I wanted to revisit this question for APEX 24.1, as the UT still doesn't make alignments I would consider an intuitive request - and my previous notes need revision, and old links are broken.
https://forums.oracle.com/ords/apexds/post/18-2-item-button-alignment-2812
If I try to place an Optional item and a button next to each other on the same row, where the button has start new row false, the natural alignment isn't great

Things can be slightly improved by using template option Spacing Top Small

And Floating items have their own issue of misaligned size.

Note in all these cases I've applied these to the item and button Layout Column CSS classes respectively, to try get them as close together as possible
padding-right-none
padding-left-none
Revisiting comments from @fac586 on the linked post, I've tried the following classes on the page
.button-notop {margin-top: 0px !important;}
.item-notop .t-Form-labelContainer
,.item-notop .t-Form-inputContainer {padding-top: 0px;}
.floating-notop {padding-top: 0px !important;}
Where I set the relevant namesakes on the Appearance CSS classes attributes.
The Optional item displays to my expectation, but only when the template size is Large

The Floating item is top aligned, but the height still mismatches. I tried applying u-flex-grow-1, but it had no effect.

Does anyone have some interesting techniques to solve this?