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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A nurse is evaluating a newborn to determine the 5-minute APGAR score. The newborn's assessment findings are as follows:

- Heart rate: 112 beats/min
- Respiratory effort: Slow, weak cry
- Muscle tone: Some flexion of extremities
- Reflex irritability: Grimace in response to stimulation
- Color: Body pink, hands and feet cyanotic

Calculate the newborn's APGAR score.

Answer: 6 points

Answer

6
The APGAR score is calculated based on five parameters, each scored from 0 to 2. This newborn receives 1 point for Appearance (acrocyanosis), 2 points for Pulse (>100 bpm), 1 point for Grimace (grimace to stimulation), 1 point for Activity (some flexion), and 1 point for Respiration (weak cry). The total sum is 1 + 2 + 1 + 1 + 1 = 6 points.

Step-by-Step Solution

1
Assign points for Appearance (Color)
1 point
The newborn has a pink body but cyanotic extremities (acrocyanosis), which warrants 1 point instead of 2 (completely pink) or 0 (completely blue/pale).
2
Assign points for Pulse (Heart rate)
2 points
A heart rate of 112 beats/min is above the 100 beats/min threshold, earning the maximum of 2 points.
3
Assign points for Grimace (Reflex irritability)
1 point
A grimace response to stimulation scores 1 point, whereas a vigorous cry or active withdrawal would score 2 points.
4
Assign points for Activity (Muscle tone)
1 point
Demonstrating only some flexion of the extremities earns 1 point, as opposed to active motion which would earn 2 points.
5
Assign points for Respiration (Respiratory effort)
1 point
A slow, weak cry scores 1 point, unlike a good, strong cry which would score 2 points.
6
Calculate the total score
6 points
1 (Color) + 2 (Pulse) + 1 (Grimace) + 1 (Activity) + 1 (Respiration) = 6.

Key Concept

APGAR Scoring Interpretation
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Topics

Ante/Intra/Postpartum and Newborn Care

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