A nurse is caring for the child the following day. Click to highlight the findings that indicate the child is progressing as expected. To deselect a finding, click on the finding again. Nurses' Notes Day 2, 0730: Drowsy and lethargic, but responsive to verbal stimuli. Nuchal rigidity present. Mucous membranes pink and moist. Cervical lymph slightly enlarged. Respirations are regular. No accessory muscle use noted. Breath sounds clear anterior posterior bilaterally. Heart rhythm regular without murmurs. Radial pulse 2+ bilateral. Capillary refill less than 2 seconds. Abdomen flat and non- distended. Bowel sounds active in all 4 quadrants. Extremities are warm and dry to touch. Good skin turgor. Flow Sheet Temperature 38.9° C (102" F) Heart rate 104/min Respiratory rate 24/min Blood pressure 104/80 mm Hg SpO2 98% on room air

Rationale for correct choices • Mucous membranes pink and moist: Indicates adequate hydration and perfusion status. The improvement from the prior day’s assessment reflects positive fluid balance and appropriate nursing management. • SpO2 98% on room air: Reflects adequate oxygenation without supplemental oxygen, demonstrating respiratory stability and effective tissue oxygen delivery. Rationale for findings not indicating expected progress • Nuchal rigidity present: Persistence of nuchal rigidity indicates ongoing meningeal irritation and does not reflect improvement. This finding requires continued monitoring and management to prevent complications. • Temperature 38.9° C (102° F): The child remains febrile, indicating that infection is still present. Although other vital signs are improving, the fever demonstrates that full clinical resolution has not yet occurred.