A nurse is assessing a 5-month-old infant. Which of the following findings should the nurse report to the provider?

Choice A Reason:

Shrug their shoulders against mild pressure. The accessory nerve controls the movement of the trapezius and sternocleidomastoid muscles. To assess this nerve, the nurse should ask the child to shrug their shoulders against mild resistance or pressure applied by the nurse's hands on the child's shoulders. This action assesses the strength and symmetry of the trapezius muscles.

Choice B Reason:

Move their tongue in all directions. This action assesses the function of the hypoglossal nerve (cranial nerve XII), which controls tongue movement.

Choice C Reason:

Follow a light in the six cardinal positions. This action assesses the function of the extraocular muscles and cranial nerves III, IV, and VI, which control eye movements.

Choice D Reason:

Show their teeth while smiling. This action primarily assesses the facial nerve (cranial nerve VII), which controls facial expressions, including smiling and showing teeth.

Correct answer: C

Choice A Reason:

Instructing the child to drink fluids through a straw should be avoided immediately after a tonsillectomy. The sucking motion required when using a straw can potentially disrupt the healing process and dislodge the blood clot at the surgical site, leading to bleeding. Therefore, this action is not recommended.

Choice B Reason:

Avoid milk products such as milk, icecream and pudding initially because they coat the throat, causing the child to cough to clear the throat.

Choice C Reason:

Placing the child in a side-lying position helps maintain an open airway and allows drainage of saliva and potential blood.

Choice D Reason:

Encouraging the child to deep breath and cough is generally a good practice to prevent respiratory complications post-anesthesia. However, immediate post-tonsillectomy, the focus might be more on airway patency and monitoring for signs of bleeding or adverse reactions rather than deep breathing and coughing.