A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?

A. A client who consumes all the food from their meal tray. This is a normal finding and does not require immediate reporting to the nurse. It can be documented by the AP as part of routine care.
B. A client who has a prescription for compression stockings and did not receive them. Compression stockings are a prescribed intervention to prevent complications such as deep vein thrombosis. The nurse must be informed to ensure timely application and follow-up.
C. A client who requests to sit in the bedside chair while watching TV. This is a non-urgent and appropriate activity that does not require nursing intervention unless the client has specific mobility restrictions.
D. A client who requests assistance to use the bedside commode. Assisting with toileting is within the AP’s scope of practice and does not need to be reported unless there is an issue (e.g., change in condition, abnormal findings).

A. Measure the tubing from the nose to the distal port. Proper placement of an NG tube requires measuring from the tip of the nose to the earlobe, then to the xiphoid process. This ensures the tube reaches the stomach without curling or entering the airway.
B. Position the child at a 10 to 20 angle after feeding. A head elevation of at least 30 to 45 degrees is necessary during and after NG feedings to reduce the risk of aspiration. A 10 to 20 degree angle is too low and unsafe for post-feeding positioning.
C. Complete the feeding in 5 min. NG feedings should be given slowly over 20 to 30 minutes to prevent gastrointestinal discomfort, cramping, or vomiting. A 5-minute infusion is too rapid and may overwhelm the child’s digestive capacity.
D. Warm the formula in the microwave. Microwaving formula can lead to uneven heating and hot spots, which pose a burn risk to the child. Formula should be warmed by placing the container in warm water and testing the temperature before administration.