A nurse is assisting in the preparation of an in-service for a group of unit nurses about ethical principles. Which of the following nursing actions should the nurse include as an example of fidelity?

A. Laboratory electrolyte levels: The client’s potassium (3.7 mEq/L) and sodium (137 mEq/L) are within expected reference ranges. These values do not indicate electrolyte imbalance or metabolic instability that would require holding the feeding. Electrolyte disturbances can occur with enteral nutrition, but current results do not support discontinuation.

B. Oxygen saturation: An oxygen saturation of 96% on room air reflects adequate oxygenation and does not indicate aspiration or respiratory compromise. If aspiration from tube feeding had occurred, decreased oxygen saturation or respiratory distress might be present. Current findings do not justify holding the feeding based on oxygenation status.

C. Abdominal findings: A distended, firm, and tense abdomen suggests possible feeding intolerance, delayed gastric emptying, or bowel obstruction. These findings increase the risk for regurgitation and aspiration if feeding continues. Abdominal distention in the presence of enteral nutrition warrants holding the feeding and notifying the provider for further evaluation.

D. Blood glucose: A blood glucose of 152 mg/dL falls within the prescribed correction scale requiring 2 units of regular insulin. Mild hyperglycemia is common with enteral feedings and is addressed with sliding-scale insulin as ordered. This value alone does not require stopping the feeding.

E. Gastric residual: A gastric residual of 90 mL may indicate delayed gastric emptying, particularly when accompanied by abdominal distention. Elevated residual volumes increase the risk of aspiration if feeding continues. Clinical context, including abdominal findings, supports holding the feeding and notifying the provider.

F. pH of gastric contents: A pH of 6.4 is higher than expected for gastric contents, which are typically acidic (pH ≤5). An elevated pH raises concern for possible tube displacement into the respiratory tract or small intestine. This finding requires further verification of placement before continuing feedings.

A. Allow the infant to have soft foods: After cleft palate repair, oral intake is typically restricted to prevent trauma to the surgical site. Soft or solid foods can disrupt sutures and increase the risk of bleeding or infection. Oral intake is usually limited to clear liquids or specially prepared feeds until healing is sufficient.

B. Maintain elbow restraints on the infant: Elbow restraints (arm splints) help prevent the infant from touching or putting fingers or objects in the mouth, which could damage the surgical site. This intervention protects the integrity of the repair during the critical postoperative healing period and reduces the risk of complications such as dehiscence or infection.

C. Instruct the parents to feed the infant with a spoon: Spoon feeding can apply pressure to the palate and sutures, potentially causing trauma to the repair site. Feeding is often done using specialized devices such as a syringe, cup, or soft-tipped feeders designed to minimize contact with the surgical area.

D. Tell the parents to avoid brushing the infant's teeth for two weeks: Oral hygiene is still important after cleft palate repair, but brushing must be gentle to avoid trauma. Complete avoidance is unnecessary; instead, the nurse should instruct parents to use soft-bristled brushes and avoid the immediate surgical site while maintaining overall oral cleanliness.