A nurse in the clinic is providing information to a client who has mastitis of the left breast. The client asks the nurse. "Does this mean that I must stop nursing my baby?" Which of the following is an appropriate statement by the nurse?

A. Gastric content pH: The pH of the gastric aspirate increased from 4.8 to 6.4, which may indicate a change in gastric emptying or possible contamination with intestinal contents. However, a pH of 6.4 alone is not an immediate reason to hold enteral feeding unless accompanied by other concerning signs.

B. Abdominal findings: The client has a distended, firm, and tense abdomen, which may indicate intolerance to the tube feeding, delayed gastric emptying, or possible bowel obstruction. These physical findings require immediate attention because continuing enteral feeding could worsen complications such as vomiting, aspiration, or bowel perforation.

C. Oxygen saturation: The client’s oxygen saturation is 96% on room air, which is within normal limits. While hypoxia can be a sign of aspiration or respiratory compromise, the current oxygenation does not indicate an immediate need to hold feeding or notify the provider.

D. Gastric residual: A residual volume of 90 mL with a pH of 6.4 suggests delayed gastric emptying or intolerance of the feeding. High residuals increase the risk of aspiration and indicate that the client may not tolerate additional enteral nutrition. Holding the feeding and notifying the provider is warranted to prevent complications.

E. Blood glucose: The client’s blood glucose is slightly elevated at 152 mg/dL, which falls within the range for administering correctional insulin per provider orders. Although ongoing monitoring is important, this glucose level does not require holding the feeding.

F. Laboratory electrolyte levels: The client’s potassium (3.7 mEq/L) and sodium (137 mEq/L) are within normal limits. There are no electrolyte abnormalities that would necessitate holding the tube feeding at this time, though continued monitoring is important for ongoing nutritional support.

A. The alpha-fetoprotein test identifies a risk for ABO incompatibility: Alpha-fetoprotein (AFP) testing is not used to assess blood type compatibility. ABO incompatibility is determined through maternal and fetal blood typing and antibody screening.

B. The provider will draw the alpha-fetoprotein sample from an umbilical vein: AFP is measured via maternal blood draw, not from the umbilical vein. This noninvasive maternal serum screening reduces risk to the fetus.

C. The alpha-fetoprotein test screens for neural tube defects: AFP is a protein produced by the fetal liver, and abnormal maternal serum levels can indicate neural tube defects (such as spina bifida) or other fetal anomalies. This test is typically performed between 16 and 18 weeks gestation.

D. The provider will collect the alpha-fetoprotein sample during an amniocentesis: While AFP can be measured in amniotic fluid, the standard screening at 16 weeks is a maternal serum AFP blood test. Amniocentesis is not routinely required for initial AFP screening.