A nurse inserts a nasogastric tube before an infant is to receive a tube feeding. What action should the nurse take when the infant begins to cough and gag?
a. Auscultating for breath sounds
b. Removing the tube, then reinserting it
c. Administering the tube feeding slowly
d. Observing the infant for circumoral cyanosis
Ans: b. Removing the tube, then reinserting it
The infant's response indicates that the tube may be in the trachea rather than the stomach. The tube should be removed, reinserted, and verified for its placement before the feeding is started. Auscultating for breath sounds does not provide information about the placement of the tube. The tube should be removed immediately; it is unsafe to assess the infant for additional signs of respiratory distress. It is unsafe to administer the feeding until placement in the stomach has been confirmed.
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