A nurse is collecting data from a child who is postoperative following a tonsillectomy. Which of the following is a clinical manifestation of a hemorrhage?

A. Lethargy: Lethargy can be a concerning sign in a postoperative child, especially following a procedure involving the central nervous system like VP shunt insertion. It could indicate increased intracranial pressure or other neurological complications, which require immediate attention. Therefore, this is a priority finding.

B. Urine output 70 mL in 2 hr: While monitoring urine output is important for assessing hydration and renal function, a urine output of 70 mL in 2 hours may not be immediately concerning in a 4-year-old child. However, if this pattern continues or if there are signs of dehydration, it should be addressed. It's not as urgent as assessing for neurological changes.

C. Lying flat on the unaffected side: The positioning of the child, lying flat on the unaffected side, may or may not be concerning depending on the specific instructions provided postoperatively. While positioning can affect the function of the VP shunt, it may not necessarily indicate an immediate complication.

D. Respiratory rate 20/min: A respiratory rate of 20 breaths per minute is within the normal range for a 4-year-old child. While changes in respiratory rate can indicate respiratory distress, this respiratory rate alone is not immediately concerning.

A. Machine-like murmur.

This option is correct. A characteristic clinical manifestation of a large patent ductus arteriosus is a continuous "machine-like" murmur heard on auscultation. This murmur is typically heard best at the upper left sternal border and may radiate to the back.

B. Chronic hypoxemia.

Chronic hypoxemia is not typically a primary manifestation of a large PDA. While PDA can lead to increased pulmonary blood flow and potentially contribute to pulmonary congestion, chronic hypoxemia may not be a prominent feature unless complications such as heart failure develop.

C. Cyanosis with crying.

Cyanosis with crying is more commonly associated with cyanotic congenital heart defects such as tetralogy of Fallot. While PDA can contribute to cyanosis in certain circumstances, it is not typically a consistent clinical manifestation.

D. Weak pulse.

A weak pulse is not typically associated specifically with a large PDA. Infants with PDA may have bounding pulses due to increased blood flow through the ductus arteriosus.