Question

The nurse first listens for bowel sounds in the right lower quadrant (RLQ) and hears high-pitched gurgling sounds that occur irregularly.

What action should the nurse take next?

- Move to the right upper quadrant (RUQ) to hear the sounds more distinctly.
- Continue to listen over the RLQ for 5 to 15 seconds.
- Change to the bell of the stethoscope to listen.
- Listen for 5 minutes before documenting the activity of the bowel sounds.

Answer 1

The nurse should continue to listen over the RLQ for 5 to 15 seconds after hearing high-pitched gurgling sounds to make a proper assessment of bowel activity before documenting or moving to another quadrant.

Step-by-step explanation:

After hearing high-pitched gurgling bowel sounds in the right lower quadrant (RLQ), the nurse should continue to listen over the RLQ for 5 to 15 seconds. High-pitched, irregular gurgling sounds can be normal bowel sounds and do not immediately require listening in other quadrants. However, if the sounds are unusually high-pitched or occur more frequently than 5-30 times per minute, it may indicate bowel hypermotility.

It is not necessary to switch to the bell of the stethoscope, as bowel sounds are typically high pitched and are better heard with the diaphragm. The recommendation to listen for up to 5 minutes is applicable when no bowel sounds are initially heard, to ensure that hypoactive or absent bowel sounds are not missed. Documenting bowel sounds requires a full assessment in all quadrants (RLQ, right upper quadrant (RUQ), left lower quadrant (LLQ), and left upper quadrant (LUQ)) before making any conclusions about bowel activity.