A nurse is caring for a client in the intensive care unit.

Exhibits

The nurse is reviewing the admission assessment, nurses' notes, vital signs, and laboratory results. Drag words from the choices below to fill in each blank in the following sentence. The nurse identifies that the client's and can indicate the development of delirium.

A. Holding the newborn in an en face position: This action promotes bonding between the mother and the newborn and is a positive interaction.

B. Asking the father to change the newborn's diaper: Involving the father in caregiving tasks fosters family involvement and bonding.

C. Viewing the newborn's actions to be uncooperative: This suggests a negative perception of the newborn's behavior, which could indicate potential issues with bonding or misunderstanding

infant cues, requiring the nurse's intervention.

D. Requesting the nurse take the newborn to the nursery so she can rest: While rest is important for the mother, separating the newborn from the mother could disrupt bonding and breastfeeding, so this action should be discussed further with the client to explore other options.

A. The wall suction setting does not directly indicate the functioning of the NG tube.

B. Greenish-yellow drainage fluid may indicate the presence of bile in the stomach, suggesting

that the NG tube is not adequately draining gastric contents, which could indicate a malfunction.

C. An aspirate pH of 3 indicates gastric acidity, which is expected in the stomach and does not necessarily indicate a problem with NG tube function.

D. Abdominal rigidity may suggest intra-abdominal pathology but does not specifically indicate NG tube dysfunction.