A nurse is caring for the child the following day. Exhibits 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