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

The nurse on the neuro floor just took report of a 22-month-old child who was admitted an hour ago to the ED after a head injury. In the ED, the apical pulse was 94, BP was 108/62, respirations were irregular, with a rate of 22-28 per minute, with an O2 sat of 98%. Which of the following would the nurse do first upon admission?