Health Promotion and Maintenance
80. A nurse prepares to insert a nasogastric tube in a 10-month-old child. Which actions should the nurse take to complete this procedure? Prioritize the nurse's actions by placing each correct step in sequential order.
. Aspirate gastric contents.
. Have the child begin a bottle feeding.
. Place child supine with head and neck elevated.
. Inject 10 mL of air into the tube while auscultating the stomach.
. Tape tube securely to infant's cheek.
. Measure from the infant's earlobe to the area of the stomach.
Test-Taking Tip
Note that the nursing tasks related to NG tube insertion are similar for adults and children–the differences pertain to tube sizes and volume of air/fluid.
Content Area: Child Health, Gastrointestinal; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration
Health Promotion and Maintenance
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Answer 1 is correct because, once the tube is inserted, placement must be verified by both auscultation and aspiration of gastric contents. Answer 2 is incorrect since feeding the infant prior to, during, or immediately after the procedure may cause vomiting and would contradict the gavage feeding order. Answer 3 is correct because the child should first be placed on the back with the chest elevated prior to NG tube placement, to prevent aspiration if the child gags during the procedure. Answer 4 is incorrect because 10 mL of air is too much. No more than 5 mL should be used in young children because the extra air can cause discomfort and lead to abdominal distention. Answer 5 is correct because taping the tube to the cheek after it has been inserted prevents the child from being able to get fingers around the tube and pull it out. Answer 6 is incorrect because the tube should be measured first from the tip of the nose, extended to the earlobe, and then extended to the area past the xiphoid process. This measurement technique provides the best estimation of the length of tube necessary for stomach placement.