The patient presents to the emergency department after having a metal beam fall on his head at a work site. He was wearing a helmet which broke with the impact. He was unconscious at the scene but is awake now, and his initial assessment is completely benign. Which finding upon reassessment 30 minutes later is most concerning?

The nurse is called to assist a 32-year-old G1P0 female who is in active labor with a viable intrauterine pregnancy at 30-weeks estimated gestational age. The patient delivers a neonate who requires intubation due to secondary apnea. The nurse auscultates to assess for endotracheal tube placement and notes breath sounds are louder on the right than the left. Which of the following is the next best step in management?

The nurse is assessing the skin of a patient who uses a wheelchair for mobility. The nurse notes an area over the patient’s left ischium that is shiny and pinkish-red with a serous exudate. The area measures 5 cm x 4 cm and depth of the wound is insignificant. Which of the following terms is the most appropriate for the nurse to use when documenting this finding?