The school nurse is assessing a student for scoliosis. When comparing the right and left sides, which landmark, if uneven, could indicate a problem? Select all that apply.

A. Document the oral temperature in the health care record: Accurate documentation of vital signs is a legal and clinical necessity for tracking the patient's postoperative trajectory. A temperature of 38°C represents a low-grade pyrexia that must be recorded to establish a trend. This data is essential for subsequent clinical decision-making and interdisciplinary communication.

B. Offer a blanket to prevent patient shivering: While blankets provide comfort, they can further insulate a febrile patient and cause a paradoxical rise in core body temperature. Shivering is a physiological mechanism to generate heat, but external warming during a fever is generally contraindicated unless the patient is in the chill phase. Nursing interventions should focus on heat dissipation.

C. Inspect the surgical incision for redness, swelling, heat, & pain: Assessment of the operative site is critical to differentiate between physiological postoperative inflammation and early surgical site infection. The nurse must evaluate for localized rubor, tumor, calor, and dolor as part of a comprehensive febrile workup. This helps identify the potential source of the elevated temperature.

D. Administer acetaminophen as ordered pm to reduce fever: Acetaminophen acts on the hypothalamic heat-regulating center to reduce fever and provide postoperative analgesia. Administration is appropriate when the temperature meets the threshold defined in the standing PRN orders. This intervention improves patient comfort and reduces the metabolic demands associated with pyrexia.

E. Notify the Health Care Provider (HCP): While low-grade fevers are common within 24 hours of surgery due to atelectasis or inflammatory stress, the HCP must be informed of any deviations from baseline. This ensures that the surgical team can order diagnostic tests, such as a chest X-ray or urinalysis, if indicated. Timely notification is a key component of postoperative surveillance.

A. Fetal movement: By the eighth month of gestation, the fetus has developed sufficient muscular coordination and size for its activity to be visible through the maternal abdominal wall. These movements indicate fetal well-being and are a hallmark of late-stage pregnancy assessment. The nurse can often palpate or observe these shifts during the physical examination.

B. Linea nigra: This is a hyperpigmented linear streak extending from the symphysis pubis to the top of the fundus, caused by increased melanocyte-stimulating hormone. It is a common physiological integumentary change that occurs during the second and third trimesters. It typically resolves postpartum but is a prominent feature in late pregnancy.

C. Striae: Also known as striae gravidarum or stretch marks, these are linear jagged scars resulting from the rapid expansion of the abdomen and hormonal changes. They appear as pink, silver, or purple indents in the skin where dermal collagen has stretched. They are highly prevalent in the third trimester as the uterus reaches maximum distension.

D. Vernix caseosa: This is a thick, white, sebaceous substance that coats the skin of the fetus in utero to provide protection and lubrication. While it is present on the fetus, it is not an observable characteristic of the maternal abdomen during an external assessment. It only becomes visible to the nurse upon delivery of the neonate.

E. Scaphoid profile: A scaphoid abdomen is characterized by a concave or sunken appearance where the anterior wall is recessed. This is anatomically impossible in the eighth month of pregnancy due to the large, gravid uterus displacing the abdominal contents forward. A pregnant abdomen at this stage is protuberant or globular.