NCLEX-RN practice › Health Promotion and Maintenance
NCLEX newborn question: calculate the Apgar score
Health Promotion and Maintenance · Multiple choice · Clinical judgment step: Analyze cues
Client record
1-minute assessment
- Heart rate
- 90/min
- Respiratory effort
- slow, irregular
- Muscle tone
- some flexion of extremities
- Reflex irritability
- grimace with suction
- Color
- body pink, hands and feet blue
The nurse assesses a newborn at 1 minute after birth. What is the Apgar score?
- A. 3
- B. 5
- C. 7
- D. 8
Show the answer and rationales
Answer: B
Each Apgar sign scores 0 to 2. Heart rate below 100, weak irregular breathing, some flexion, grimace and acrocyanosis each score 1, for a total of 5 (moderate depression).
- A. Incorrect. This undercounts; each finding scores 1.
- B. Correct. Correct. Heart rate below 100 = 1, slow irregular breathing = 1, some flexion = 1, grimace = 1, acrocyanosis = 1. Total 5.
- C. Incorrect. This would need at least two findings to score 2, such as a heart rate above 100 and a good cry.
- D. Incorrect. This overcounts; none of the findings scores 2.
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