The nurse is documenting assessment findings of a 37-year-old male with abdominal pain. Which is the most appropriate manner of documenting patient’s symptoms?

The nurse is supervising the student nurse who is making a call to the provider about a patient who is decompensating. The student states, “Hello, Dr. Smith. This is Carly and I’m taking care of Alex Wright in room 433. He is in the hospital after surgery for a ruptured appendix. Over my shift his temperature has increased by 4 degrees and his heart rate is elevated. His blood pressure is decreased from the previous shift as well. Could you please come examine him?” Which additional comments are the priority for the nurse to add? Select all that apply.

A baby is born precipitously to a mother who did not have prenatal care. The neonate requires only the initial steps of resuscitation but is found to have a bilateral cleft lip and palate. Review the patient’s assessment here: Position at rest: Complete flexion Square window: 0° Arm recoil: 75° Popliteal angle: 80° Scarf sign: Elbow does not cross midline Heel to ear: Foot does not reach the umbilicus Skin: No veins visible, cracking of skin at joints, dry Lanugo: Mostly bald skin Plantar surface: Creases over entire sole Breast: 4 mm bud with raised areola Ear: Formed pinna with instant recoil Genitals: Descended testes bilaterally, rugae over entire scrotum For which referrals does the nurse advocate for the baby prior to discharge? Select all that apply.