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Maternal Newborn Nursing

22.1 Apgar Scoring

Maternal Newborn Nursing22.1 Apgar Scoring

Learning Objectives

By the end of this section, you will be able to:

  • Describe the purpose of the Apgar scoring assessment
  • Define the questions the neonatal nurse needs to ask before an infant is born in the birth room
  • Demonstrate all steps to complete an Apgar assessment

Immediately after birth, assessment of the newborn's overall physical condition is imperative to provide the most appropriate care for them. The Apgar assessment is performed by a member of the team caring for the newborn. The results of the assessment completed by the nurse will be shared with the provider and/or team. Though the newborn’s Apgar cannot predict morbidity and mortality, it can describe their condition and provide a record and evaluation of their fetal-to-neonatal transition.

In 1953, Virginia Apgar, MD, created a tool for assessing the newborn at 1 minute and again at 5 minutes post birth. This assessment included heart rate, respiration, reflex irritability, muscle tone, and color, all of which evaluate the response of the neonate when transitioning from life inside the uterus, or intrauterine life, to life outside the uterus, or extrauterine life. The tool is called the Apgar score (American College of Obstetricians and Gynecologists [ACOG], 2015) (Figure 22.2). This assessment score does not predict any neurologic outcome of the neonate, nor does it predict mortality or morbidity. However, if the score is less than 7 at 5 minutes post birth, both the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) recommend that another Apgar assessment be performed at 10 minutes (ACOG, 2015). A low score reflects the need for additional resuscitation effort.

Dr. Virginia Apgar assessing a newborn baby.
Figure 22.2 Virginia Apgar Dr. Virginia Apgar created the Apgar assessment tool to increase the survival rate of newborn babies. (credit: “Dr. Virginia Apgar welcoming world's newest guest” by Al Ravenna, World Journal Tribune/Library of Congress, Prints and Photographs Division, NYWT&S Collection, LC-USZ62-131540, Public Domain)

The nurse who assesses the newborn in the labor and delivery room is often referred to as the baby nurse or the nurse responsible for the neonate. The labor nurse must continue to assist the birthing person after birth; therefore, an additional nurse comes into the room at the time of birth and is responsible for the newborn after birth, a second patient who requires individualized care. The neonatal nurse’s role includes ensuring a fully stocked, correctly calibrated radiant warmer set to a safe temperature with all items necessary to facilitate resuscitation if needed and to assist with the transition to extrauterine life. Prior to delivery, the neonatal nurse needs to know the answers to the following questions:

  • How many babies are expected?
  • What is the gestational age of the newborn(s)?
  • What is the status (ruptured or intact) of the amniotic membranes, and what is the color of the amniotic fluid?
  • Were there any complications during pregnancy, labor, and/or birth?
  • Are there any untreated maternal risk factors, including group B streptococcus (GBS)–positive status, lack of prenatal care, hypertension, or hyperglycemia?
  • What, if any, medications is the birth parent taking or receiving prior to delivery?
  • Were there any congenital findings that would put the newborn at an increased risk at delivery?

The answers to those questions will prepare the nurse for what to expect when the newborn is delivered.

  • If there are multiple newborns, each will need a neonatal nurse.
  • If this is a preterm newborn, the nurse will need to notify the neonatal intensive care (NICU) team to join the room. Not all facilities offer this level of support and instead will have supportive personnel present to assist with resuscitative efforts. Up to four additional trained staff may be needed for complex birthing situations.
  • In some cases, the amniotic fluid shows evidence of meconium, the neonate’s first bowel movement consisting of amniotic fluid, mucus, lanugo, and bile. Meconium staining indicates the newborn passed the stool while in utero and is therefore at risk for aspirating. The nurse will need to monitor the newborn’s airway more closely at birth.
  • If other complications occurred during labor and birth, the nurse will need to adjust the plans for postdelivery care based on the complications.

These items must be taken into consideration as the nurse prepares to evaluate the neonate after the birth.

Newborn Muscle Tone (Activity)

The tension of healthy muscles that contribute a slight resistance to passive displacement of a limb is called muscle tone (Simon et al., 2023). The nurse assesses the degree to which the newborn is moving their extremities from flexion to extension. To receive the full 2 points for muscle tone/activity in this category, the newborn will have spontaneous, active movements in all extremities. If their arms and legs are flexed with little movement, the score will be a 1. If there is no movement and the newborn appears floppy with very little muscle tone, they will be given a score of zero for this category. This and every category will be reassessed in 5 minutes for any improvements.

A healthy term newborn will have elbows and hips that are flexed and have knees flexed up toward the abdomen, thus scoring 2 points on the Apgar assessment. A preterm or ill newborn may have more flaccid extremities and will therefore have points deducted from the Apgar score because they demonstrate less flexion in their muscle tone.

Pulse or Heart Rate

The nurse will auscultate the newborn’s heart rate at the apex or palpate at the junction of the umbilical cord and the skin. The average heart rate of a newborn is 110 to 160 beats per minute (bpm) (Children's Hospital of Philadelphia, 2022). If the heart rate is greater than 100 bpm, the nurse will score the newborn 2 points on the Apgar and go on to the next step of the assessment. However, if the newborn does not have a heartbeat or if the heart rate is less than 100 bpm, the nurse will need to initiate neonatal resuscitation immediately and call for more personnel, including the neonatal intensive care team, if the health system offers that level of support. A heart rate of less than 100 bpm receives a score of 1 on the Apgar assessment, whereas a score of zero indicates no heartbeat was found while auscultating or palpating.

Newborn Reflex Irritability or Grimace

The grimace response, or reflex irritability, also known as grimace response, describes the newborn’s response to stimulation from the nurse. For example, the nurse will assess the response from the newborn when they rub the soles of the newborn’s feet or back with a baby blanket to stimulate them. A normal newborn will cry or become agitated, while a compromised newborn won’t have much response. A cry or agitated response from a newborn to stimulation will receive the full 2 points; newborns who have mild reactions will receive a 1 on the Apgar assessment. Newborns who have an absent response to stimulation will receive a zero score.

Appearance of Newborn Skin Color

The nurse will assess the newborn for cyanosis, specifically on the trunk, and for pallor of the skin. Newborns will generally have acrocyanosis, cyanosis found only on the hands and feet, which is an expected finding that may last up to a week. Observation of acrocyanosis requires a score of 1 on the Apgar assessment. A newborn who is born pale or completely cyanotic is scored zero. The rare newborn who is completely pink is scored with a 2.


The nurse must pay careful attention to how the newborn is breathing, observing particularly for any adventitious breath sounds, any retractions or grunting, or a complete absence of breath sounds. Ideally, the nurse wants to see a newborn crying vigorously, and the nurse will work to dry and stimulate a newborn until the vigorous cry is achieved. Lack of spontaneous respiratory effort requires immediate intervention. (See Table 22.1 for a summary of the Apgar chart.)

Indicator 0 Points 1 Point 2 Points
A Activity (muscle tone) Absent, loose, flaccid without activity; floppy tone Arms and legs flexed with little movement Spontaneous, active motion with flexed muscle tone resisting extension
P Pulse Absent Less than 100 beats per minute Greater than 100 beats per minute
G Grimace (reflex or irritability in response to stimulation) Zero response to stimulation Limited response to stimulation Crying, movement, pulling away upon stimulation
A Appearance (skin color) Pale or blue Pink, but extremities are blue Entirely pink
R Respirations Not breathing Slow and irregular, weak or gasping Crying vigorously
Table 22.1 Apgar Chart

Apgar Scoring and Escalating the Level of Care

If a newborn has a 1-minute Apgar score of 6 or below, care is escalated as needed. A 5-minute Apgar score may be improved because of earlier assistance or, if it is under 7, may require the nurse to continue escalated care. Immediate care often means the 5-minute Apgar shows an improved newborn transition response. The nurse will need to continue resuscitative efforts by adding a 10-minute Apgar score and possibly initiating respiration therapy (more on that topic follows). If a neonate, whether term or preterm, is having difficulty breathing and is without proper muscle tone, they should be brought to the radiant warmer immediately post birth and given additional assessment (Hammer, 2021). Neonates who are having difficulties early in the transitional period need to have a thermometer attached to them to assess thermoregulation. These neonates need to stay between 36.5° C and 37.4° C (97.7° F and 99.3° F), as the risk for hypothermia is increased in newborns who are already struggling with the transition to life.

The newborn found to have insufficient respiratory effort or increased work of breathing can be supported with nursing interventions to assist during transition. These interventions include nasal suctioning with a bulb syringe, monitoring their oxygen saturations with a pulse oximeter, and repositioning to best maintain an open airway. If these supportive measures do not result in improved respiratory effort, positive pressure can be provided.

Unfolding Case Study

Newborn Care: Part 1

Brianne delivered a male infant, Marcus, vaginally. The delivery was complicated by shoulder dystocia. Apgar score was 5 at one minute and 9 at five minutes; birth weight, 3995 g (8 lbs 14 oz); length, 21 inches (52.5 cm).

PMH Maternal Medical History
  • Not currently taking any over-the-counter medications or herbal preparations
  • Negative history for STIs.
  • Denies any surgeries
  • Denies any previous pregnancies
Social History
Parents live in a two-bedroom apartment on the second floor in a building with only a freight elevator. They have a small dog named Candy.
Prenatal History
BP range 118-128/64-80
Fundal Height at 36 weeks 40 cm
Gestational Diabetes
36 years old, G1 P1
No known allergies
Nursing Notes Delivery Summary
After 20 hours of labor, Brianne had a vaginal delivery of a male infant with mild shoulder dystocia. Infant birth weight is 3995 g (8 lbs 14 oz). Placenta delivered spontaneously and intact by inspection. A second-degree vaginal laceration was repaired. Quantitative blood loss 450 mL
Father, Trey, present for labor and birth, very supportive
Marcus was dried off immediately after birth with warm blankets, and a hat was placed on his head. After the umbilical cord was clamped and cut, Marcus was placed directly on Brianne’s chest to begin skin to skin. Marcus and Brianne were covered with a warmed blanket.
Flow Chart Newborn assessment data at 30 minutes of age
Temp: 97.8º F (ax)
Heart rate: 160 bpm
Resp: 66 breaths
Pulse oximetry: 92%
Color: pink with acrocyanosis
Respirations: shallow, irregular
Nasal flaring
Marcus has not been interested in nursing.
Capillary glucose: 42
Provider’s Orders Observe in Labor and Birth unit
VS every 30 minutes ×2, then hourly ×2, then every 4 hours
Erythromycin ointment to both eyes within 1 hour of birth
Phytonadione 1 mg IM anterior thigh within 1 hour of birth
Encourage skin-to-skin contact until temperature stable
Breast feed on demand
Monitor intake and output until discharge
Initial bath at 4 hours of age
The nurse assesses Marcus at 30 minutes of age. Highlight the cues that demonstrate Marcus is having respiratory difficulty.
Which data obtained during the newborn assessment is of most concern?
  1. Respirations of 66
  2. Pulse oximetry of 92%
  3. Nasal flaring
  4. Capillary glucose of 42

Positive pressure ventilation is a form of respiratory therapy that involves the delivery of room air or a mixture of oxygen and room air by bag-valve mask into the lungs (Potchileev et al., 2022). Use of the mask requires the nurse to form a tight seal around the newborn’s mouth and nose. This is done by making a “C” shape with the thumb and first finger around the mask of the bag-valve mask and applying firm but gentle pressure to the newborn’s face while delivering breaths to the newborn at a rate of 30 to 60 per minute (Figure 22.3). The bag-valve mask should be connected to the oxygen flowmeter using 100% oxygen or blended oxygen and a self-inflating bag (Hammer, 2021). Positive pressure ventilation is initiated if the neonate is apneic, is gasping for air, or has a heart rate of less than 100 bpm. The nurse provides supportive care by way of thermoregulation, stimulation, and oxygenation. After effective respirations and circulation, thermoregulation is the most critical factor for successful transition to extrauterine life. Immature physiologic and anatomic states of the newborn put them at increased risk for hypothermia because they are unable to maintain their own safe body temperature. Additionally, the nurse will need to call a specially trained team, whether that is a neonatal resuscitation team or a pediatric provider, to assess the newborn. All nurses who choose to work in an obstetrics unit will eventually be trained in neonatal resuscitation and know these steps, so that if a newborn needs additional assistance with transition, the nurse will be qualified to help while waiting for the NICU team to arrive. Figure 22.4 shows the steps in the neonatal resuscitation algorithm.

Caregiver placing a neonatal bag valve mask on a newborn.
Figure 22.3 Neonatal Bag-Valve Masks Neonatal bag-valve masks are smaller than adult bag-valve masks but made in a similar fashion. The nurse uses their thumb and first finger in a “C” shape to ensure the mask forms a tight seal around the neonate’s mouth and nose. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
A chart detailing the Neonatal resuscitation algorithm.
Figure 22.4 Neonatal Assessment Algorithm This is the neonatal resuscitation (NRP) guideline algorithm that is used to guide immediate resuscitation in the immediate postbirth period. CPAP, continuous positive airway pressure; ETT, endotracheal tube; GA, gestational age; HR, heart rate; IV, intravenous; PPV, positive pressure ventilation; UVC, umbilical venous catheter. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

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