The nurse is evaluating an infant's tolerance of a feeding post-pyloromyotomy. Which finding indicates the infant is not tolerating the feeding?
1. Need for burping after 30 cc
2. Presence of bowel sounds
3. Passing gas
4. Emesis
4
Rationale:
1. Burping after 30 cc would indicate tolerance of the feeding.
2. The presence of bowel sounds would indicate tolerance of the feeding.
3. Passing gas would be an expected finding following a pyloromyotomy, and would indicate tolerance of the feeding.
4. An infant is not tolerating feedings after a pyloromyotomy if emesis is present.
You might also like to view...
A needle's gauge reflects its outer diameter
Indicate whether the statement is true or false
A neighborhood health center is researching its origins. Which of the legislative acts most likely provided funds for its development?
a. Emergency Maternity and Infant Care Act of 1943 b. Medicaid legislation c. Social Security Act of 1935 d. Economic Opportunity Act
When asked about drug allergies, a patients says, "I cant take sulfa drugs because I'm allergic to them." Which question should the nurse ask next?
A. "Do you have any other drug allergies?" B. "Who prescribed that drug for you?" C. "How long ago did this happen?" D. "What happened when you took the sulfa drug?"
Which of the following examples of documentation best describes the data?
A. "Small amount of clear yellow urine voided." B. "Voided 220 mL clear yellow urine." C. "A small amount of urine voided into absorbent pad." D. "Patient incontinent of urine."