A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse?

A. A gastric residual volume (GRV) of 250 mL is a finding that requires monitoring but typically does not require "immediate" intervention or the cessation of feeding. Current evidence-based guidelines often suggest that feedings should not be held unless the GRV exceeds 500 mL in a single measurement or if the client shows signs of intolerance (e.g., abdominal distension, nausea). While 250 mL indicates a slight delay in gastric emptying, it is not an acute emergency compared to the risk of aspiration from supine positioning. B. The client is lying in a supine position: The client lying in a supine position requires immediate intervention. Clients receiving enteral feedings must have the head of the bed elevated to at least 30° to 45° at all times to prevent gastric reflux and aspiration. In a post-laryngectomy client, the risk is even higher because the anatomical changes to the upper airway make it easier for regurgitated feeding to enter the trachea. The nurse must immediately raise the head of the bed to ensure the client's safety. C. The infusion pump for administering continuous feeding is turned off: The pump being turned off interrupts nutrition delivery, which is undesirable, but it does not pose an immediate risk to the client’s safety. Correcting the pump can be done after addressing more urgent issues. D. The enteral feeding bag and tubing are not dated: Lack of dating increases the risk of infection due to prolonged use, but this is a routine safety concern and does not require immediate intervention compared with high gastric residual volumes that pose aspiration risk.