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
Assessing the oral cavity for Koplik spots is not relevant for varicella. Koplik spots are associated with measles, not varicella. Varicella, also known as chickenpox, typically presents with a rash that starts on the trunk and spreads to the rest of the body, along with other symptoms like fever and malaise.
Choice B rationale
Administering aspirin for fever is contraindicated in children with varicella due to the risk of Reye’s syndrome. Reye’s syndrome is a rare but serious condition that can occur when aspirin is given to children with certain viral infections, including varicella. It can cause swelling in the liver and brain.
Choice C rationale
Providing the child with a warm blanket can offer comfort to the child, helping to alleviate chills or discomfort associated with fever. However, it is not a specific intervention for managing varicella. The primary focus should be on preventing the spread of the infection through appropriate precautions.
Choice D rationale
Initiating airborne precautions is essential for preventing the spread of varicella. Varicella is transmitted via airborne droplets, and using airborne precautions (such as negative air-flow rooms) helps prevent the spread of the virus to other patients and healthcare workers. If negative air-flow rooms are not available, isolating patients in closed rooms with no contact with people without evidence of immunity is recommended.
Correct Answer is D
Explanation
Choice A rationale
Placing the infant in a recumbent position during feeding is not recommended as it can increase the risk of aspiration. The infant should be held in an upright or semi-upright position to facilitate safe swallowing and digestion.
Choice B rationale
Allowing the infant 45 minutes for each feeding can be too long and may lead to fatigue and decreased feeding efficiency. It is generally recommended to limit feeding sessions to 20-30 minutes to ensure the infant gets adequate nutrition without becoming overly tired.
Choice C rationale
Allowing the infant to self-soothe by crying prior to feeding is not advisable, especially for infants with heart failure. Crying can increase the infant’s metabolic demands and oxygen consumption, which can be detrimental to their condition.
Choice D rationale
Implementing a 3-hour feeding schedule helps ensure that the infant receives regular and consistent nutrition. This schedule can help manage the infant’s energy levels and prevent fatigue, which is important for infants with heart failure.