A nurse is caring for a toddler. Exhibits Which of the following findings require immediate follow-up by the nurse? Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Nurses' Notes 0920: Toddler is irritable, sitting on guardian's lap. Clear drainage draining from nose. Oral mucosa dry. Cervical lymph nodes nonpalpable. Lung sounds clear in all lung fields. Nonproductive, occasional cough present. Apical heart rate regular, no murmur. Capillary refill 3 seconds. Abdomen nontender, bowel sounds hyperactive. Previous weight (4 weeks ago) 12 kg (26.5 lb) Current weight 11.4 kg (25 lb) Vital Signs 0910: Temperature 39.6° C (103.2° F) Blood pressure 88/42 mm Hg Heart rate 150/min Respiratory rate 28/min Oxygen saturation 96% on room air