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Apgar Score: Overview and Practice Questions (2024)

by | Updated: May 9, 2024

The Apgar score, developed by Dr. Virginia Apgar in 1952, remains one of the most widely used tools in assessing the health of newborns.

This simple yet effective scoring system evaluates a newborn’s vital signs at one and five minutes after birth, providing valuable insights into their immediate well-being.

With its ability to quickly identify infants who may require immediate medical attention, the Apgar score has revolutionized neonatal care and significantly reduced infant mortality rates worldwide.

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What is the Apgar Score?

The Apgar score is a quick assessment performed on newborns at one and five minutes after birth to evaluate their health. It rates five criteria—skin color, heart rate, reflexes, muscle tone, and breathing effort—each on a scale from 0 to 2, with a total possible score of 10. Higher scores indicate better overall health for the newborn.

Apgar score chart illustration

Apgar Scoring System Criteria

The Apgar scoring system is used to assess the immediate health status of a newborn at one and five minutes after birth. Each of the five criteria is scored on a scale from 0 to 2, and the scores are summed to provide an overall measure of the baby’s physical condition.

Here are the criteria:

  • A – Appearance
  • P – Pulse
  • G – Grimace
  • A – Activity
  • R – Respiratory Effort

Appearance

Appearance is a method for assessing the baby’s skin color to gauge oxygenation. A score of 0 indicates blue or pale skin all over, a score of 1 signifies blue at the extremities with a pink body, and a score of 2 is given when the skin is completely pink.

Pulse

Pule is used to measure the baby’s heart rate. A score of 0 is assigned if there is no heartbeat, 1 if the heart rate is below 100 beats/min, indicating a slower rate, and 2 for a heart rate above 100 beats/min, which is considered normal.

Grimace

Grimace, or reflex irritability, is a criterion used to evaluate the newborn’s response to stimulation, such as a light pinch. A score of 0 means no response, 1 for a grimace or feeble response, and 2 for a prompt response such as a sneeze, cough, or vigorous cry.

Activity

Activity is used to check the baby’s muscle tone and activity. A score of 0 indicates no movement (floppy), 1 for some movement of extremities, and 2 for active motion or well-flexed limbs.

Respiratory Effort

This assesses the baby’s breathing effort. A score of 0 is given if the baby is not breathing, 1 if the breathing is weak, slow, or irregular, and 2 for strong, robust crying that indicates normal breathing.

Note: Each component of the APGAR score is critical for determining the immediate medical needs of a newborn.

Apgar Score Results

The Apgar score results range from 0 to 10, with the score derived from assessing five key signs in a newborn at one and five minutes after birth.

The interpretation of the results is generally as follows:

  • Severe Distress: Newborns with scores of 0 to 3 are typically in critical condition and may require immediate, vigorous resuscitation and medical intervention.
  • Moderate Difficulty: Newborns with scores of 4 to 6 may be having some difficulty adapting to the outside environment and could need medical assistance, such as oxygen and some resuscitation procedures.
  • Normal: A score from 7 to 10 suggests that the newborn is in good health. Infants with these scores typically require routine post-delivery care.

The Apgar score is designed to quickly summarize the health of the newborn to determine if immediate medical care is necessary. However, it is not intended to predict long-term health issues.

If the scores remain low after repeated tests, more in-depth diagnostic procedures may be necessary to understand and address any underlying conditions.

How is the Apgar Test Performed

The Apgar test is performed on newborns to quickly assess their health status and determine if any immediate medical care is needed.

Here’s how it is typically conducted:

  • Timing: The test is conducted twice—first at one minute after birth and again at five minutes after birth. If there are concerns about the baby’s condition or if the score at five minutes is low, the test may be repeated at 10 minutes.
  • Scoring: Each of the five components of the Apgar score—Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing effort)—is evaluated and scored from 0 to 2.
  • Assessment: The test is typically performed by a pediatrician, nurse, midwife, or respiratory therapist who observes these signs and assigns the scores. Each sign is quickly evaluated over the first few minutes of life outside the womb.
  • Interpretation: The scores from each category are summed to create a total score out of 10. This score helps healthcare providers understand whether the baby needs immediate medical treatment. A higher score indicates fewer health issues.
  • Response: Depending on the Apgar score, medical professionals might take various actions. A low score (especially under 4) might require resuscitation and urgent medical attention, while a score between 4 and 6 might lead to some medical intervention. Scores of 7 and above generally mean the baby is in good health.

Note: This quick and effective test is a critical part of neonatal care, helping ensure that newborns receive appropriate and immediate medical attention as needed.

Apgar Score Practice Questions

1. What is the definition of Apgar score?
The APGAR score is a quick assessment tool used to evaluate the health of newborns immediately after birth.

2. Who invented the Apgar score?
It was developed by Dr. Virginia Apgar in 1952.

3. How often should the Apgar score be assessed on a neonate?
1 and 5 minutes after birth

4. You’re assessing the one-minute Apgar score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 130, pink body and hands with cyanotic feet, weak cry, flexion of the arms and legs, active movement and crying when stimulated. What is your patient’s Apgar score?
The Apgar score is 8.

5. You’re assessing the one-minute Apgar score of a newborn baby. On assessment, you note the following about your newborn patient: weak cry, some flexion of the arm and legs, active movement and cries to stimulation, heart rate 145, and pallor all over the body and extremities. What is your patient’s Apgar score?
The Apgar score is 6.

6. A newborn’s five-minute Apgar score is 5. Which of the following nursing interventions will you provide to this newborn?
Some resuscitation assistance, such as oxygen, rubbing the baby’s back, and reassessing the Apgar score.

7. When would you reassess the Apgar score?
The Apgar score is performed at 1 minute and 5 minutes after birth and reassessed at 10 minutes (5 minutes later) after birth if the score is 6 or less.

8. You’re assessing the five-minute Apgar score of a newborn baby. On assessment, you note the following about your newborn patient: pink body and hands with cyanotic feet, heart rate 109, grimace to stimulation, flaccid, and irregular cry. What is your patient’s Apgar score?
The Apgar score is 5.

9. You’re assessing the five-minute Apgar score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 97, no response to stimulation, flaccid, absent respirations, and cyanotic throughout. What is your patient’s APGAR score?
The Apgar score is 1.

10. A newborn’s one-minute Apgar score is 8. What should you recommend?
Routine post-delivery care

11. You’re assessing the one-minute Apgar score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 101, cyanotic body and extremities, no response to stimulation, no flexion of extremities, and strong cry. What is your patient’s Apgar score?
The Apgar score is 4.

12. Starting at which number on the Apgar score should you need to start resuscitation efforts?
An Apgar score of 6.

13. You are assessing the one-minute Apgar score for a newborn. She is pink all over and has a pulse of 130. As you dry her off, she begins to cry vigorously and kick her legs. What is her Apgar score?
The Apgar score is 10.

14. A newborn has a pink torso but blue hands and feet. Her pulse rate is 60, and she does not respond to your attempts to stimulate her. She also appears to be limp and taking slow, gasping breaths. What is her Apgar score?
The Apgar score is 3.

15. One minute after birth, a newborn is actively crying in response to your bulb syringe. His body is pink, and he is moving his extremities which are blue. His heart rate is 110. What is his Apgar score?
The Apgar score is 9.

16. A newborn has a weak cry and is curling his arms and legs. His extremities are blue and his body is pink. He has a pulse of 90 and weak respirations. What is his Apgar score?
The Apgar score is 5.

17. What is measured with the Apgar score?
Breathing effort, heart rate, muscle tone, reflexes, and skin color.

18. What is the Apgar scale?
It is a quick, objective method to comparatively evaluate the vital functions of the newborn

19. What is the maximum score an infant can receive on any one of the 5 criteria?
2

20. What is the lowest score an infant can receive on any one criterion?
0

21. What does an Apgar score of 10 mean?
The infant is in good health.

22. What does an Apgar score of 0 mean?
The infant is stillborn.

23. When is the Apgar score typically assessed after birth?
The Apgar score is typically assessed at 1 minute and 5 minutes after birth.

24. What do the letters in “Apgar” stand for?
The letters in “Apgar” stand for Appearance, Pulse, Grimace, Activity, and Respiration.

25. What is the purpose of the Apgar score?
The purpose of the Apgar score is to quickly assess the newborn’s overall condition and need for immediate medical intervention after birth.

26. A newborn’s one-minute Apgar score is 7. What does this indicate?
A one-minute Apgar score of 7 indicates that the newborn is in generally good condition, with some minor adjustments possibly needed.

27. How does a healthcare provider calculate the total Apgar score?
A healthcare provider adds up the individual scores given for each criterion (Appearance, Pulse, Grimace, Activity, and Respiration) to obtain the total Apgar score.

28. What is the significance of the 5-minute Apgar score compared to the 1-minute score?
The 5-minute Apgar score provides an indication of the newborn’s response to resuscitative efforts and overall stability compared to the 1-minute score, which reflects the immediate condition after birth.

29. What is the purpose of the Apgar score being reassessed at 5 minutes after birth?
The 5-minute Apgar score helps to evaluate the newborn’s response to resuscitative efforts and provides additional information about their condition compared to the 1-minute score.

30. How is each criterion of the Apgar score assessed?
Each criterion of the Apgar score is assessed independently, assigning a score of 0, 1, or 2 based on specific observations related to that criterion.

31. How does a low Apgar score influence the immediate care of a newborn?
A low Apgar score may indicate the need for immediate medical intervention, such as resuscitation or additional monitoring, to support the newborn’s transition to life outside the womb.

32. What factors can influence a newborn’s Apgar score?
Factors such as maternal medication use, fetal distress during labor, premature birth, and congenital anomalies can influence a newborn’s Apgar score.

33. What is the significance of a low Apgar score at 5 minutes after birth?
A low Apgar score at 5 minutes after birth may indicate ongoing issues with the newborn’s health and may prompt further medical evaluation and intervention.

34. How does the Apgar score assist healthcare providers in decision-making?
The Apgar score provides healthcare providers with a standardized way to quickly assess and communicate the newborn’s condition, which helps guide decisions regarding immediate care and intervention.

35. Can the Apgar score predict long-term outcomes for newborns?
While the Apgar score provides valuable information about the newborn’s immediate condition, it is not intended to predict long-term outcomes. Other factors and assessments are considered for long-term prognosis.

36. How can healthcare providers ensure accuracy and consistency when assessing the Apgar score?
Healthcare providers can ensure accuracy and consistency by using standardized criteria and guidelines for assessing each component of the Apgar score and by training staff in its proper application.

37. What actions should be taken if a newborn’s Apgar score is persistently low?
If a newborn’s Apgar score is persistently low, healthcare providers may initiate additional interventions, such as providing respiratory support, administering medications, or transferring the newborn to a higher level of care.

38. Is the Apgar score used beyond the immediate postnatal period?
While the Apgar score is primarily used in the immediate postnatal period, it may also be referenced during subsequent assessments and medical evaluations to provide context for the newborn’s initial condition.

39. Can variations in Apgar scoring occur between different healthcare providers?
Yes, variations in Apgar scoring can occur between different healthcare providers due to differences in interpretation, observation skills, and environmental factors. Regular training and calibration can help minimize these variations.

40. How does a newborn’s gestational age affect the interpretation of the Apgar score?
Gestational age can influence the interpretation of the Apgar score, as premature newborns may have lower scores initially but improve over time, while full-term newborns are expected to have higher scores.

41. What is the significance of the Apgar score in determining the need for neonatal intensive care unit (NICU) admission?
A low Apgar score may indicate the need for NICU admission to provide specialized care and monitoring for newborns who require additional support in the immediate postnatal period.

42. Can maternal factors, such as maternal health conditions or medications, affect the Apgar score?
Yes, maternal factors, including maternal health conditions such as diabetes or hypertension, as well as medications administered during labor, can influence the newborn’s condition and affect the Apgar score.

43. How does the Apgar score complement other assessments of newborns, such as umbilical cord blood gas analysis?
The Apgar score provides a quick, bedside assessment of the newborn’s condition, while umbilical cord blood gas analysis provides more detailed information about the newborn’s oxygenation and acid-base status, complementing the Apgar score in guiding clinical management.

44. Are there circumstances where the Apgar score may not accurately reflect the newborn’s condition?
Yes, there are circumstances where the Apgar score may not accurately reflect the newborn’s condition, such as when maternal medications affect the newborn’s responsiveness or when congenital anomalies impact the newborn’s appearance or reflexes.

45. What is a normal Apgar score?
A normal Apgar score is typically 7 or above.

46. What does the G stand for in Apgar?
The G stands for “Grimace” in Apgar.

47. What does the second A in Apgar stand for?
The second A in Apgar stands for “Activity.”

48. What does an Apgar score of 2 mean?
An Apgar score of 2 indicates the highest level of performance for that criterion.

49. What is a normal Apgar score at 1 minute?
A normal Apgar score at 1 minute is typically 7 or above.

50. What is the highest Apgar score possible?
The highest Apgar score possible is 10.

Final Thoughts

The Apgar score remains an indispensable tool in neonatal care, serving as a first-line indicator of a newborn’s general health status and immediate medical needs.

While it does not predict long-term health outcomes, its role in guiding prompt medical interventions for newborns cannot be overstated.

By effectively identifying those in need of immediate care, the Apgar score helps optimize the health outcomes of newborns, making it a cornerstone of pediatric healthcare practices worldwide.

John Landry, BS, RRT

Written by:

John Landry, BS, RRT

John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.

References

  • Faarc, Walsh Brian PhD Rrt-Nps Rrt-Accs Rpft. Neonatal and Pediatric Respiratory Care. 5th ed., Saunders, 2018.
  • Simon LV, Hashmi MF, Bragg BN. APGAR Score. [Updated 2023 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024.

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