A nurse is caring for a 5-year-old child following a tonsillectomy and adenoidectomy. Which of the following findings should the nurse identify as an indication of hemorrhage?
Continuous swallowing.
Blood pressure 95/56 mm Hg.
Heart rate 54/min.
Flushing of the face.
The Correct Answer is A
Choice A rationale
Continuous swallowing can be an indication of hemorrhage following a tonsillectomy and adenoidectomy. This is because the child may be swallowing blood that is coming from the surgical site.
Choice B rationale
Blood pressure of 95/56 mm Hg is within the normal range for a 5-year-old child and does not specifically indicate hemorrhage.
Choice C rationale
A heart rate of 54/min is lower than the normal range for a 5-year-old child and may indicate bradycardia, but it is not a specific sign of hemorrhage.
Choice D rationale
Flushing of the face is not a specific sign of hemorrhage. It may indicate other conditions but is not typically associated with bleeding following a tonsillectomy and adenoidectomy.
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Correct Answer is A
Explanation
Choice A rationale
The first voided specimen is discarded to ensure that the 24-hour urine collection starts with an empty bladder and accurately reflects the urine produced over the entire period.
Choice B rationale
Voiding every hour is not necessary and may not be practical for a 24-hour urine collection.
Choice C rationale
The final specimen should be included in the same container as the rest of the 24-hour urine collection.
Choice D rationale
Cleansing the perineum with a povidone-iodine solution is not required for a 24-hour urine collection.
Correct Answer is A
Explanation
Choice A rationale
The presence of the Doll’s eye reflex (oculocephalic reflex) beyond the newborn period is abnormal and should be reported. This reflex should disappear by 2-3 months of age. Its persistence may indicate neurological issues.
Choice B rationale
No head lag when pulled to a sitting position is a normal finding in a 4-month-old infant. By this age, infants typically have developed enough neck muscle strength to hold their head steady.
Choice C rationale
The presence of tears when crying is a normal finding in a 4-month-old infant. Tear production usually begins around 2-3 months of age.
Choice D rationale
A positive Babinski reflex is normal in infants up to 2 years old. It is an expected finding and does not require notification to the provider.