A nurse in a long-term care facility is implementing a nutrition plan for a client who is at risk for malnutrition. Which of the following actions should the nurse include in the plan? (Select all that apply.)

A. "There are so many variables that you'll have to ask your obstetrician."

This response dismisses the client's question and fails to provide helpful information. While the client should discuss their specific situation with their obstetrician, the nurse should still offer some general guidance or information.

B. "The primary consideration is what type of incision was performed this time."

This is the correct response because it provides relevant information to the client's question. The type of incision made during the cesarean birth can influence the options for future deliveries. For example, a low transverse incision may make a vaginal birth after cesarean (VBAC) more likely, whereas a vertical incision might increase the likelihood of needing a repeat cesarean.

C. "A repeat cesarean birth is safer for both you and your baby."

This statement may not be accurate for all clients and situations. While repeat cesarean births are sometimes recommended for medical reasons, such as certain pregnancy complications or a previous cesarean with a vertical incision, it is not necessarily the safest option for all clients. This response also lacks consideration of the client's individual circumstances.

D. "It's too soon for you to be worrying about this now."

This response invalidates the client's concerns and fails to address their question. It's important to validate the client's feelings and provide them with accurate information to address their concerns.

A) Measure the client's gastric residual every 12 hr: While monitoring gastric residual volume is important to prevent complications such as aspiration or gastric distention, it is typically done prior to each intermittent feeding, not every 12 hours for clients receiving continuous enteral feedings. Continuous feeding does not necessitate less frequent monitoring of gastric residuals.

B) Keep the client's head elevated at 15° during feedings: Elevating the client's head during feedings helps reduce the risk of aspiration. However, this action is not specific to initiating continuous enteral feedings and should be maintained throughout the client's enteral feeding regimen.

C) Obtain the client's electrolyte levels every 4 hr: Monitoring electrolyte levels every 4 hours is not necessary as part of routine care for a client initiating continuous enteral feedings. While electrolyte levels may be monitored periodically, the frequency would depend on the client's clinical condition and the healthcare provider's orders.

D) Flush the client's tube with 30 mL of water every 4 hr: Flushing the client's tube with water helps maintain patency and prevent clogging, which is especially important for clients receiving continuous enteral feedings. This action helps ensure that the tube remains clear and functional, allowing for uninterrupted delivery of the enteral feeding solution.