A nurse is assessing an infant who has acute otitis media.
Which of the following findings should the nurse expect? (Select all that apply.)

Choice A rationale:

Attaching the feeding bag tubing to the end of the NG tube is a step in the enteral feeding process, but it is not the first action the nurse should take. First, the nurse needs to assess the pH of the gastric secretions to confirm the NG tube placement in the stomach. If the pH is acidic (usually below 5.5), it indicates that the NG tube is in the stomach. If the pH is alkaline, it may suggest the tube is in the respiratory tract, and feeding should not be initiated. Therefore, this choice is not the correct first action.

Choice B rationale:

Flushing the tube with water is important to ensure it is clear and not clogged. However, it is not the first action the nurse should take. Checking the pH of the gastric secretions is crucial to confirm the NG tube placement before any other interventions. If the nurse encounters resistance while flushing the tube, it could indicate a misplaced tube, emphasizing the importance of checking the pH first.

Choice C rationale:

Checking the pH of the gastric secretions is the correct first action before administering enteral feeding. Gastric secretions are acidic (usually below 5.5), confirming the tube's placement in the stomach. This step ensures the safety of the feeding process and prevents complications such as aspiration pneumonia. Once the placement is confirmed, the nurse can proceed with other steps, such as attaching the feeding bag tubing and setting the administration rate on the feeding pump.

Choice D rationale:

Setting the administration rate on the feeding pump is a necessary step in enteral feeding but should only be done after confirming the tube placement by checking the pH of the gastric secretions. If the nurse administers the feeding without confirming the tube placement, there is a risk of aspiration, which can be life-threatening.

Choice A rationale:

Discouraging the parents from allowing siblings to view the body can prevent healthy grieving and closure for the siblings. Allowing siblings to view the body, if they wish, can help them understand the reality of the situation and cope with their emotions in a healthy way.

Choice B rationale:

Providing a follow-up phone call 1 week following the infant's death is a good practice, but it is not the most immediate and crucial action in this situation. Acknowledging the family's feelings of guilt and providing emotional support should take precedence.

Choice C rationale:

Avoiding discussing details of the attempt to revive the infant might hinder the family's ability to process the situation. Open communication, including discussing the events leading to the infant's death, can help the family members come to terms with their loss.

Choice D rationale:

Acknowledging the family members' feelings of guilt is the correct choice. Parents and family members often experience guilt after the death of an infant from SIDS, wondering if there was something they could have done differently. The nurse should acknowledge these feelings and provide reassurance, emphasizing that SIDS is not the result of parental actions or negligence.