NCLEX Review Apgar Scoring

Assess and document APGAR at 1 and 5 minutes

• Appearance
› Pink torso and extremities: Score = 2
› Pink torso, blue extremities: Score = 1
› Blue all over: Score = 0

• Pulse
› >100: Score = 2
› 100: Score = 1
› Absent: Score = 0

• Grimace (irritability)
› Vigorous cry: Score = 2
› Limited cry: Score = 1
› No response to stimulus: Score = 0

• Activity
› Actively moving: Score = 2
› Limited movement: Score = 1
› Flaccid: Score = 0

• Respiratory Effort
› Strong loud cry: Score = 2
› Hypoventilation, irregular: Score = 1
› Absent: Score = 0

Totals*
*8-10: normal; 4-6: moderate depression; 0-3: aggressive resuscitation