A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?
increased pain
Frequent swallowing
Poor fluid intake
Drooling
The Correct Answer is B
Correct answer: B
A. Increased pain: Increased pain is a common and expected finding after a tonsillectomy. The surgical removal of tonsils creates wounds in the throat, which can cause discomfort and pain during the healing process. However, increased pain alone is not a specific manifestation of hemorrhage. Hemorrhage would be indicated by other signs, such as drooling, frequent swallowing, or vomiting blood.
B. Frequent swallowing: This can indicate that the child is swallowing blood, which is a common sign of bleeding at the surgical site. Children might not always show obvious signs of bleeding in the mouth, so frequent swallowing can be a subtle but critical indicator of hemorrhage.
C. Poor fluid intake: Poor fluid intake is a common concern after a tonsillectomy due to postoperative pain and discomfort in the throat. The child may be reluctant to drink or eat initially because of their sore throat. However, poor fluid intake alone is not an indicative sign of hemorrhage. Hemorrhage would present with other symptoms, such as drooling, frequent swallowing, or vomiting blood.
D. Drooling: While drooling can occur due to discomfort, pain, or difficulty swallowing, it is not as specific or immediate a sign of hemorrhage as frequent swallowing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Children with sickle cell anemia are prone to dehydration, which can worsen the sickling of red blood cells and trigger a sickle cell crisis. Therefore, it is essential to maintain good hydration to prevent crises. Offering fluids to the child multiple times every day helps to keep them well-hydrated.
Option B is not necessary unless there is a specific medical reason to restrict outdoor play. Regular play is essential for a child's physical and emotional development.
Option C is important, but it is not specific to discharge teaching after an acute crisis episode. Monitoring the child's temperature daily is essential to detect early signs of infection, which can be a trigger for sickle cell crises.
Option D is not recommended because applying cold compresses can cause vasoconstriction and may worsen pain in children with sickle cell anemia. Heat therapy, warm compresses, or a warm bath are more appropriate for pain relief during a sickle cell crisis. However, pain management should be discussed with the healthcare provider to ensure the most appropriate approach for the individual child's needs.
Correct Answer is C
Explanation
Infants with gastroesophageal reflux should be placed in an infant seat or an upright position after feedings to help prevent regurgitation and aspiration of stomach contents into the airway. Placing the infant in an upright position facilitates gravity-assisted movement of stomach contents down and away from the esophagus, reducing the likelihood of reflux. It is essential to ensure that the infant seat is appropriate for the child's age and size and that the infant is safely secured within it.
The other options are not recommended for infants with gastroesophageal reflux:
When caring for an infant with gastroesophageal reflux (GER), the nurse should place the infant in an infant seat or an upright position following feedings. Placing the infant in an upright position helps to reduce the risk of reflux and regurgitation. Gravity can assist in keeping the stomach contents from flowing back into the esophagus, reducing the potential for discomfort and reflux symptoms.
The other options are not recommended for an infant with GER:
A. Placing the infant in a prone position (lying on the stomach) after feedings can increase the risk of choking and aspiration. It is essential to avoid this position, especially after feeding, to reduce the risk of reflux and its complications.
B. Placing the infant on his left side is not the preferred position for GER management. While the left side is often recommended for sleeping to reduce the risk of sudden infant death syndrome (SIDS), it is not specifically indicated for GER management after feedings.
D. Placing the infant on his right side is also not the preferred position for GER management after feedings. The right side does not provide the benefits of an upright position in reducing the risk of reflux and regurgitation.
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