A nurse is caring for a patient who has cirrhosis of the liver.
The patient’s vital signs are as follows: Heart rate 101/min, Temperature 36 C (96.9 F), Respiratory rate 24/min, Blood pressure 82/58 mm Hg, Oxygen saturation 92%. Which of the following assessment findings require immediate follow-up? Select all that apply.

Step 1: Convert All Fluid Intake to Milliliters (mL)

To accurately record the patient's fluid intake, first, convert each fluid measurement to milliliters:

• 1 cup of coffee = 240 mL
• 4 oz of orange juice = 118.3 mL
• 3 oz of water = 88.7 mL
• 1 cup of flavored gelatin = 236.6 mL
• 1 cup of tea = 240 mL
• 5 oz of broth = 147.9 mL
• 3 oz of water (another serving) = 88.7 mL

Step 2: Calculate Total Fluid Intake

Add all the converted fluid amounts together:

• Total fluid intake = 240 mL (coffee) + 118.3 mL (orange juice) + 88.7 mL (water) + 236.6 mL (gelatin) + 240 mL (tea) + 147.9 mL (broth) + 88.7 mL (water) = 1,160.2 mL

Step 3: Round to the Nearest Whole Number

Round the total to the nearest whole number:

• Rounded total = 1,160 mL

The nurse should record 1,160 mL on the patient’s chart.

Choice A rationale

The statement “Do you think you could keep him in the nursery for the next feeding so I can get some sleep?” indicates that the mother may be experiencing inhibited parental attachment.

After childbirth, it is normal for a new mother to feel tired and need rest. However, consistently preferring to have the baby cared for in the nursery rather than spending time bonding may suggest inhibited parental attachment.

Choice B rationale

The statement “I don’t need a baby bath demonstration. I know how to do it.”. suggests that the mother is confident in her ability to care for her baby, which is a positive sign of parental attachment. It shows that she is prepared and willing to take on the responsibilities of parenthood.

Choice C rationale

The statement “I wish he had more hair. I will keep a hat on his head until he grows some.”. may indicate a slight disappointment in the baby’s appearance but does not necessarily indicate inhibited parental attachment. It’s common for parents to have certain expectations or hopes about their baby’s appearance.

Choice D rationale

The statement “He’s got my husband’s nose, that’s for sure.”. indicates that the mother is observing and commenting on the baby’s features, which is a positive sign of parental

attachment. Recognizing familial features helps in bonding and forming an attachment with the baby.