During the shift assessment of the healthy, full-term neonate born 24 hours ago to the 25-year-old G1P1 mother who had an uncomplicated pregnancy and delivery, the nurse notes the urethral meatus is on the ventral part of the penile shaft. The assessment is also notable for wide-spaced, downward-slanting eyes that resemble the baby’s father. The baby is pink, well-perfused, and breathing comfortably with normal heart and lung sounds. The mother reports the child is breastfeeding every 2 hours and has voided and stooled several times. Which additional assessment is most important? 

The nurse prepares a diphtheria, tetanus, and pertussis (DTaP) vaccination for a 6-year-old patient. The patient’s mother states, “Wait! He’s already gotten that vaccine, several times when he was younger. I have it written down in his records.” Which response by the nurse is appropriate?

The 25-year-old G1P0 female at 31 weeks estimated gestational age presents to the labor and delivery unit. The nurse assesses the patient and palpates the head of the fetus to be 2 inches above the maternal ischial spines. Which term does the nurse use to document this finding?