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.

Choice A rationale

Cleaning the catheter after each use with soap and water is a crucial step in preventing infection during self-catheterization.

Choice B rationale

The angle at which the penis should be held during catheter insertion can vary, but a 30 to 45- degree angle is not typically recommended.

Choice C rationale

Performing catheterization when feeling the urge to void is not typically part of the instructions for clean intermittent self-catheterization.

Choice D rationale

Inflating the balloon when the urine flow stops is not a step in clean intermittent self- catheterization. This step is associated with indwelling catheters, not intermittent catheters.

The correct answer is Choice A

Choice A rationale: Ensuring that the mother calls and the nurse takes the baby to the room maintains security and safety protocols. It prevents unauthorized individuals from handling the infant, thus minimizing the risk of abduction or harm.

Choice B rationale: Showing photo identification alone is not sufficient to ensure the safety of the newborn. The nurse should directly handle the transfer of the baby to maintain strict security measures and verify the proper identification in the process.

Choice C rationale: Allowing someone to push the baby in a wheeled bassinet without proper authorization and identification verification does not adhere to safety protocols. The nurse should always verify and manage the transfer to ensure the infant’s security.

Choice D rationale: Carrying the grandchild to the room without adequate identification verification and authorization does not follow safety protocols. The nurse should always be involved in the transfer to prevent any security breaches and ensure the infant’s safety.