Which fundal height is documented as normal for the woman who is 30 weeks pregnant?

The 32-year-old patient presents to the emergency department complaining of difficulty breathing, cough, and chills. Vital signs are notable for a temperature of 38.4°C, heart rate 118 bpm, respiratory rate 24, oxygen saturation 87% on room air, and blood pressure of 98/62 mmHg. Upon assessment, the nurse notes nasal flaring, diminished breath sounds in the right upper lobe, and subcostal retractions. Capillary refill time is 4 seconds. The patient admits waking up in a pool of vomit after binge drinking 3 nights ago. Which orders does the nurse anticipate? Select all that apply.

During hourly rounds, the nurse notes a patient’s right heel has an erythematous area that is warm to the touch. The skin is intact but does not blanch with pressure. Which of the following terms is most appropriate for the nurse to use when documenting this finding?