A nurse is caring for a client on an acute mental health unit.

Exhibits

Complete the following sentence by using the list of options.

The nurse should delegate the client's

____________

 and focus on

_________

Bowel perforation is a serious complication that can occur as a result of necrotizing enterocolitis (NEC), which is a condition often seen in preterm infants. In NEC, the intestines become inflamed and can eventually rupture, leading to bowel perforation. The neonate's symptoms, including abdominal distention, firm abdomen, decreased bowel sounds, and a small amount of blood in the stool, are consistent with NEC. The abdominal x-ray showing marked distention of the intestine further supports this diagnosis.

Necrotizing enterocolitis (NEC) is a common and life-threatening condition in preterm infants (like this neonate born at 34 weeks gestation), particularly those receiving enteral feedings. It can lead to bowel perforation, sepsis, and other serious complications.

A. Perform chest percussion and vibration. Chest percussion and vibration help loosen and mobilize mucus in the airways, which is essential for clients with productive cough and a history of smoking-related respiratory issues. This intervention facilitates effective expectoration and improves breathing.

B. Place the client in a supine position. Placing the client in a supine position can worsen shortness of breath, especially in individuals with respiratory distress. The client should be positioned upright or in a high-Fowler's position to facilitate lung expansion.

C. Instruct the client to perform diaphragmatic breathing. Diaphragmatic breathing helps improve lung expansion, reduce the work of breathing, and promote relaxation. This technique is particularly useful for clients with an irregular breathing pattern and anxiety.

D. Assess the client's breath sounds. Continuous assessment of breath sounds is critical to monitor the effectiveness of interventions, such as oxygen therapy and nebulization, and to detect any worsening of respiratory status.

E. Restrict the client's fluid intake. Fluid intake should not be restricted unless contraindicated, as hydration helps thin mucus, making it easier to expectorate. This is particularly important for clients with a productive cough.

F. Increase oxygen flow rate to 4 L/min. Increasing the oxygen flow rate beyond 2 L/min requires caution in clients with chronic obstructive pulmonary disease (COPD) or similar conditions, as higher oxygen levels can suppress their respiratory drive. Oxygen therapy should be titrated carefully based on the provider's prescription and monitoring of oxygen saturation.