Newborn Assessment: Apgar and the First Hours

Maternal & Newborn · Newborn Assessment & Care·Updated 2026-10-28

What it is

At birth the newborn shifts from placental to pulmonary gas exchange: the lungs expand, pulmonary vascular resistance falls, and the foramen ovale and ductus arteriosus begin to close. The newborn loses heat quickly and cannot shiver; it makes heat by metabolizing brown fat, which consumes oxygen and glucose. That is why cold stress leads to hypoglycemia and respiratory distress, and why drying and warming come first.

What the NCLEX focuses on

Apgar at 1 and 5 minutes: heart rate, respiratory effort, muscle tone, reflex irritability and color, each scored 0 to 2; repeat every 5 minutes while below 7.
The Apgar never delays resuscitation; breathing and heart rate decide it within the first minute.
Expected findings: acrocyanosis, irregular breathing with short pauses, milia, erythema toxicum, Mongolian spots, molding, caput succedaneum, pseudomenstruation and uric acid crystals.
Caput succedaneum is edema that crosses suture lines and resolves in days; cephalohematoma is blood that does not cross sutures and raises the jaundice risk.
Report: central cyanosis, jaundice in the first 24 hours, sustained respiratory rate above 60/min with grunting, flaring or retractions, temperature instability, an asymmetric Moro reflex, and a hip click.
Hypoglycemia risk: infants of diabetic mothers, large or small for gestational age, preterm, and cold-stressed infants; signs are jitteriness, poor feeding and hypothermia.
First-hours care: vitamin K IM, erythromycin eye ointment, hepatitis B vaccine, matching identification bands, and the first bath delayed until the temperature is stable.

Priority nursing actions

Dry, stimulate and place the newborn skin to skin, or under a radiant warmer; remove wet linens.
Assess breathing and heart rate; start positive-pressure ventilation within 60 seconds for apnea, gasping or a heart rate below 100/min.
Assign the Apgar score at 1 and 5 minutes.
Maintain temperature, start early feeding, and check glucose in at-risk or symptomatic newborns.
Apply identification bands, give vitamin K and eye prophylaxis, then complete the full physical and gestational age assessment.

Numbers to know

Value	Normal	Why it matters
Heart rate	110 to 160/min	Below 100/min at birth needs ventilation
Respiratory rate	30 to 60/min, irregular, pauses under 20 seconds	Sustained rate above 60 with grunting signals distress
Axillary temperature	97.7 to 99.5 F (36.5 to 37.5 C)	Cold stress uses glucose and oxygen
Apgar	7 to 10 normal; 4 to 6 moderate difficulty; 0 to 3 severe	Repeat every 5 minutes while below 7
Weight	2,500 to 4,000 g; loss up to 10%, regained by 10 to 14 days	Greater loss signals poor feeding
Head circumference	32 to 38 cm, about 2 cm larger than the chest	Abnormal size suggests microcephaly or hydrocephalus
Blood glucose	Below 40 mg/dL (2.2 mmol/L) is low	Feed and recheck; IV dextrose if symptomatic or persistent

Common exam traps

Choosing to finish the 1-minute Apgar before starting resuscitation: wrong because ventilation starts within 60 seconds based on breathing and heart rate.
Choosing routine tracheal suctioning for a limp newborn born through meconium: wrong because current neonatal resuscitation starts positive-pressure ventilation.
Choosing a warm bath for a cold, jittery newborn: wrong because bathing causes evaporative heat loss; rewarm under a radiant warmer and check glucose.
Choosing to report acrocyanosis or Mongolian spots: wrong because both are expected; document location of the spots.
Choosing to call caput succedaneum a bleed: wrong because caput is edema that crosses sutures and resolves without treatment.

What to teach

Place the baby on the back on a firm, flat surface for every sleep; room-share without bed-sharing.
Feed 8 to 12 times in 24 hours; by day 5, expect at least 6 wet diapers a day.
Keep the cord clean and dry and fold the diaper below it; use a rear-facing car seat in the back seat.
Call for a temperature of 100.4 F (38 C) or higher, yellow skin spreading downward, poor feeding or lethargy.

Client handout: Caring for Your Newborn at Home (nurse guide and printable patient handout).

Try 2 NCLEX-style questions on this topic

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Question 1 · QID 5A3B1C7A

At 1 minute after birth a newborn has a heart rate of 112 beats per minute, slow irregular respirations with a weak cry, some flexion of the extremities, a grimace when the nares are suctioned, and a pink body with blue hands and feet. Which Apgar score should the nurse assign?

Select the best answer.

A. 6
B. 10
C. 8
D. 4

Question 2 · QID F1D16014

The nurse assesses a term newborn at 2 hours of age. Which findings are within expected limits? Select all that apply.

A. Respiratory rate of 48 per minute, irregular, with pauses of 10 seconds
B. Head circumference of 34 cm and chest circumference of 32 cm
C. Heart rate of 138 beats per minute
D. Weight of 3,400 g
E. Axillary temperature of 36.0 C (96.8 F)
F. Sustained respiratory rate of 72 per minute with grunting

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More tips on Maternal & Newborn

Prenatal Care: Labs, Fundal Height and Danger SignsDate the pregnancy, time the routine prenatal labs, interpret fundal height, and teach the danger signs a pregnant client reports at once.Fetal Heart Rate Patterns and DecelerationsRead baseline, variability and decelerations, match each deceleration to its cause, and give intrauterine resuscitation in the right order.Postpartum Hemorrhage: Recognize Early, Act FastSpot hemorrhage before the blood pressure falls, firm a boggy uterus, empty the bladder, and give uterotonics within their contraindications.

Sources

Aziz K, Lee HC, Escobedo MB, et al. Part 5: Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16 suppl 2):S524-S550.
American Academy of Pediatrics Committee on Fetus and Newborn; American College of Obstetricians and Gynecologists Committee on Obstetric Practice. The Apgar Score. Pediatrics. 2015;136(4):819-822.
Adamkin DH; Committee on Fetus and Newborn. Postnatal glucose homeostasis in late-preterm and term infants. Pediatrics. 2011;127(3):575-579.
Perry SE, Hockenberry MJ, Cashion K, Alden KR, Olshansky E, Lowdermilk DL. Maternal Child Nursing Care. 7th ed. Elsevier; 2022.

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