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 D
Explanation
Choice A rationale
Asking the child’s parent to leave the room during the procedure may increase the child’s anxiety and make the procedure more traumatic. Parental presence can provide comfort and reduce anxiety.
Choice B rationale
Performing the procedure in the unit’s playroom may not provide the necessary equipment and sterile environment required for a venipuncture. It is important to perform the procedure in a controlled and sterile environment.
Choice C rationale
Explaining the procedure in detail to the child 3 hours prior to the procedure may increase anxiety and anticipation, making the procedure more traumatic. It is better to explain the procedure closer to the time of the procedure.
Choice D rationale
Applying a topical anesthetic cream 1 hour prior to the procedure helps reduce pain and discomfort during the venipuncture, promoting atraumatic care. This approach minimizes the child’s pain and anxiety.
Correct Answer is C
Explanation
Choice A rationale
Checking the newborn’s eyes every 8 hours is not necessary for the management of hyperbilirubinemia or phototherapy. The primary concern during phototherapy is monitoring the newborn’s temperature and hydration status.
Choice B rationale
Placing mittens on the newborn’s hands is unrelated to the management of hyperbilirubinemia or phototherapy. Mittens are typically used to prevent the newborn from scratching themselves.
Choice C rationale
Monitoring the newborn’s temperature every 2 hours is essential during phototherapy because infants are at risk of hypothermia due to increased heat loss from the lights. This helps ensure the newborn maintains a stable body temperature.
Choice D rationale
Applying lotion to the newborn’s skin is not recommended during phototherapy as it can interfere with the effectiveness of the lights. The lotion can act as a barrier, reducing the amount of light that reaches the skin.