A neonate is being fed 20 mL every 3 hours by orogastric gavage. At the beginning of this feeding, the nurse aspirates 15 mL of gastric residual. The nurse should:
1. Withhold the feeding and notify the physician.
2. Replace the residual and continue with the full feeding.
3. Replace the residual, but only give 5 mL of the feeding.
4. Withhold the feeding and check the residual in 3 hours.
1
Rationale:
1. Residual of more than half the amount of feeding indicates a feeding intolerance, and could be a sign of necrotizing enterocolitis. Early detection of enterocolitis is essential, and aggressive management is required. Therefore, the physician should be notified of this finding.
2. The amount of residual is too much to replace and continue with the feeding.
3. The amount of residual is too much to replace and continue with the feeding.
4. Waiting for 3 hours to recheck the residual could delay treatment of a serious condition.
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