborn’s ability to adjust to extrauterine life.
Identify any resuscitation needs.
Five Signs you’ll assess
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2.
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heart rate
respiratory effort
muscle tone
reflex irritability
color
For each sign you will score 0 1 2 optimal total score of 10.
 Determine muscle tone by flexion and movements of the extremities. A score of zero means his extremities are
flaccid, 1 means there is some flexion of some extremities, and 2 means his extremities are well flexed.
 Evaluate reflex irritability by gently rubbing the soles of newborn’s feet to illicit a response. A score of zero
means no response, 1 means he responded with the grimace, and 2 he responded with a cry.
 Evaluate the newborn’s heart rate by auscultating at the apex with the neonatal stethoscope. A score of zero
means that heart rate is absent, 1 means the heart rate is below 100 beats per minute, 2 means it is above 100
beats per minute.
 Next, observe the movement of chest wall to assess respiratory effort. An Apgar score of zero means the
respiratory effort is absent, a score of 1 means the newborn has minimal respiratory effort and a weak cry, a
score of 2 there are a regular respiration and a good strong cry.
 Finally, note the newborn’s color, a score of zero means the newborn’s color is pale or blue, 1 means he has a
pink body with blue extremities known as acrocyanosis, and a score of 2 means he is completely pink.
What Apgar score would you give the newborn in the video if the heart rate is 120/min?
 A score of 7-10 is within the expected reference range and indicates that the newborn is adjusting to
extrauterine life adequately. Lowers score may warrant resuscitative interventions.
 Apgar scoring results score between 0-3 severe reflects severe distress. Score of 4-6 indicate moderate difficulty
with extrauterine life adjustment. Score 7-10 indicate that the newborn is adapting adequately to extrauterine
life.
 This newborn receives the score of 9 at 1 minute, and 9 at 5 minutes, he lost 1 point for color. If the newborn
needs a resuscitation immediately at delivery, initiate it before 1 minute Apgar scoring. Be certain to check all
resuscitative equipment prior to the delivery to make sure this function properly and document the findings and
intervention in the newborn’s medical record.
• Maternal medications can affect Apgar scoring of the newborn. Other factors that can affect the Apgar score include
the gestational age of the newborn, trauma during childbirth, hypovolemia, hypoxia, and congenital anomalies. The
nurse should conduct the Apgar score at 1 min and 5 minutes following birth. Place the newborn skin to skin on the
mother's chest. Rationale: The greatest risk to this newborn is injury from hypothermia; therefore, the priority action is
to place the newborn skin to skin on the mother's chest to assist with the newborn's transition to extrauterine life.