When calculating a 1-minute APGAR, the nurse evaluates the following assessment data: Heart rate 120 BPM; strong cry; well-flexed; reflex-crying: body pink; acrocyanosis present in hands and feet.

In view of these findings, the nurse should assign an APGAR score of:

Step 1 is to calculate the change in blood pressure. Change in systolic blood pressure = 148 mm Hg - 130 mm Hg = 18 mm Hg. Change in diastolic blood pressure = 88 mm Hg - 80 mm Hg = 8 mm Hg.

Step 2 is to calculate the change in weight. Change in weight = 44.5 kg - 42.2 kg = 2.3 kg.

Step 3 is to calculate the change in pulse oximetry. Change in pulse oximetry = 98% - 100% = -2%.

Choice A rationale

Drinking tap water is not a primary concern with nerve agent exposure as these agents primarily affect the nervous system through inhalation, dermal absorption, or ingestion of contaminated food/water sources, not through tap water unless the water source itself is contaminated. Public water systems are usually well-protected.

Choice B rationale

While staying indoors with doors and windows closed is a valid protective measure against airborne contaminants like nerve agents, it doesn't encompass the full range of exposure routes, as nerve agents can also be absorbed dermally. Therefore, this statement alone is incomplete for effective teaching.

Choice C rationale

Nerve agents are organophosphorus compounds that inhibit acetylcholinesterase, leading to cholinergic crisis. They are highly volatile and can be inhaled as vapor or aerosol, or absorbed through the skin and mucous membranes, which makes this statement accurate regarding exposure pathways.

Choice D rationale

Decontamination from nerve agents typically involves immediate removal of contaminated clothing and washing with copious amounts of soap and water, or using reactive skin decontamination lotion (RSDL). However, bactericidal soap and hot water alone may not be sufficient for complete decontamination, and specialized decontamination procedures are often required in a hazardous material situation.