A nurse is caring for a 9-year-old child on the pediatric unit.
Complete the following sentence by using the lists of options.
The nurse should plan to
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Rationale for correct choices
• Inspect the child's oropharynx: Vomiting bright red emesis after tonsillectomy indicates possible postoperative hemorrhage. Immediate inspection of the oropharynx allows the nurse to assess the source, amount, and severity of bleeding. Prompt identification of bleeding is critical to prevent hypovolemic shock and guide urgent interventions.
• Obtaining a set of vital signs: Vital signs provide objective data about the child’s hemodynamic status. Tachycardia, hypotension, or altered respiratory rate may indicate significant blood loss. Monitoring blood pressure, heart rate, and oxygen saturation helps determine the urgency of treatment and guides fluid resuscitation or other emergency measures.
Rationale for incorrect choices
• Place the child in a supine position: Placing the child supine could worsen bleeding or increase the risk of aspiration if emesis occurs. Standard care is to maintain the child upright or sitting forward to allow drainage and minimize airway compromise. Supine positioning is not appropriate immediately after post-tonsillectomy bleeding.
• Offer the child a red popsicle: Red-colored foods or drinks can mask the presence of ongoing bleeding, delaying recognition of hemorrhage. It is unsafe to offer red popsicles until bleeding is ruled out and the child is stable. Non-red liquids or clear fluids are safer during assessment.
• Encouraging the child to cough and deep breathe: While coughing and deep breathing are important for postoperative respiratory care, they are contraindicated if active bleeding is suspected. Coughing could dislodge clots and exacerbate hemorrhage. Airway safety and hemodynamic assessment take priority.
• Requesting a prescription for codeine: Administering codeine for pain is inappropriate in the presence of suspected bleeding because opioids can mask symptoms and depress respirations. Pain management should be secondary to stabilization and assessment of hemorrhage risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. “Our children can stay up as late as they prefer.” This statement reflects a permissive parenting style, where few rules are enforced and children have significant freedom. Parents in this style often avoid setting firm boundaries, which contrasts sharply with the strict control seen in authoritarian parenting.
B. “Our children are allowed to make their own choices.” This reflects an authoritative parenting style, which balances independence with guidance. Authoritative parents encourage decision-making while still providing consistent rules and support. This collaborative, approach differs significantly from the rigid and demanding nature of authoritarian parenting.
C. “We make decisions as a family.” This statement also aligns with authoritative parenting, which values communication, mutual respect, and shared problem-solving. Children’s input is considered, helping them develop confidence and reasoning skills. Such family-centered decision-making is not present in authoritarian households.
D. “We expect our children to do what we say without any questions.” Authoritarian parenting focuses on obedience, strict rules, and limited negotiation. Children are expected to comply without explanation, and parents often enforce discipline rigidly. This style places emphasis on control rather than communication.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Rationale for Correct Choices
- Endometritis: This uterine infection is common after cesarean delivery, especially with prolonged rupture of membranes. The client’s uterine tenderness, elevated fundus, boggy consistency, and foul-smelling lochia are hallmark signs of endometritis, making it the most likely diagnosis.
- Uterus and lochia: The presence of a tender uterus that is elevated above the umbilicus and only firms with massage, combined with dark, malodorous lochia, strongly suggests infection of the uterine lining. These findings point specifically to endometritis rather than general postpartum changes.
Rationale for Incorrect Choices
- Mastitis: Although the client reports heavy, warm breasts with nipple discomfort, there is no breast erythema, localized swelling, or high-grade fever typical of mastitis. These symptoms are likely due to engorgement related to lactation rather than infection.
- Pneumonia: The client’s respiratory assessment shows clear lungs with only slight basal changes common postoperatively. There are no signs of cough, sputum production, hypoxia, or respiratory distress, which makes pneumonia an unlikely cause of her symptoms.
- Fever: A temperature of 38.2°C is above normal, but mild postpartum fever can have various causes, including engorgement, dehydration, or early infection. Fever alone is not specific enough to confirm a diagnosis without targeted findings.
- WBC count: Although an elevated WBC of 33,000/mm³ raises concern, postpartum leukocytosis can be physiologic or related to many infections. It is not diagnostic of endometritis without more specific correlating signs like uterine tenderness and abnormal lochia.
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