Newborn Assessment Exam Review Questions and Complete Solutions

APGARS and interventions assesment begins immediately after birth assessments of - respirations, crying - reflexes, irritability - heart rate, pulse - color, body and extremeties -tone (muscle tone) interventions based upon these assessments to begin immediately Do NOT wait for one minute APGAR to begin interventions - gives you a picture at the time how that baby is doing; a low score you cannot make assumptions - looking at airway, breathing, circulation - look at muscle tone - do it at one minute and five minutes - if you need to do resuscitation then you do it at 10 minutes and then maybe 15 minutes Heart rate: 0= absent 1= slow, less than 100/min 2= greater than 100/min Respiratory rate 0= absent 1= slow, weak cry 2= good cry Muscle tone 0= flaccid 1= some flexion of extremeties 2= well-flexed reflex irritability 0= none 1= grimace 2= cry color 0= blue, pale 1= pink body, cyanotic hands and feet (acrocyanosis) 2= completely pink an apgar score is assigned based on a quick review of systems that is completed at 1 and 5 minutes of life. this allows the nurse to rapidly assess extrauterine adaptation and intervene with appropriate nursing actions 0-3 indicates severe distress 4-6 indicates moderate difficulty 7-10 indicates minimal or no difficulty with adjusting to extrauterine life the APGAR score developed by virginia apgar, MD evaluates five variables on a scale of 0-2 total score ranges from 0-10 assigned at 1 and 5 minutes additional scoring if the 5 minute score is 7 limitations - measures a depression of vital signs - dependent upon subjective evaluation there is some subjectivity; a person is different from another person in scoring targeted SpO2 after birth 1 minute= 60-65% 2 minutes= 65-70% 3 minutes= 70-75% 4 minutes= 75-80% 5 minutes= 80-85% 10 minutes= 85-95%