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 B

Explanation

The American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) recommend that the first dose of MMR vaccine be given at 12-15 months of age.

A. 6 months is too early for the MMR vaccine.

D. 2 months is also too early for the MMR vaccine.

C. 24 months is slightly beyond the recommended range for the first dose of MMR vaccine, which is given between 12-15 months of age.

A. Refer the child to the healthcare provider and schedule evaluation of blood pressure in two weeks. B. Measure the child's blood pressure three times during the visit and determine the highest of the readings. C. Conduct a head-to-toe assessment and omit repeated blood pressures during the examination. D. Take the blood pressure two more times during the visit and determine the average of the three readings.

Correct Answer is D

Explanation

If a child's systolic blood pressure is greater than the 90th percentile during a routine clinic visit, the nurse should take the blood pressure two more times during the visit and determine the average of the three readings. This will provide a more accurate assessment of the child's blood pressure. Referring the child to the healthcare provider and scheduling an evaluation of blood pressure in two weeks

A. may be necessary if the child's blood pressure remains elevated, but it is not the next action that should be taken. Measuring the child's blood pressure three times during the visit and determining the highest of the readings

B. is not recommended because it may overestimate the child's blood pressure. Conducting a head-to-toe assessment and omitting repeated blood pressures during the examination

C. is not appropriate because it does not provide an accurate assessment of the child's blood pressure.

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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?

Nursing Test Bank

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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?