A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?

Correct answer: A
A. Encourage the parents to rock the infant:Rocking provides comfort and soothing for the infant. It helps reduce anxiety and promotes relaxation during the immediate postoperative period

B. Administer ibuprofen as needed for pain:Administering ibuprofen as needed for pain is not typically recommended for infants under 6 months of age without specific instructions from the healthcare provider. Ibuprofen is generally avoided in young infants due to potential risks of adverse effects, especially in the immediate postoperative period
C. Position the infant on her abdomen: After cleft lip repair surgery, it is generally recommended to position the infant on her back to prevent any pressure on the surgical site and to minimize the risk of infection. Placing the infant on her abdomen may interfere with the healing process and increase the risk of complications.

D. Offer the infant a pacifier.
Avoid the use of oral suction or placing objects in the mouth such as a tongue depressor, thermometer, straws, spoons, forks, or pacifiers.

D. A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing.
A significant drop in blood pressure when changing positions from lying to standing may indicate orthostatic hypotension, which can be a sign of dehydration, blood loss, or other underlying medical issues. This can be a cause for concern, especially if the client is an adolescent, as it may lead to decreased perfusion of vital organs and may require immediate medical attention.

The other options are as follows:
A. A client who has a burn injury to an estimated 5% of his leg and is crying - While it's essential to assess and address the client's pain and comfort, this finding does not indicate an immediate need for medical attention. Pain management and wound care can be addressed based on the severity of the burn and the client's pain level.
B. A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation - This finding is concerning, and the nurse should notify the provider to reassess pain management and evaluate for potential complications related to the fracture. However, it may not require immediate medical attention unless there are signs of severe pain or complications.
C. A client who is 1 day postoperative and has a temperature of 37.5° C (99.5° F) - A slight increase in temperature in the immediate postoperative period may not be unusual and can be attributed to the normal inflammatory response after surgery. The nurse should continue monitoring the client's temperature and report any further changes or additional signs of infection or complications to the provider.
Overall, while all findings should be addressed and managed appropriately, the significant drop in blood pressure (option D) should be reported immediately due to the potential implications for the client's overall health and well-being.