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

The correct answer is: D

Choice A reason:

Placing an infant on their left side after feeding is not the most recommended position for managing gastroesophageal reflux (GER). While it may be better than lying flat on the back, it does not provide the same benefits as keeping the infant in an upright position.

Choice B reason:

Positioning an infant on their right side is generally not advised for GER management. This position can potentially worsen reflux as it may facilitate the backflow of stomach contents into the esophagus due to the stomach's anatomical orientation.

Choice C reason:

Placing an infant in a prone position, especially after feeding, is strongly discouraged due to the increased risk of sudden infant death syndrome (SIDS). Although this position may reduce gastroesophageal reflux, the potential risks far outweigh the benefits.

Choice D reason:

Placing an infant in an infant seat is the recommended position following feedings for a child with GER. This position helps keep the infant upright, allowing gravity to aid in keeping the stomach contents from coming back up into the esophagus. However, it's important to note that the infant seat should not be inclined, as semi-supine positioning can exacerbate GER.

Choice A reason: This statement is normal, as an infant who is 2 months old should be alert and responsive to stimuli. The nurse should assess the infant's level of consciousness and responsiveness using the AVPU scale (alert, voice, pain, unresponsive).

Choice B reason: This statement is normal, as an infant who is 2 months old should have warm and dry skin and a tone that is appropriate for their ethnicity. The nurse should assess the infant's skin color, temperature, moisture, and turgor.

Choice C reason: This statement is abnormal, as an infant who is 2 months old should not have a distended abdomen or a visible mass in the right upper quadrant. This could indicate a serious condition such as a liver tumor, a bowel obstruction, or a hernia. The nurse should report this finding to the provider and monitor the infant for signs of pain, vomiting, or jaundice.

Choice D reason: This statement is normal, as an infant who is 2 months old should have full range of motion in their extremities and no clicks noted. The nurse should assess the infant's muscle strength, tone, and symmetry, and check for any signs of hip dysplasia, such as a positive Barlow or Ortolani test.