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Difficulty: EasyAnte/Intra/Postpartum and Newborn Care

A nurse is performing an assessment on a newborn 11 minute after birth. The nurse notes the following findings:
- Heart rate: 114114 beats/min
- Respiratory effort: Loud, vigorous cry
- Muscle tone: Active, spontaneous movement of all extremities
- Reflex irritability: Vigorous cry and pulls away during bulb syringe suctioning
- Color: Pink trunk with bluish hands and feet

Calculate the newborn's 11-minute APGAR score. (Enter only the final numeric value)

Answer: 9

Answer

9
The correct answer is 9. The APGAR score evaluates five categories on a scale of 0 to 2. The newborn scores 1 point for color (acrocyanosis) and 2 points each for heart rate (>100), reflex irritability (pulls away), muscle tone (active movement), and respiratory effort (vigorous cry). The total sum is 9.

Step-by-Step Solution

1
Evaluate Appearance (Color).
1 point
The newborn has a pink trunk with bluish hands and feet, which is known as acrocyanosis. This is a normal finding at 1 minute but deducts one point from a perfect score.
2
Evaluate Pulse (Heart Rate).
2 points
The heart rate is 114 beats/min. Any heart rate greater than 100 beats/min receives the maximum of 2 points.
3
Evaluate Grimace (Reflex Irritability).
2 points
Vigorously crying and pulling away during stimulation (suctioning) indicates excellent reflex irritability, earning 2 points.
4
Evaluate Activity (Muscle Tone).
2 points
Active, spontaneous movement of all extremities indicates strong muscle tone, scoring 2 points.
5
Evaluate Respiration (Respiratory Effort).
2 points
A loud, vigorous cry demonstrates optimal respiratory effort, scoring 2 points.
6
Calculate the total APGAR score.
9
The sum of the five individual components is 1+2+2+2+2=91 + 2 + 2 + 2 + 2 = 9.

Key Concept

APGAR Scoring System
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Topics

Ante/Intra/Postpartum and Newborn Care

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