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HLT-LPN37-04 · Lesson 8 · 18 clock hours · lab

Newborn Assessment, Care, and APGAR Scoring

Objective. Students perform a systematic newborn physical assessment, calculate APGAR scores from given data at one and five minutes, and implement priority interventions for a newborn requiring resuscitation support within LPN scope.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

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Newborn Assessment, Care, and APGAR Scoring

The first minutes and hours after birth are among the most critical in a person's life. As an LPN, you work under the direction of an RN or provider to support systematic newborn assessment, implement thermoregulation interventions, and recognize when a newborn needs immediate resuscitation support. Accuracy and speed matter equally.

The APGAR Score

The APGAR score is a rapid clinical tool used at one minute and five minutes after birth to evaluate a newborn's transition to extrauterine life. Each of five signs is scored 0, 1, or 2, for a maximum of 10.

| Sign | 0 | 1 | 2 |

|---|---|---|---|

| Appearance (skin color) | Blue/pale all over | Blue extremities, pink body | Pink all over |

| Pulse (heart rate) | Absent | Below 100 bpm | 100 bpm or above |

| Grimace (reflex irritability) | No response | Grimace | Cry or cough/sneeze |

| Activity (muscle tone) | Limp | Some flexion | Active motion |

| Respiration | Absent | Weak, irregular | Strong cry |

Interpreting scores:

The one-minute score reflects the newborn's response to labor and birth. The five-minute score better predicts short-term outcomes. If the five-minute score is below 7, scoring continues every five minutes up to 20 minutes per facility protocol. Report any score below 7 to the RN or provider immediately—this is a priority safety action within LPN scope.

Head-to-Toe Newborn Physical Assessment

Perform the assessment in a systematic sequence to avoid omissions. Use a warmed environment or radiant warmer to prevent heat loss during the exam.

Measurements first:

Head and face: Palpate fontanels—the anterior fontanel is diamond-shaped and soft; the posterior is triangular and smaller. A bulging fontanel may indicate increased intracranial pressure; a sunken fontanel may indicate dehydration. Assess for molding, caput succedaneum (edema crossing suture lines), or cephalohematoma (does not cross suture lines).

Eyes, ears, nose, mouth: Check for symmetry, intact palate, and patent nares. Ears should be at or above the eye line.

Neck, clavicles, chest: Palpate clavicles for fractures (birth injury). Auscultate lung and heart sounds.

Abdomen: Should be soft and rounded. Cord should have two arteries and one vein; inspect for signs of infection.

Genitalia and anus: Confirm patent anus; assess genitalia appropriate to gestational age.

Extremities and spine: Count digits; assess for hip symmetry (Ortolani/Barlow tests are RN/provider scope; observe positioning). Inspect spine for dimples or tufts of hair.

Skin: Note color (acrocyanosis of hands and feet is normal in the first hours), vernix, lanugo, and any lesions.

Newborn Reflexes

Absent or asymmetrical reflexes warrant reporting to the RN.

Gestational Age Indicators

Physical and neuromuscular characteristics help estimate gestational age. Preterm newborns have fewer plantar creases, less cartilage in the ear, and greater lanugo. Post-term newborns may show peeling skin and long nails. The Ballard or New Ballard Score is a formal tool used by the RN or provider.

Thermoregulation Interventions

Newborns lose heat rapidly through evaporation, conduction, convection, and radiation. Cold stress causes hypoglycemia and increased oxygen consumption.

Priority steps after birth:

1. Dry and stimulate immediately—remove wet linens; rub back and soles.

2. Skin-to-skin placement on mother's chest with blanket cover retains heat effectively.

3. Radiant warmer: Set to servo-control mode; place temperature probe on abdomen (not over a bony area). Check that the warmer is pre-warmed before placing the newborn.

4. Hat and blanket: Double-wrap if skin-to-skin is not immediately possible; significant heat loss occurs through the head.

Safety: Never leave a newborn unattended on a radiant warmer with side rails down. Monitor axillary temperature (normal 36.5–37.5 °C / 97.7–99.5 °F). Report hypothermia (below 36.5 °C) or hyperthermia to the RN promptly.

LPN Scope and Escalation

Within LPN scope you perform and document assessments, calculate APGAR scores, and implement thermoregulation and basic resuscitation support steps (drying, stimulating, positioning airway, supplemental oxygen) as directed. Initiating advanced resuscitation, interpreting gestational age tools, and making medical diagnoses are outside LPN scope. Always escalate abnormal findings to the supervising RN or provider without delay.

Key terms9

APGAR scoreA five-sign scoring system (Appearance, Pulse, Grimace, Activity, Respiration) rated at one and five minutes after birth to assess a newborn's transition to extrauterine life; maximum score is 10.
AcrocyanosisBluish discoloration limited to the hands and feet in the first hours after birth; a normal finding in healthy term newborns.
Anterior fontanelThe diamond-shaped, soft membranous space at the top of the skull where cranial bones have not yet fused; normally closes by 12–18 months of age.
Moro reflexA normal newborn startle reflex in which the arms extend and then flex in response to sudden movement or sound; its absence or asymmetry is abnormal.
ThermoregulationThe newborn's ability to maintain body temperature; immature at birth due to limited subcutaneous fat, large body surface area, and inability to shiver.
Caput succedaneumDiffuse edema of the newborn scalp that crosses suture lines, caused by pressure during delivery; resolves within a few days.
CephalohematomaA collection of blood between the periosteum and skull bone that does not cross suture lines; resolves over weeks and may be associated with jaundice.
Radiant warmerAn open bed with an overhead heat source used to maintain newborn temperature during assessment and procedures; servo-control mode regulates heat based on a skin temperature probe.
Babinski reflexFanning of the toes upward when the sole is stroked from heel to toe; normal in newborns but abnormal in children older than approximately two years.

Worked examples4

1. APGAR Card A — One minute after birth: Skin is blue all over; heart rate is 80 bpm; the infant grimaces when a catheter is passed; some flexion of extremities is noted; respirations are weak and irregular. Calculate the one-minute APGAR score.
  1. Appearance: blue all over = 0
  2. Pulse: 80 bpm (below 100) = 1
  3. Grimace: grimace only = 1
  4. Activity: some flexion = 1
  5. Respiration: weak, irregular = 1
  6. Add all five values: 0 + 1 + 1 + 1 + 1 = 4
Answer: One-minute APGAR score = 4. This falls in the 4–6 range (moderate concern). Priority nursing actions: stimulate the infant, provide supplemental oxygen as directed, and notify the RN immediately.
2. APGAR Card B — Five minutes after birth: Skin is pink all over; heart rate is 112 bpm; the infant cries vigorously when stimulated; active motion of all extremities; strong cry present. Calculate the five-minute APGAR score.
  1. Appearance: pink all over = 2
  2. Pulse: 112 bpm (100 or above) = 2
  3. Grimace: vigorous cry = 2
  4. Activity: active motion = 2
  5. Respiration: strong cry = 2
  6. Add all five values: 2 + 2 + 2 + 2 + 2 = 10
Answer: Five-minute APGAR score = 10. This is in the 7–10 range (normal). Routine newborn care continues; no additional resuscitation is indicated.
3. APGAR Card C — One minute after birth: Body pink, hands and feet blue; heart rate 96 bpm; grimaces when stimulated; some flexion; weak, irregular respirations. Calculate the score and classify it.
  1. Appearance: body pink, extremities blue = 1
  2. Pulse: 96 bpm (below 100) = 1
  3. Grimace: grimace = 1
  4. Activity: some flexion = 1
  5. Respiration: weak, irregular = 1
  6. Add: 1 + 1 + 1 + 1 + 1 = 5
Answer: One-minute APGAR score = 5, in the 4–6 range (moderate concern). Initiate stimulation and supplemental oxygen per RN direction; reassess at five minutes.
4. A term newborn's head circumference is measured at 34 cm and chest circumference at 31 cm. Are these findings within expected normal ranges, and what is the difference between the two measurements?
  1. Normal head circumference at term: approximately 33–35 cm. Finding of 34 cm is within normal range.
  2. Normal chest circumference at term: approximately 30–33 cm. Finding of 31 cm is within normal range.
  3. Calculate difference: 34 cm − 31 cm = 3 cm.
  4. Expected difference: head circumference normally exceeds chest by approximately 2–3 cm at term.
Answer: Both measurements are within normal limits. The 3 cm difference (head larger than chest) is expected for a term newborn. Document findings and report any values outside normal ranges to the RN.
In class: Use a newborn simulator to practice head-to-toe newborn physical assessment in the correct sequence, documenting findings including head circumference, chest circumference, weight, length, skin color, fontanels, reflexes (Moro, rooting, sucking, Babinski), and gestational age indicators. · Score five written APGAR scenario cards at one minute and five minutes, interpret each score (0–3, 4–6, 7–10), and state the priority nursing action for two scores below 7. · Demonstration and return demonstration of newborn thermoregulation interventions: dry and stimulate, skin-to-skin placement, radiant warmer operation, and proper hat and blanket technique—instructor observes and rates each step on a skills checklist.
Materials: Newborn simulator, infant scale, tape measure, stethoscope, APGAR scenario cards, radiant warmer (demo unit or model), infant hats/blankets, newborn assessment reference card, maternal-newborn textbook, NCLEX-PN test plan (Health Promotion and Maintenance; Physiological Adaptation)
Check: Newborn assessment completed in correct sequence with ≥ 78% of findings accurately recorded; all five APGAR scores calculated correctly with accurate interpretation; thermoregulation return demonstration passes all critical steps on checklist.

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Physiological Adaptation
1. A newborn at one minute of life has the following assessment: entire body blue/pale, heart rate absent, no response to stimulation, limp muscle tone, and no respirations. What is the APGAR score?
Health Promotion and Maintenance
2. The LPN is preparing a radiant warmer for a newborn delivery. Which action is the highest priority before placing the newborn on the warmer?
Health Promotion and Maintenance
3. During a newborn assessment the LPN notes a scalp swelling that crosses the sagittal suture line and is soft and edematous. Which term correctly describes this finding?
Physiological Adaptation
4. A newborn's five-minute APGAR score is 5. What is the LPN's priority action?
Health Promotion and Maintenance
5. When stroking the sole of a newborn's foot from heel toward the toes, the toes fan upward and the great toe dorsiflexes. The LPN correctly documents this as which finding?
Health Promotion and Maintenance
6. Which measurement finding in a term newborn should the LPN report to the RN as a potential abnormality?
Physiological Adaptation
7. A newborn delivered three minutes ago is being dried and stimulated but remains limp with no cry and a heart rate below 100 bpm. Which action is within LPN scope as the first response?
Health Promotion and Maintenance
8. The LPN is assessing a newborn's reflexes. Which reflex is correctly elicited by placing a finger in the newborn's mouth?
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