A nurse is reviewing electronic health record (EHR) documentation with an assistive personnel (AP). The nurse should reinforce that the AP is permitted to document in which of the following sections of the EHR?

A. Tell the children to alternate standing on one foot and observe their balance: Assessing balance does not evaluate spinal curvature or detect scoliosis. While balance testing may identify neuromuscular issues, it is not part of standard scoliosis screening and does not reveal lateral spinal deviations.

B. Ask the children to bend forward at the waist and observe them from behind: The forward bend (Adam’s forward bend) test is the recommended screening method for scoliosis. Observing from behind allows the nurse to detect asymmetry in the shoulders, ribs, or hips, which may indicate spinal curvature. This method is simple, noninvasive, and effective for early detection.

C. Tell the children to stand up straight and observe them facing forward: Viewing the child from the front while standing upright may reveal gross asymmetry but is less sensitive than the forward bend test. Subtle spinal curvatures are often not noticeable when the child is standing upright.

D. Ask the children to raise their hands over their head and turn from side to side: Raising arms and twisting does not provide clear visualization of spinal asymmetry. Scoliosis screening relies on observing the alignment of the spine and rib cage during forward flexion, not rotational movements.

A. Laboratory electrolyte levels: The client’s potassium (3.7 mEq/L) and sodium (137 mEq/L) are within expected reference ranges. These values do not indicate electrolyte imbalance or metabolic instability that would require holding the feeding. Electrolyte disturbances can occur with enteral nutrition, but current results do not support discontinuation.

B. Oxygen saturation: An oxygen saturation of 96% on room air reflects adequate oxygenation and does not indicate aspiration or respiratory compromise. If aspiration from tube feeding had occurred, decreased oxygen saturation or respiratory distress might be present. Current findings do not justify holding the feeding based on oxygenation status.

C. Abdominal findings: A distended, firm, and tense abdomen suggests possible feeding intolerance, delayed gastric emptying, or bowel obstruction. These findings increase the risk for regurgitation and aspiration if feeding continues. Abdominal distention in the presence of enteral nutrition warrants holding the feeding and notifying the provider for further evaluation.

D. Blood glucose: A blood glucose of 152 mg/dL falls within the prescribed correction scale requiring 2 units of regular insulin. Mild hyperglycemia is common with enteral feedings and is addressed with sliding-scale insulin as ordered. This value alone does not require stopping the feeding.

E. Gastric residual: A gastric residual of 90 mL may indicate delayed gastric emptying, particularly when accompanied by abdominal distention. Elevated residual volumes increase the risk of aspiration if feeding continues. Clinical context, including abdominal findings, supports holding the feeding and notifying the provider.

F. pH of gastric contents: A pH of 6.4 is higher than expected for gastric contents, which are typically acidic (pH ≤5). An elevated pH raises concern for possible tube displacement into the respiratory tract or small intestine. This finding requires further verification of placement before continuing feedings.