The nurse evaluates a newborn immediately after birth to have a heart rate of 90, blue extremities, no response to a catheter in the naris, weak respiratory effort, and no muscle tone. The nurse should document the APGAR as:


•APGAR stands for Appearance, Pulse, Grimace, Activity, and Respiration. Each is rated as 0, 1, or 2, then all scores are added up.

•For appearance: 0 is pale or blue all over, 1 is blue at the extremities, and 2 is body and extremities pink.

•Pulse rate: 0 is heart rate absent, 1 is heart rate below 100, 2 is heart rate above 100.

•Reflex irritability (Grimace): 0 is absence of response to stimulation, 1 is a feeble cry or grimace after stimulation, 2 is cry or pulls away after stimulation.

•Muscle tone: 0 is none, 1 is some flexion, and 2 is flexed arms and legs that can resist extension.

•Respiration: 0 is absent, 1 is weak and irregular, and 2 is strong cries.

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