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.

Bulging tympanic membranes

Pain rating of 5 using FLACC scale

Refusal of bottle

Temperature: 101° F (38.3° C)

Agitation while collecting vital signs

Use of pacifier

Heart rate of 188 beats/minute

Respirations: 56 breaths/minute

Warm, pale skin