Patient Data Exhibits The nurse is reviewing the client's admission information. Which signs or symptoms warrant immediate follow-up by the nurse? Select all that apply.

Rationale: A. Bulging tympanic membranes: Bulging and erythematous tympanic membranes indicate acute otitis media, which requires prompt evaluation and potential antibiotic therapy to prevent complications. Immediate follow-up ensures proper management. B. Pain rating of 5 using FLACC scale: Moderate pain reflects the infant’s discomfort from the ear infection. Pain management with acetaminophen is appropriate, but it does not require urgent intervention beyond scheduled analgesics. C. Refusal of bottle: Refusal to feed may indicate dehydration, lethargy, or worsening illness. This symptom warrants immediate assessment to ensure the infant receives adequate hydration and nutrition. D. Temperature: 101°F (38.3°C): Low-grade fever is common in infections and can be managed with antipyretics. It does not alone require urgent follow-up unless it rises or persists. E. Agitation while collecting vital signs: Temporary agitation is expected during procedures in infants and is not an indicator of deterioration. Observation is sufficient. F. Use of pacifier: Pacifier use provides comfort and is non-concerning. It does not indicate a need for immediate follow-up. G. Heart rate of 188 beats/minute: Tachycardia in a 4-month-old exceeds normal limits and may indicate fever, dehydration, or early sepsis. Prompt follow-up is necessary to identify underlying causes. H. Respirations: 56 breaths/minute: Tachypnea exceeds the normal range for this age group (30–50 breaths/minute) and may indicate respiratory distress or infection, requiring immediate assessment. I. Warm, pale skin: Warm, pale skin can signal poor perfusion or early circulatory compromise. Immediate evaluation ensures the infant’s hemodynamic status is stable.