Difficulty: Medium
Average Score: 75%
Simulated
Passage / Scenario
The nurse in the neonatal intensive care unit has completed the morning assessment of a preterm infant.Item 1 of 1
Nurses' Notes
0934: Client receiving continuous tube feeding via 5 Fr nasogastric tube in the right nare. Abdomen was taut and distended. Dry diaper. Hypoactive bowel sounds in all four quadrants. Large gastric residual that was undigested formula with some bile. Skin hot to the touch and pale pink in tone. Vital signs: T 100┬░ F (37.8┬░ C), P 137, RR 49.
Complete the sentence below by choosing from the list of options. The client is at the highest risk for developing---------------------------
Correct answer
B
Rationale
The infant is demonstrating manifestations consistent with NEC.
The infant's prematurity, being in the NICU, having a distended abdomen, hypoactive bowel sounds, and increased gastric residual are consistent with NEC.
The nurse must notify the physician of these findings and request an abdominal radiograph (x-ray) order.
This is the gold standard diagnostic test. The nurse should also turn off the tube feeding and obtain a prescription for parenteral antibiotics.
Hyperbilirubinemia is a possibility, considering this client's prematurity. However, nothing in the assessment suggests this concern at this time, as the skin was warm and pink in tone. Individuals with hyperbilirubinemia usually present with skin characterized by jaundice, or icterus, a yellowish discoloration.
The client is unlikely to have fluid volume overload because the client does not have tachycardia, and the client's fever puts the infant at risk for fluid volume deficit.
The infant's prematurity, being in the NICU, having a distended abdomen, hypoactive bowel sounds, and increased gastric residual are consistent with NEC.
The nurse must notify the physician of these findings and request an abdominal radiograph (x-ray) order.
This is the gold standard diagnostic test. The nurse should also turn off the tube feeding and obtain a prescription for parenteral antibiotics.
Hyperbilirubinemia is a possibility, considering this client's prematurity. However, nothing in the assessment suggests this concern at this time, as the skin was warm and pink in tone. Individuals with hyperbilirubinemia usually present with skin characterized by jaundice, or icterus, a yellowish discoloration.
The client is unlikely to have fluid volume overload because the client does not have tachycardia, and the client's fever puts the infant at risk for fluid volume deficit.