A nurse is caring for a client who is receiving continuous enteral tube feeding and reports cramping and abdominal distention. Which of the following actions should the nurse take?

Choice A rationale:
A temperature of 37.2°C (99°F) is within the normal range (approximately 36.5°C to 37.5°C or 97.7°F to 99.5°F) and does not specifically indicate fluid volume deficit. It's important to consider this value along with other findings.
Choice B rationale:
(Correct Choice) A pulse rate of 118/min is indicative of tachycardia, which can be a sign of fluid volume deficit. When the body is experiencing a decrease in fluid volume, the heart rate often increases as a compensatory mechanism to maintain adequate circulation. Tachycardia helps to pump a reduced blood volume more rapidly to vital organs.
Choice C rationale:
A blood pressure of 152/90 mm Hg is elevated but does not solely indicate a fluid volume deficit. While low blood pressure can be a sign of dehydration, high blood pressure does not necessarily correlate directly with fluid volume status.
Choice D rationale:
Central venous pressure (CVP) of 25 mm Hg is elevated. CVP reflects the pressure in the vena cava and right atrium, indicating the amount of blood returning to the heart. An elevated CVP might be seen in fluid volume excess or right-sided heart failure, not fluid volume deficit.

Choice A rationale:
Diluting juice with 50 percent water to supplement between feedings is not recommended for newborns. Newborns should primarily be receiving breast milk or formula to ensure proper nutrition. Offering diluted juice can lead to inadequate intake of essential nutrients and unnecessary exposure to sugar. It's important for the newborn's diet to be appropriate for their stage of development.
Choice B rationale:
Beginning and ending with the same breast during feeding sessions promotes effective breastfeeding and adequate milk supply. This approach ensures that the baby receives both the foremilk (low-fat milk that comes at the beginning of a feeding) and hindmilk (higher-fat milk that comes later in a feeding), which is important for proper nutrition and growth. This choice demonstrates an understanding of the principles of breastfeeding.
Choice C rationale:
Feeding the baby on demand at least eight times each day is a suitable recommendation. Newborns have small stomachs and need frequent feedings to meet their nutritional needs and support healthy growth. Feeding on demand helps establish a good milk supply and ensures that the baby gets enough milk to thrive.
Choice D rationale:
Using pumped breast milk within 72 hours of refrigeration is a correct statement. Breast milk can be refrigerated for a limited time while maintaining its nutritional quality. Using pumped milk within 72 hours helps minimize the risk of bacterial growth and ensures that the baby receives milk that's still rich in nutrients and antibodies.