A nurse is caring for a 10-day-old neonate who was born at 33 weeks' gestation. Which of the following actions assist the nurse in assessing for signs of feeding tolerance? (Select all that apply.)
a. Check for presence of bowel sounds
b. Assess temperature
c. Check gastric residual by aspirating stomach contents
d. Assess stools
ANS: a, c, d
Feedback
a. Feedings should be held and physician notified if bowel sounds are absent.
b. The neonate's temperature has no direct effect on feeding tolerance.
c. Aspirated stomach contents are assessed for amount, color, and consistency. This assists in the evaluation of the degree of digestion and absorption.
d. Stools are assessed for consistency, amount, and frequency. This assists in the evaluation of the degree of digestion and absorption.
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