A nurse is assisting with the care of a client who is in labor with ruptured membranes and has herpes simplex virus with active lesions.
Which of the following actions should the nurse take?

This action indicates that the charge nurse should intervene because adding food coloring to the tube feeding is not recommended and can cause adverse effects such as aspiration, diarrhea, and allergic reactions.

Choice A is wrong because checking the volume of the aspirate is a correct action to assess gastric residual volume and prevent complications such as nausea, vomiting, and aspiration.

Choice B is wrong because checking the pH of the aspirate is a correct action to verify the placement of the NG tube and prevent accidental administration of enteral feeding into the lungs.

Choice C is wrong because administering 15 mL of water before administering the feeding is a correct action to flush the NG tube and prevent clogging.

Normal ranges for gastric residual volume are less than 250 mL for adults and less than 5 mL/kg for children. Normal ranges for pH of gastric aspirate are less than 5.5 for adults and less than 4 for children.

Obturator.

An obturator is a device that is inserted into the tracheostomy tube to guide it through the stoma and prevent tissue damage. It should be removed after the tube is inserted and kept near the bedside in case of accidental decannulation.

Choice A is wrong because povidone-iodine is an antiseptic solution that is not routinely used for tracheostomy care. It can cause skin irritation and damage to the mucous membranes.

Choice C is wrong because an irrigation set is not needed for a tracheostomy tube.

Irrigation can introduce bacteria and increase the risk of infection. It can also cause coughing and bleeding.

Choice D is wrong because hemostats are not used for a tracheostomy tube.

Hemostats are surgical instruments that are used to clamp blood vessels or tissues. They have no role in tracheostomy care.

Some other supplies that the nurse should place in the room are a trach tube the same size as the current tube and one size smaller, a portable suction machine with battery backup, and tubing that connects to the suction machine. Other supplies may include saline solution, syringes, gauze squares, gloves, a trachea tube brush, a waterproof drape, non-woven sponges, pipe cleaners, cotton tipped applicators, a T-drain sponge, twill tape, a trach holder, a speaking valve, a stoma cover, and a nebulizer.