A nurse is assessing a preterm infant who has necrotizing enterocolitis (NEC).

Which of the following findings should alert the nurse to a possible bowel perforation?

All of these findings can indicate a possible bowel perforation in a preterm infant with necrotizing enterocolitis (NEC).NEC is a serious condition that causes inflammation and necrosis of the intestinal tissue, and can lead to a hole (perforation) in the bowel wall.Bacteria can leak through this hole and cause infection and sepsis.NEC usually develops within two to six weeks after birth, and mostly affects premature babies.

Choice A is wrong because bloody stools are not specific for bowel perforation.They can also be seen in mild cases of NEC or other causes of gastrointestinal bleeding.

Choice B is wrong because abdominal distension is a common sign of NEC, but not necessarily of bowel perforation.It can be caused by gas accumulation, fluid retention, or inflammation of the bowel wall.

Choice C is wrong because bilious vomitus is also a non-specific sign of NEC or other causes of bowel obstruction.It can indicate a problem with the passage of food or bile through the intestines.

This is because preterm infants are born before or during critical periods of brain development and need to reduce stress and promote neurological development.Cluster care means grouping care activities together and timing them according to the infant’s cues, such as alertness, hunger, and sleepiness.This way, the infant can have longer periods of undisturbed sleep, which is essential for brain maturation.

Choice B is wrong because keeping the lights and noise level high can cause sensory overload and stress for the preterm infant.The NICU environment should be dimmed and quiet to mimic the womb and support the infant’s circadian rhythm.

Choice C is wrong because avoiding touching or holding the infant can deprive the infant of human contact and bonding, which are important for emotional and social development.Preterm infants can benefit from gentle touch, massage, and kangaroo care, which is holding the baby with direct skin-to-skin contact.These interventions can help with body temperature, breastfeeding, weight gain, and attachment.

Choice D is wrong because changing the infant’s position frequently can disrupt the infant’s sleep and cause stress.Preterm infants should be positioned in a way that supports their posture and alignment, such as flexion, midline orientation, and containment.Positioning aids such as blankets, rolls, or nests can be used to provide boundaries and comfort for the infant.