A nurse is reviewing the laboratory results for a client who started a weight loss program 3 months ago. Which of the following findings is an indication that the program has been effective?

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.

A) "This is a cephalhematoma, which can occur spontaneously":

This is the correct response. A cephalhematoma is a collection of blood between the skull bone and its periosteum and does not cross suture lines. It often develops after vacuum extraction during delivery due to rupture of blood vessels. It is typically benign and resolves on its own over several weeks to months as the blood is reabsorbed by the body. It is important to reassure the mother that this is a common occurrence and usually resolves without intervention.

B) "Mongolian spots can be found on the skin of many newborns":

Mongolian spots are blue-gray birthmarks that commonly appear on the skin of newborns, typically over the buttocks and lower back. They are not related to the swelling on the baby's head and do not cross suture lines.

C) "This is erythema toxicum, which is a transient condition":

Erythema toxicum is a benign rash that appears in many newborns within the first few days of life. It presents as small, yellow or white papules surrounded by erythema and often resolves without treatment within a week. It is not related to the swelling on the baby's head and does not cross suture lines.

D) "A caput succedaneum occurs due to compression of blood vessels and will cross the sutures lines on the baby's head":

While a caput succedaneum is a collection of serosanguinous fluid that crosses suture lines and typically resolves within a few days after birth, it is usually associated with swelling over the presenting part of the fetus during labor, not vacuum extraction. Additionally, caput succedaneum is not typically located on the top of the head, where the swelling from a cephalhematoma would be observed.