A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?
Drooling
Poor fluid intake
Increased pain
Frequent swallowing
The Correct Answer is D
Choice A reason: Drooling is not a sign of hemorrhage, but rather a sign of difficulty swallowing or breathing. Drooling may occur after a tonsillectomy due to throat pain or swelling, but it does not indicate bleeding.
Choice B reason: Poor fluid intake is not a sign of hemorrhage, but rather a sign of dehydration or nausea. Poor fluid intake may occur after a tonsillectomy due to throat pain or fear of swallowing, but it does not indicate bleeding.
Choice C reason: Increased pain is not a sign of hemorrhage, but rather a sign of inflammation or infection. Increased pain may occur after a tonsillectomy due to tissue damage or healing, but it does not indicate bleeding.
Choice D reason: Frequent swallowing is a sign of hemorrhage, as it indicates that the child is trying to clear blood from the throat. Frequent swallowing may occur after a tonsillectomy due to bleeding from the surgical site or a ruptured blood vessel.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Applying and releasing elbow restraints every hour prevents the infant from touching or injuring the surgical site, while allowing some movement and circulation. This is a standard nursing intervention for infants who have undergone cleft palate repair.
Choice B reason: Keeping the infant supine is not recommended, as it increases the risk of aspiration and bleeding. The infant should be placed in a side-lying or upright position to facilitate drainage and prevent pressure on the suture line.
Choice C reason: Feeding the infant with a spoon for 48 hours is not necessary, as it may cause discomfort and trauma to the palate. The infant can be fed with a special nipple or a syringe with a rubber tip that delivers small amounts of formula or breast milk to the side of the mouth.
Choice D reason: Suctioning the mouth with an oral suction tube is contraindicated, as it may damage the palate and cause bleeding or infection. The nurse should use a bulb syringe to gently suction the nose and mouth if needed.
Correct Answer is D
Explanation
The correct answer is: D
Choice A reason:
Placing an infant on their left side after feeding is not the most recommended position for managing gastroesophageal reflux (GER). While it may be better than lying flat on the back, it does not provide the same benefits as keeping the infant in an upright position.
Choice B reason:
Positioning an infant on their right side is generally not advised for GER management. This position can potentially worsen reflux as it may facilitate the backflow of stomach contents into the esophagus due to the stomach's anatomical orientation.
Choice C reason:
Placing an infant in a prone position, especially after feeding, is strongly discouraged due to the increased risk of sudden infant death syndrome (SIDS). Although this position may reduce gastroesophageal reflux, the potential risks far outweigh the benefits.
Choice D reason:
Placing an infant in an infant seat is the recommended position following feedings for a child with GER. This position helps keep the infant upright, allowing gravity to aid in keeping the stomach contents from coming back up into the esophagus. However, it's important to note that the infant seat should not be inclined, as semi-supine positioning can exacerbate GER.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today