Answer :
Answer:
Option 2, 5 minutes
Explanation:
During abdominal assessment, the nurse must auscultate (listen to) the four quadrants of the abdomen for bowel tones.
The gurgling and rumbling of the gastrointestinal (GI) tract -- also known as borborgymi -- indicate expected motility is occurring or progress is being made towards a return to the patient's routine patterns. Typically, the nurse places their stethoscope on these quadrants for 15 to 30 seconds each in order to assess if the bowel sounds are normoactive (5-30 sounds a minute with one sound every 5-15 seconds), hyperactive (30+ sounds within a minute), or hypoactive (less than 5 sounds in a minute). A more accurate estimate of how many bowel tones are heard within a minute would be to simply listen for the entire minute itself; however, this may be a more time-consuming task in the nurse's busy schedule and the patient likely will not become hypoactive quite soon after being normoactive or hypoactive.
Silent bowel sounds, however, can be a late sign that the patient is experiencing a bowel obstruction or paralytic ileus, both which can be emergent complications. In order to confirm that no tones are heard, the nurse must auscultate the regions of the abdomen for a much longer amount of time.
To confirm silent or absent bowel sounds as an observed finding, the nurse should listen to the abdomen for at least 5 minutes. This gives the nurse conclusive evidence to report to the provider, who can then process new orders for the patient on how the pathology causing the absent tones will be remedied.
2 minutes per quadrant can achieve this goal of at least 5 minutes, same with 10 minutes in total, but they are not necessarily more productive or conclusive than listening for 5 minutes.
Option 2, 5 minutes, is the answer.
