The nurse notices that a child is spitting up small amounts of blood in the immediate postoperative period after a tonsillectomy. What would be the best intervention?

Notify the health care immediately.

Continue to assess for bleeding.

Suction the back of the throat.

Encourage the child to cough.

Answer and Explanation

The Correct Answer is A

A. Notifying the healthcare provider immediately is the best intervention because spitting up blood post-tonsillectomy could indicate bleeding, which requires prompt medical evaluation and intervention.

B. While continuing to assess for bleeding is important, immediate notification of the healthcare provider takes precedence to address potential complications.

C. Suctioning the throat might be contraindicated and could increase the risk of further bleeding.

D. Encouraging coughing is not appropriate as it could increase bleeding risk.

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Correct Answer is D

Explanation

A. A storybook may provide comfort and information but is less interactive in helping the child process the experience of injections.

B. Playing in the playroom is beneficial for normalizing hospital stays but does not directly address the child’s distress regarding injections.

C. A video game can be a good distraction but does not provide therapeutic engagement with the fear or anxiety related to injections.

D. Allowing the child to play with a needleless syringe and a doll is therapeutic as it gives the child a sense of control and understanding of the injection process, helping to reduce fear and anxiety.

A. Implement contact precautions. B. Measure the infant's head circumference. C. Weigh the infant D. Monitor the infant's intake and output. E. Offer the infant small, frequent feeding of thickened liquids. F. Evaluate the infant's pain level using the FACES scale. G. Plan to administer a plain water enema to the infant.

Correct Answer is ["C","D"]

Explanation

A. Contact precautions are not indicated unless there is an infectious disease concern, which is not mentioned in this scenario.

B. Head circumference is routine for well-baby visits and neurological conditions (e.g., hydrocephalus). It is not related to pyloric stenosis assessment.

C. Regular weighing is crucial to assess for weight loss due to vomiting and dehydration. Monitoring weight helps evaluate the severity of the infant's condition and the effectiveness of ongoing treatment.

D. Tracking intake and output is essential for managing hydration status and ensuring the infant is receiving adequate fluids. It helps in assessing the balance between fluid loss due to vomiting and fluid replacement.

E. This intervention is not appropriate for hypertrophic pyloric stenosis. The primary treatment for this condition is surgical intervention, and feeding changes alone will not resolve the underlying issue.

F. The FACES scale is typically used for older children who can self-report pain. For an infant, alternative pain assessment methods would be used, such as observing behavioral cues.

G. An enema is not indicated for hypertrophic pyloric stenosis and may worsen the infant's condition. The focus should be on hydration and surgical preparation rather than enemas.

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The nurse notices that a child is spitting up small amounts of blood in the immediate postoperative period after a tonsillectomy. What would be the best intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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