A nurse on a mental health unit is receiving the change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first?

• Abdomen distended: Abdominal distention is a sign of impaired gastric emptying or intolerance to enteral feeding. The increase from 96.5 cm to 101 cm indicates accumulation of gastric contents, which can lead to vomiting, aspiration, or discomfort. Prompt follow-up is required to evaluate feeding tolerance and adjust the enteral regimen.

• Nausea: Nausea in a client receiving enteral feeding can indicate delayed gastric emptying, overfeeding, or potential obstruction. Coupled with abdominal distention and high residual volumes, it suggests intolerance to the current feeding schedule or formula. Immediate assessment is necessary to prevent complications like aspiration.

• Gastric residual volume 620 Ml: A gastric residual volume over 500 mL is considered critically high and indicates severe delayed gastric emptying. High residuals increase the risk of aspiration pneumonia and require holding or adjusting the feeding, notifying the healthcare provider, and assessing for gastrointestinal complications.

• Casual glucose 275 mg/dL: A glucose of 275 mg/dL exceeds the desired limit for a client receiving enteral feeding. Hyperglycemia can result from high-calorie formulas, underlying diabetes, or stress response. Persistent hyperglycemia increases the risk of infection, delayed wound healing, and other complications, warranting immediate follow-up and possible insulin therapy adjustments.

• Abdominal girth at umbilicus 101 cm (39.8 in): An increase in abdominal girth from 96.5 cm to 101 cm, combined with a report of nausea, confirms that the gastrointestinal tract is not processing the intermittent feedings, possibly due to a paralytic ileus or delayed gastric emptying.

Rationale for incorrect choices

• pH of gastric aspirate 3.0: The pH of gastric aspirate within this range reflects acidic gastric contents, which is expected and does not indicate immediate complications. While pH monitoring is important for verifying tube placement, these values do not require urgent follow-up.

• Abdominal girth 96.5 cm: The initial abdominal girth is within normal limits and shows no signs of distention. This is a baseline measurement and does not indicate intolerance to feeding, so it does not require immediate follow-up.

• Gastric residual volume 30 mL: A low residual volume indicates good gastric emptying and feeding tolerance. No urgent action is necessary for this finding and it reflects proper enteral nutrition management.

A. "Plan for your son to meet his sister for the first time at home.": Introducing the newborn in a neutral or controlled setting such as the hospital can help prepare the older child gradually. Waiting until arriving home may increase anxiety or feelings of displacement, as the child suddenly encounters the new sibling in their primary environment without prior adjustment.

B. "Give your son a little gift from his new sister.": Providing a small gift “from the baby” is a well-supported strategy in pediatric and family-centered care to promote positive sibling bonding. It helps the older child feel included, valued, and less threatened by the new sibling, reducing jealousy and fostering acceptance during the transition period.

C. "Give your son plenty of 'alone time with his sister.": Preschool-aged children require supervision when interacting with a newborn to ensure safety. Encouraging unsupervised or “alone” time can place the infant at risk due to the child’s limited understanding of gentle handling and boundaries.

D. "Hold your daughter when your son first meets her.": Holding the newborn during the first introduction may make the older child feel excluded or replaced. It is often recommended that the parent greet the older child first without holding the baby, then introduce the newborn to promote a sense of security and continued importance.