A neonate is fed 20 mL of formula every three hours by orogastric lavage. At the beginning of this feeding, the nurse aspirates 15 mL of gastric residual. Which action by the nurse is the most appropriate?
1. Withhold the feeding and notify the healthcare provider.
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 three hours.
Correct Answer: 1
Rationale: 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 healthcare provider should be notified of this finding. The amount of residual is too much to replace and continue with the feeding, and waiting for three hours to recheck the residual could delay treatment of a serious condition.
You might also like to view...
The following information should not be included on your résumé
A. Accurate spelling and grammar B. Family information C. Clear objective D. Education and experience
A patient is complaining of an inability to breathe nasally because of severe rhinitis. The nurse is aware that the nose plays what important role in breathing that is disrupted when the nasal passages are blocked?
A) It decreases the number of pathogens inhaled. B) Inspired air is warmed and humidified. C) Carbon dioxide will not be inhaled. D) It simulates surfactant release from the alveoli.
A 60-year-old man has been brought to the emergency department (ED) by ambulance after his wife phoned 911 when he experienced a sudden onset of severe chest pain
In the ED, the patient has received morphine, had an electrocardiogram (ECG), and had blood work drawn. In the event of a myocardial infarction, which of the following cardiac biomarkers would usually be first detectable? A) CK-MB B) Myoglobin C) Troponin T D) Troponin I
A patient with type 1 diabetes mellitus is preparing for a moderate 30-minute exercise period. Which action best indicates understanding of condition management?
a. The patient reduces insulin use during days when exercise periods are planned. b. The patient administers insulin after exer-cise rather than before exercise. c. The patient eats a high-carbohydrate snack before the exercise period. d. The patient consumes a simple carbohy-drate snack after 30 minutes of activity.