A nurse is assessing a preschool-age child who is in the immediate postoperative period following a tonsillectomy. Which of the following assessment findings is the priority?

The child's throat pain increases.

The child refuses clear liquids.

The child cries often.

The child swallows frequently.

Answer and Explanation

The Correct Answer is D

Rationale:
A.   The child's throat pain is expected post-tonsillectomy and can be managed using analgesics or an ice collar. However, this is not a priority finding compared to frequent swallowing which may indicate bleeding which is a life-threatening complication of tonsillectomy.
B.   Refusing clear liquids may indicate discomfort but is not as urgent as a potential increase in throat pain.
C.   Crying often may be a response to discomfort but does not necessarily indicate a complication requiring immediate intervention.
D.   This assessment finding indicates that the child might have bleeding in the throat, which is a life-threatening complication of tonsillectomy. The nurse should

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Correct Answer is A

Explanation

A. This is the first step to control bleeding and prevent further blood loss.
B. Monitoring the distal pulse is important, but controlling bleeding takes precedence.
C. Vital signs can wait momentarily until the bleeding is under control.
D. Reinforcing the dressing may be necessary, but controlling bleeding is the immediate priority.

A. No head lag when pulled to a sitting position B. Doll's eye reflex intact C. Presence of tears when crying D. Positive Babinski reflex

Correct Answer is B

Explanation

A. No head lag when pulled to a sitting position is a normal finding at 4 months of age.
B. They should not have doll's eye reflex intact, which means that their eyes move in the opposite direction of their head when turned. This reflex normally disappears by 3 months of age and its persistence may indicate brain damage.
C. The presence of tears when crying is a normal finding at 4 months of age.
D. They should also have positive Babinski reflex, which means that their toes fan out when their sole is stroked. This reflex normally disappears by 12 months of age.

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A nurse is assessing a preschool-age child who is in the immediate postoperative period following a tonsillectomy. Which of the following assessment findings is the priority?

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