A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?

Choice A reason: Withholding fluids until the client demonstrates a gag reflex is a preventive measure to avoid aspiration of liquids into the lungs. The gag reflex is a protective mechanism that prevents foreign objects from entering the airway. It can be impaired by anesthesia, surgery, or trauma. Therefore, the nurse should assess the client's gag reflex before offering fluids or food¹.

Choice B reason: Suctioning the nasopharynx as needed is another preventive measure to avoid aspiration of blood or secretions into the lungs. The nurse should monitor the client for signs of bleeding, such as frequent swallowing, restlessness, or bright red drainage. The nurse should also avoid stimulating the throat with tongue blades, straws, or suction catheters, as this can cause bleeding or spasm¹.

Choice C reason: Placing a bedside humidifier at the head of the client's bed is not a preventive measure to avoid aspiration, but rather a comfort measure to soothe the throat and reduce inflammation. Humidified air can help moisten the mucous membranes and promote healing. However, it does not prevent fluids or solids from entering the airway².

Choice D reason: Performing chest physiotherapy is not a preventive measure to avoid aspiration, but rather a treatment measure for clients who have respiratory complications, such as atelectasis or pneumonia. Chest physiotherapy involves percussion, vibration, and postural drainage to mobilize and remove secretions from the lungs. It is not indicated for clients who are postoperative following a tonsillectomy, as it can increase the risk of bleeding or pain³.

Choice E reason: Administering an antiemetic drug if the client is nauseous is a preventive measure to avoid aspiration of vomitus into the lungs. Nausea and vomiting are common postoperative complications that can be caused by anesthesia, pain, or opioids. The nurse should assess the client's nausea level and administer antiemetic drugs as prescribed. The nurse should also position the client on the side or with the head elevated to prevent aspiration¹.

Choice A reason: Drooling is not a sign of hemorrhage, but rather a sign of difficulty swallowing or breathing. Drooling may occur after a tonsillectomy due to throat pain or swelling, but it does not indicate bleeding.

Choice B reason: Poor fluid intake is not a sign of hemorrhage, but rather a sign of dehydration or nausea. Poor fluid intake may occur after a tonsillectomy due to throat pain or fear of swallowing, but it does not indicate bleeding.

Choice C reason: Increased pain is not a sign of hemorrhage, but rather a sign of inflammation or infection. Increased pain may occur after a tonsillectomy due to tissue damage or healing, but it does not indicate bleeding.

Choice D reason: Frequent swallowing is a sign of hemorrhage, as it indicates that the child is trying to clear blood from the throat. Frequent swallowing may occur after a tonsillectomy due to bleeding from the surgical site or a ruptured blood vessel.