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
A dietitian should be consulted for a newly admitted child to assess and plan for the child’s nutritional needs, especially if the child has specific dietary requirements or is at risk for malnutrition.
Choice B rationale
An occupational therapist may be involved later in the child’s care, but they are not typically the first referral for a newly admitted child.
Choice C rationale
A physical therapist may be involved later in the child’s care, but they are not typically the first referral for a newly admitted child.
Choice D rationale
A speech-language pathologist may be involved later in the child’s care, but they are not typically the first referral for a newly admitted child.
Correct Answer is D
Explanation
Choice A rationale
Odorless urine is not a specific indicator of effective treatment for acute poststreptococcal glomerulonephritis (APSGN)16.
Choice B rationale
A temperature of 37.2°C (99°F) is within the normal range and does not specifically indicate effective treatment for APSGN16.
Choice C rationale
No report of pain with voiding is not a specific indicator of effective treatment for APSGN16.
Choice D rationale
Clear urine indicates that the hematuria (blood in urine) has resolved, which is a sign of effective treatment for APSGN1617.