A nurse is caring for a newborn who is receiving phototherapy treatment. Which of the following actions should the nurse take?

A. Maintain bed elevation at 20°: The head of the bed should be elevated to at least 30° to 45° during enteral feedings to reduce the risk of aspiration. A 20° angle is inadequate for preventing reflux and potential aspiration.
B. Flush the tubing with 30 ml of water every 4 hr: Routine flushing of the feeding tube helps maintain patency and prevent clogging. Flushing every 4 hours is standard practice for continuous feedings to ensure uninterrupted delivery.
C. Place enough formula in the container to last 18 hr: Open system formula should be discarded after 4 hours to reduce the risk of bacterial contamination. Filling the container for 18 hours exceeds safe hang time recommendations.
D. Check for gastric residual every 12 hr: Gastric residuals should typically be checked every 4 to 6 hours for continuous feedings, or per facility policy. Waiting 12 hours may delay the identification of feeding intolerance or complications.

Rationale for Correct Choices:

• Antibiotic prescription: The client presents with signs of a postoperative wound infection: fever (38.8°C), increased WBC count (14,800/mm³), purulent drainage, and incisional swelling. These findings warrant prompt antibiotic therapy to prevent further complications.
• WBC count: The rise in WBC count from 8,000 to 14,800/mm³ over three days is a key indicator of an infectious process, particularly concerning postoperatively. It supports the need for antibiotics.
• Temperature: The client’s fever (38.8°C/101.8°F) is consistent with a systemic response to infection. In combination with the elevated WBC and wound findings, it confirms the need for antimicrobial treatment.

Rationale for Incorrect Choices:

• IV fluids: While fluids are essential postoperatively, the client shows no signs of hypovolemia or dehydration—mucous membranes are moist and blood pressure is stable. Fluids are not the priority.
• Laxative: Although the client hasn’t had a bowel movement, they are passing flatus and show some motility. The acute concern is infection, not constipation, making laxatives inappropriate as the primary intervention.
• Prescription for IV iron: The client has stable but low hemoglobin levels (around 10.3 g/dL), likely due to surgery. However, there’s no acute drop or symptomatic anemia requiring immediate IV iron over addressing infection.
• Hemoglobin: Although low, the hemoglobin level is stable and does not indicate an acute issue. It does not justify antibiotic use or serve as the primary clinical concern at this time.
• Bowel sounds: Hypoactive bowel sounds are common postoperatively and are not indicative of infection alone. They do not support the use of antibiotics directly.
• Blood pressure: The client’s blood pressure remains within normal limits postoperatively and does not show signs of septic or hypovolemic shock. It’s not relevant to initiating antibiotics.
• Transferrin level: Transferrin reflects protein status and iron transport; although low, it doesn’t indicate acute infection. It is unrelated to the decision to initiate antibiotics.
• Skin turgor: Normal skin turgor suggests adequate hydration. There’s no indication of dehydration or fluid imbalance requiring action.
• Bowel movements: Absence of bowel movement is common postoperatively and expected after colon surgery. While important to monitor for ileus, these are not the primary indicators for an antibiotic prescription.