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.
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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Related Questions
Correct Answer is C
Explanation
A. Reading a story is beneficial but does not directly support the toddler's developmental task of autonomy and initiative.
B. Feeding the toddler is a basic need but does not support the development of independence.
C. Allowing the toddler to pull a talking-duck toy supports their developmental task of autonomy and initiative by promoting physical activity and exploration.
D. Watching a puppet show is a passive activity and does not foster the active exploration needed for this developmental stage.
Correct Answer is A
Explanation
A. Acetaminophen is appropriate for managing mild discomfort post-procedure.
B. Tub baths are generally avoided for the first few days to prevent infection at the catheterization site; sponge baths are preferred.
C. Keeping the child home for 1 week might be excessive; follow the healthcare provider's specific instructions regarding activity and school return.
D. Clear liquids are typically offered as tolerated, but the primary concern post-procedure is monitoring the insertion site and ensuring the child rests adequately.
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