Question

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

A. 2
B. 3
C. 5
D. 1

Answer 1

Using the APGAR scoring criteria, the newborn's APGAR score is calculated as 3, which is considered critical and indicates a need for immediate medical intervention.

Step-by-step explanation:

The APGAR score is a test given to newborns soon after birth to assess their general well-being. The score is based on five criteria: appearance (skin color), pulse (heart rate), grimace response (reflex), activity (muscle tone), and respiration effort. In the given scenario, the newborn has a heart rate of 90 (1 point), blue extremities (1 point for appearance), no response to a catheter in the naris (0 points for grimace), weak respiratory effort (1 point), and no muscle tone (0 points). Adding these together gives the newborn an APGAR score of 3.

This score is considered critical, as any score lower than 7 at the 5-minute mark can indicate the need for medical assistance. A score below 5 suggests an emergency situation where immediate intervention is required. High scores, typically above 8, indicate the baby has transitioned well from the womb to outside world.