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Newborn Assessment: APGAR, Reflexes, and Red Flags

Newborn Assessment: APGAR, Reflexes, and Red Flags

By Dr. Jamila Abudheil, PhD, RN·4 min read·Updated 2026-10-06
The short answer

APGAR scores five signs (heart rate, respiratory effort, muscle tone, reflex irritability and colour) from 0 to 2 at one and five minutes, where 7 to 10 is reassuring, 4 to 6 needs intervention and 0 to 3 needs resuscitation. The score guides immediate care but does not predict long-term outcome, and a low one-minute score that rises by five minutes is common and reassuring.

Newborn Transition, Assessment and Apgar▶ Watch this lesson
Newborn Transition, Assessment and Apgar

Newborn transition, assessment and Apgar: the normal values, the reflexes and the red flags.

From the Intensive NCLEX Course. See the course; the full video library is part of Pro and Ultimate.

APGAR score

Done at 1 minute and 5 minutes after birth. Five things, each scored 0, 1, or 2.

012
A — Appearance (color)Blue or pale all overBody pink, hands and feet bluePink all over
P — PulseAbsentUnder 100Over 100
G — Grimace (reflex)No responseGrimaceCry, cough, sneeze
A — Activity (tone)LimpSome flexionActive movement
R — RespirationsAbsentSlow, weak, irregularStrong cry

Scoring:

  • 7 to 10 — normal
  • 4 to 6 — moderately depressed, needs support
  • 0 to 3 — severely depressed, needs resuscitation

Blue hands and feet with a pink body is common and normal in the first hours. It scores 1 for appearance, and it is not a cause for alarm on its own.

Important: APGAR describes the baby’s condition; it does not by itself dictate resuscitation, which begins based on assessment rather than waiting for a score.

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Normal newborn values

Normal
Heart rate110–160
Respiratory rate30–60
TemperatureAbout 36.5–37.5°C
Blood glucoseVaries by protocol; low glucose is common and monitored

Newborns lose heat fast. Dry them immediately, put on a hat, use skin-to-skin contact or a warmer, and avoid drafts. Cold stress increases oxygen use and can cause low blood sugar.

Four ways a newborn loses heat: conduction to a cold surface, convection from moving air, evaporation of moisture from the skin, radiation to nearby cold objects, each with its prevention
A newborn loses heat four ways; the nurse blocks all four: warm surfaces, no drafts, dry promptly, keep away from cold windows.

Newborn reflexes

ReflexWhat it isUsually gone by
Moro (startle)Arms fling out then come together when startledAbout 3–6 months
RootingTurns toward a touch on the cheekAbout 3–4 months
SuckingSucks when the mouth is touchedGradually becomes voluntary
Palmar graspGrips a finger placed in the palmAbout 3–4 months
Plantar graspToes curl when the sole is touchedAbout 12 months
BabinskiToes fan out when the sole is strokedAbout 12–24 months
Tonic neck (fencing)Head turns, same-side arm extendsAbout 3–4 months
SteppingAppears to walk when held uprightAbout 2 months

Two points the exam tests:

A missing reflex in a newborn is abnormal.

A reflex that persists past the expected age may indicate a neurological problem. Babinski is the exception — it is normal in infants and abnormal only in older children and adults.

Red flags in the newborn

Breathing:

  • Grunting — a serious sign of respiratory distress
  • Nasal flaring
  • Chest retractions — the skin pulling in between and below the ribs
  • Respiratory rate over 60 at rest
  • Central cyanosis — blue lips, tongue, and trunk (blue hands and feet alone is normal)
  • Apnea — pauses in breathing over about 20 seconds

Any of these needs immediate attention.

Feeding and output:

  • Poor feeding or refusing to feed
  • No urine in the first 24 hours
  • No meconium stool in the first 24 to 48 hours
  • Persistent vomiting, especially if green (bile-stained) — this suggests an obstruction

Neurological:

  • A high-pitched shrill cry — associated with neurological problems and with drug withdrawal
  • Jitteriness — may indicate low blood sugar or withdrawal
  • Lethargy or difficulty waking
  • A bulging fontanel — increased pressure in the head
  • A sunken fontanel — dehydration
  • Seizure activity

Jaundice:

  • Jaundice in the first 24 hours is always abnormal and needs evaluation
  • Jaundice after 24 hours is common and is monitored
  • Feed frequently — this helps clear bilirubin through the stool

The “first 24 hours” rule for jaundice is heavily tested.

Temperature:

  • Low temperature is more common than fever in newborn illness
  • A newborn with an infection may have a LOW temperature, not a high one
Why glucose can fall after birth in the infant of a mother with diabetes: maternal glucose crossed the placenta and raised fetal insulin; after birth the glucose supply stops while insulin stays high
The infant of a diabetic mother: jittery, sweaty, poor feeding in the first hours means hypoglycemia. The insulin was built for the mother's glucose, which stopped at the cord clamp.

Umbilical cord care

  • Keep it clean and dry
  • Fold the diaper below it
  • It usually falls off in 1 to 3 weeks
  • Report redness spreading onto the abdomen, foul odor, or drainage — signs of infection

The short version

  • APGAR at 1 and 5 minutes. 7 to 10 is normal. Blue hands and feet alone is normal.
  • Heart rate 110–160, respirations 30–60
  • Dry and warm immediately — cold stress causes problems
  • Missing reflexes, or reflexes that persist too long, are abnormal
  • Grunting, flaring, and retractions = respiratory distress
  • Jaundice in the first 24 hours is always abnormal
  • A newborn with infection may be COLD, not hot

Newborn reference values and reflex timelines vary somewhat by source. Follow current pediatric guidelines.

Practice

5 NCLEX practice questions on this topic

The same questions, player and partial-credit scoring students use inside NCLEXPace: answer, submit, read the full rationale, then Next. Your score is waiting at the end. No account needed for these.

Question 1 of 5Score: 0%
Question 1 of 5Multiple Choice

Select the best answer.

The nurse observes a parent placing the newborn in a car seat before discharge. Which action by the parent requires correction?

Question 2 of 5Select-All-That-Apply (SATA)

Select all that apply.

The nurse observes a mother with her newborn on the second day after birth. Which behaviors indicate positive attachment? Select all that apply.

Select all that apply.
Question 3 of 5Multiple Choice

Select the best answer.

A newborn is being discharged at 20 hours of age, and the metabolic screening blood spot was collected just before discharge. Which instruction should the nurse give the parents?

Question 4 of 5Multiple Choice

Select the best answer.

During the assessment of a newborn delivered after a shoulder dystocia, the nurse elicits the Moro reflex and notes that the right arm does not abduct while the left responds normally. Which action should the nurse take?

Question 5 of 5Matrix / Grid (NGN)

For each skin finding in a 12-hour-old term newborn, indicate whether it is expected or should be reported.

The nurse examines the skin of a 12-hour-old term newborn. For each finding, indicate whether it is expected or should be reported to the provider.

ExpectedShould be reported
Blue color of the lips and tongue
Yellow tint to the skin and sclera
Pink blotches with small white or yellow centers on the trunk
Blue-gray flat patches over the sacrum and buttocks
Tiny white papules across the nose and chin
Note: Each row must have 1 response option selected.
0 answered · 0%
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Frequently asked questions

Common follow-up questions on Maternity, Newborn & Pediatrics.

What does APGAR measure?

Appearance (colour), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone) and Respiration (respiratory effort), each scored 0, 1 or 2 at one and five minutes of life, for a maximum of 10.

What APGAR score is normal?

Seven to ten indicates a newborn adapting well. Four to six indicates moderate difficulty requiring stimulation and oxygen, and zero to three requires immediate resuscitation. Most healthy newborns do not score a perfect 10 because peripheral cyanosis of the hands and feet is normal in the first minutes.

Which newborn reflexes should be present at birth?

Moro (startle), rooting, sucking, palmar and plantar grasp, Babinski, tonic neck and stepping. Absence of an expected reflex, or persistence beyond the age it should disappear, suggests a neurological problem and warrants further assessment.

What are newborn red flags requiring immediate action?

Central cyanosis, grunting, nasal flaring or chest retractions, a respiratory rate outside 30–60 breaths per minute, a heart rate below 100, temperature instability, jitteriness suggesting hypoglycaemia, and jaundice appearing in the first 24 hours of life.

Sources and references

  1. Lowdermilk DL, Perry SE, Cashion K, Alden KR, Olshansky EF. Maternity & Women's Health Care. 12th ed. Elsevier; 2020; Chapter: Nursing Care of the Newborn and Family.
  2. American Academy of Pediatrics, American Heart Association. Textbook of Neonatal Resuscitation (NRP). 8th ed. AAP; 2021.

Reviewed by the NCLEXPace team, October 2026.

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