While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes.

Which assessment should the nurse implement?

Inspect the posterior oropharynx.

Touch the tonsillar pillars to stimulate the gag reﬂex.

Ask the child to speak to evaluate change in voice tone.

Assess for teeth clenching or grinding.

Answer and Explanation

The Correct Answer is A

The nurse should inspect the posterior oropharynx of a child who is frequently swallowing after tonsillectomy to assess for bleeding or the presence of clots. Swallowing frequently can be a sign of postoperative bleeding, which is a potential complication of tonsillectomy.

Touching the tonsillar pillars to stimulate the gag reﬂex or asking the child to speak would not provide information about the presence of bleeding.

Assessing for teeth clenching or grinding is not related to this particular observation.

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Correct Answer is A

Explanation

At the age of 3, children should be able to speak in simple sentences with a minimum of four words. This is a normal developmental milestone for this age group. Choices B, C, and D are not appropriate developmental milestones for speech and language skills for a 3-year-old child.

A. Obtain the essential information as quickly as possible. B. Document interactions between the parent and the child. C. Ignore the child's behavior, directing questions to a parent. D. Include the child's toy in the collection of information.

Correct Answer is D

Explanation

The nurse should implement the intervention of including the child's toy in the collection of information when the child screams and tries to hide behind the parent, dropping a stuﬀed toy. This can help engage the child and make them feel more comfortable during the medical history collection process. The other options (A, B, and C) are not appropriate interventions in this situation.

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While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?

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While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes.

Which assessment should the nurse implement?