Question

The nurse is performing an Apgar assessment on a newborn client at 1 minute of life. The newborn is completely blue, has a heart rate of 110/min, and is emitting a weak cry. Active movement and flexion of extremities are noted and the newborn grimaces when nares are suctioned. Which Apgar score should the nurse assign this newborn?

1.Apgar score of 4(12%)
2.Apgar score of 5(28%)
3.Apgar score of 6(46%)
4.Apgar score of 8(12%)

Answer 1

The newborn's Apgar score is 6(46%) option (3), which is calculated based on the five criteria: appearance, pulse, grimace, activity, and respiration. The score suggests the baby is in the borderline range and may require some medical assistance. A follow-up assessment will be important for determining additional needs.

Step-by-step explanation:

The nurse should assign an Apgar score of 6(46%) option (3) to this newborn. According to the five criteria used for the Apgar assessment - appearance (skin color), pulse (heart rate), grimace (reflex), activity (muscle tone), and respiration - the newborn's scores are:

• Appearance: Completely blue indicating a score of 0.
• Pulse: Heart rate of 110/min, which warrants a score of 2.
• Grimace: Newborn grimaces when nares are suctioned, earning a score of 1.
• Activity: Active movement and flexion of extremities, indicating a score of 2.
• Respiration: A weak cry, denoting a score of 1.

These individual scores add up to a total Apgar score of 6 (0 + 2 + 1 + 2 + 1 = 6). While a score of 7 or higher is considered normal, a score of 6 suggests that the newborn is in the borderline range in terms of immediate well-being, and they might need some medical assistance but not necessarily an emergency situation. Further evaluation at the 5-minute mark will be important for determining the need for additional medical intervention.