A nurse is reviewing laboratory findings for a client who is to receive a dose of enoxaparin. For which of the following laboratory values should the nurse withhold the dose and notify the provider?

Rationale for correct choices

• Inspect the child’s oropharynx: The child has bright red emesis and visible bleeding in the posterior pharynx, which indicates active post-tonsillectomy hemorrhage. Direct visualization helps confirm the bleeding source and severity. Early inspection supports rapid intervention because post-operative tonsillar bleeding can progress quickly and become life-threatening.

• Obtaining a set of vital signs: Active bleeding and vomiting bright red blood require immediate reassessment of vital signs to detect tachycardia, hypotension, or respiratory compromise. Hemoglobin and hematocrit are already low, increasing the child’s risk for hemodynamic instability. Timely vital signs guide urgent decisions about fluid resuscitation and notifying the provider.

Rationale for incorrect choices

• Offer the child a red popsicle: Providing red-colored fluids can mask ongoing bleeding and delay recognition of hemorrhage. The priority is to assess and stabilize the child with known bleeding, not to offer oral intake. This intervention risks obscuring the color of emesis or oral bleeding.

• Place the child in a supine position: Supine positioning increases the risk of aspiration when bleeding or vomiting is present. The child should be maintained upright to allow drainage and airway protection. Supine positioning does not address the current complication and may worsen respiratory safety.

• Encouraging the child to cough and deep breathe: Coughing can dislodge clots and worsen post-tonsillectomy bleeding. The child already has active bright red bleeding, so stimulating airway pressure would increase hemorrhage risk. This intervention is inappropriate in immediate postoperative bleeding scenarios.

• Requesting a prescription for codeine: Codeine is contraindicated in children after tonsillectomy due to risk of respiratory depression from ultra-rapid metabolism. Pain is mild, and bleeding—not pain—is the priority. Requesting codeine does not address the current danger of hemorrhage.

A. A 14-year-old child who eats small but frequent meals throughout the day: This is an appropriate intervention for gastroesophageal reflux, as smaller, more frequent meals reduce gastric distention and minimize reflux episodes. No revision to the plan of care is needed for this child.

B. A 16-year-old child who takes their proton pump inhibitor 30 min before meals: Administering proton pump inhibitors before meals is correct because these medications are most effective when taken prior to food intake, allowing for optimal acid suppression. The current plan aligns with best practice.

C. A 6-year-old child who underwent a Nissen fundoplication and is tolerating a full liquid diet: Progressing to a full liquid diet after Nissen fundoplication is appropriate and indicates the child is tolerating postoperative dietary advancement. The plan of care is appropriate and requires no changes.

D. A 4-month-old child who is experiencing weight loss: Weight loss in an infant with gastroesophageal reflux is concerning and indicates inadequate nutrition or complications. The plan of care should be revised to address feeding adequacy, possible medical interventions, and close monitoring of growth and hydration status.