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","B","C","D"]
No explanation
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.