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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A nurse is evaluating a newborn at 11 minute after birth. The nurse notes the following findings: heart rate is 114114 beats/min; the newborn has a weak, irregular cry; arms and legs are flaccid; the newborn grimaces when the nares are suctioned; and the trunk is pink with cyanotic hands and feet.

Calculate the newborn's 11-minute Apgar score.

Answer: 5

Answer

5
The Apgar score evaluates five parameters on a scale of 00 to 22. For this newborn: Heart rate >100>100 is 22; weak cry is 11; flaccid tone is 00; grimace is 11; and acrocyanosis is 11. The total calculated score is 55.

Step-by-Step Solution

1
Assess Heart Rate
2 points
The heart rate is 114114 beats/min, which is greater than 100100 beats/min.
2
Assess Respiratory Effort
1 point
The newborn exhibits a weak, irregular cry rather than a strong, vigorous cry.
3
Assess Muscle Tone
0 points
The newborn's arms and legs are flaccid, showing no flexion or active movement.
4
Assess Reflex Irritability
1 point
The newborn only grimaces in response to suctioning, rather than pulling away, coughing, or sneezing.
5
Assess Color
1 point
The newborn has a pink trunk with cyanotic extremities, which is classified as acrocyanosis.
6
Calculate Total Score
5
Sum the points from all five Apgar categories: 2+1+0+1+1=52 + 1 + 0 + 1 + 1 = 5.

Key Concept

Apgar Scoring System
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Topics

Ante/Intra/Postpartum and Newborn Care

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