The nurse evaluates a newborn immediately after birth to have a heart rate of 90, blue extremities, no response to a catheter in the
Explanation
Heart rate of 90: 1 pt
Blue extremities: 1 pt
No response to a catheter in the nares: 0
Weak respiratory effort: 1 pt
No muscle tone: 0
The APGAR is: 3 pts
• 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 cries 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.