For which time period would the nurse notify the health care provider that the client had no bowel sounds?
A. 2 minutes
B. 3 minutes
C. 4 minutes
D. 5 minutes
Correct Answer: D. 5 minutes
To completely determine that bowel sounds are absent, the nurse must auscultate each of the four quadrants for at least 5 minutes; 2, 3, or 4 minutes is too short a period to arrive at this conclusion. The first item to listen for is the presence of bowel sounds. To chart an assessment finding of no bowel sounds, the nurse needs to listen over the quadrant for at least five minutes. The nurse should also do the auscultation before palpation and percussion to avoid influencing bowel sounds.
Option A: In most cases, bowel sounds are present, but the nurse needs to categorize them. She should listen for the intensity of the sound – whether it is soft or strong. The nurse should also listen for frequency. Hypoactive bowel sounds could indicate a problem, so if the nurse is having trouble hearing them, this is significant.
Option B: Auscultating bowel sounds can allow the nurse to pinpoint areas where an obstruction may have occurred. Finding no bowel sounds can mean an ileus or obstruction above that area of the intestine.
Option C: Hypoactive bowel sounds are considered as one every three to five minutes, and this can indicate diarrhea, anxiety, or gastroenteritis. Hyperactive bowel sounds are often found before a blockage. It is quite common to find one quadrant with hyperactive bowel sounds and one with none or hypoactive ones.