The nurse on the neuro unit just took report of a 22-month-o…

The nurse on the neuro unit just took report of a 22-month-old child who was admitted from the ED with a diagnosis of a head injury/rule out traumatic brain injury. On arrival to the ED, the child’s apical pulse was 94, BP was 108/62, respirations were irregular, with a rate of 22-28 per minute, O2 sat =98%. Which of the following would the nurse do first upon admission to the neuro unit?