Part of the ICU Emergencies Hub — browse every related guide in one place.
| Component | 0 | 1 | 2 |
|---|---|---|---|
| Appearance (color) | Blue/pale all over | Blue extremities, pink body (acrocyanosis) | Pink all over |
| Pulse (heart rate) | Absent | <100 bpm | ≥100 bpm |
| Grimace (reflex irritability) | No response to stimulation | Grimace only | Cry, cough, or sneeze |
| Activity (muscle tone) | Limp | Some flexion of extremities | Active motion, well-flexed |
| Respiration | Absent | Slow, irregular, weak cry | Strong cry, regular respirations |
Interpretation: 7–10 = normal (routine care); 4–6 = moderate concern (stimulation, supplemental oxygen, continued monitoring); 0–3 = severe depression (immediate resuscitation — call NICU team). APGAR is a communication and documentation tool, not a resuscitation guide — resuscitation decisions are made in real time based on breathing, heart rate, and tone, not waiting for a score.
| Parameter | Normal Range | Notes |
|---|---|---|
| Heart rate | 110–160 bpm | Can drop to 85–90 briefly during sleep; sustained HR <100 needs evaluation |
| Respiratory rate | 30–60 breaths/min | Periodic breathing (pauses up to 10 sec) is normal; apnea >20 sec is not |
| Temperature | 36.5–37.5°C (97.7–99.5°F) | Axillary preferred for routine monitoring; rectal for suspected fever |
| Blood pressure | 60–80/40–50 mmHg | Varies by gestational age and birth weight |
| SpO2 (after 10 min of life) | ≥95% | In first 10 minutes: target 85–95% (normal transition); pre-ductal (right hand) preferred |
| Blood glucose | ≥45 mg/dL after first feed | <40 mg/dL = hypoglycemia requiring intervention; check at 1–2 hours of life in at-risk infants |
Normal newborns may have mild transient tachypnea in the first 30–60 minutes as lung fluid clears. Persistent or worsening respiratory distress requires evaluation. Signs of neonatal respiratory distress (Silverman-Anderson score components):
Nasal flaring (alar nasi dilation on inspiration); grunting (expiratory grunt — newborn creates own PEEP to prevent alveolar collapse — a serious sign); intercostal and subcostal retractions; tracheal tug; cyanosis persisting beyond 10 minutes despite stimulation. Any combination of these signs after the first hour warrants notification of the pediatric or NICU team.
Newborns are at extreme risk for cold stress — they have a large surface area relative to body mass, minimal subcutaneous fat, wet skin at delivery, and limited ability to shiver. Cold stress increases oxygen consumption, causes hypoglycemia, and worsens respiratory distress. The delivery room should be 25–26°C (77°F). Immediately after delivery: dry the infant thoroughly (wet skin causes rapid evaporative heat loss), remove wet blankets, skin-to-skin contact with mother (best thermoregulation), or warm the radiant warmer.
Hypothermia (<36.5°C) in a newborn requires rewarming — place skin-to-skin or under a radiant warmer, check glucose (cold stress depletes glucose), and assess for sepsis (hypothermia can be an early sign of neonatal sepsis rather than environmental exposure).
Physiologic jaundice appears after 24 hours of life (typically day 2–3), peaks day 3–5, and resolves by 2 weeks. Caused by normal breakdown of fetal hemoglobin releasing bilirubin that the immature liver cannot conjugate quickly enough.
Pathologic jaundice appears within the first 24 hours of life — always pathologic, always requires immediate evaluation. Causes: hemolytic disease (ABO incompatibility, Rh incompatibility), G6PD deficiency, sepsis.
Assess jaundice by blanching the skin and observing the underlying color — jaundice progresses cephalocaudally (head to toe): face (bilirubin ~5 mg/dL) → chest → abdomen → thighs → feet (~20 mg/dL). Transcutaneous bilirubin meter provides non-invasive screening; serum bilirubin confirms. Phototherapy threshold is weight- and age-specific — the Bhutani nomogram is the standard reference.
At-risk infants: large for gestational age (LGA, macrosomic — often infants of diabetic mothers), small for gestational age (SGA), late preterm (34–36 weeks), infants of diabetic mothers (IDM). Screen blood glucose at 1–2 hours of life in at-risk groups.
Blood glucose <40 mg/dL in the first 4 hours of life requires intervention: prompt feeding (breastfeeding or formula 10 mL/kg), recheck glucose 30 minutes after feeding. If glucose remains <40 or infant is symptomatic (jitteriness, poor tone, seizures, apnea), IV dextrose is required — notify provider immediately. Signs of symptomatic hypoglycemia: jitteriness/tremors, high-pitched cry, poor feeding, hypotonia, seizures, apnea, cyanosis.
The umbilical cord has two arteries and one vein (AVA — two A's, one V). A single umbilical artery (SUA) is associated with renal anomalies and requires provider notification and follow-up ultrasound. Cord care: keep dry; fold diaper below the cord stump; clean with water only if soiled; watch for signs of omphalitis (redness, warmth, swelling, or purulent discharge at the base — a serious infection requiring antibiotics). The cord stump separates and falls off in 1–3 weeks.
Related guides: Pediatric nursing | Postpartum nursing | Vital signs
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