A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse?

A. Insert an indwelling catheter if the client has not voided in 3 hr: Inserting an indwelling catheter involves an invasive procedure and requires clinical judgment and assessment for contraindications such as coagulopathy, which is common in acute liver failure. This task should remain with the registered nurse (RN) rather than being delegated to an LPN.

B. Obtain the abdominal girth now and every 4 hr: Measuring abdominal girth is a repetitive, non-invasive monitoring task that is within the scope of practice of assistive personnel. The RN should delegate this task to the AP, allowing the LPN to perform tasks requiring slightly higher clinical skills.

C. Assess and document the level of consciousness every hour: Assessing neurological status requires ongoing clinical judgment and the ability to detect subtle changes in mental status, which is critical in clients with hepatic encephalopathy. This responsibility cannot be delegated and must be performed by the RN.

D. Measure the amount of gastric drainage every 2 hrs: Monitoring and documenting the amount of NG tube drainage is within the scope of practice for an LPN. It requires basic assessment skills, accurate measurement, and reporting changes to the RN, making it appropriate to delegate to the LPN.

A. "Yes, you will have to discontinue breastfeeding.": Stopping breastfeeding is not necessary with mastitis unless the mother is severely ill or the provider specifically advises it. Continuing to nurse helps relieve milk stasis and promotes healing.

B. "No, you can continue to nurse from both your breasts.": Continuing to breastfeed or pump from both breasts is recommended. Frequent emptying of the affected breast reduces engorgement, clears infection, and maintains milk supply while ensuring the infant receives safe breast milk.

C. "No, but you should alternate between the right breast and the bottle.": Alternating with bottles is unnecessary unless the mother cannot feed directly. Encouraging breastfeeding from both breasts helps resolve the infection more efficiently.

D. "Yes, but you can resume nursing when you are done with your antibiotics.": Delaying breastfeeding is not required; continuing to nurse while on antibiotics that are safe for lactation is standard practice and helps resolve mastitis faster.