A nurse is caring for a newborn who has hydrocephalus.
Which of the following manifestations should the nurse expect to find?

The correct answer is Choice B.

Choice A rationale

Notifying the health care provider immediately may be necessary if the bleeding is severe or persistent. However, in the case of small amounts of blood, it is important to continue assessing for bleeding to determine if the situation worsens. Immediate notification may not be necessary for minor bleeding.

Choice B rationale

Continuing to assess for bleeding is the best intervention for a child spitting up small amounts of blood after a tonsillectomy. This allows the nurse to monitor the situation and determine if the bleeding is worsening or if it resolves on its own. It is important to keep the child calm and avoid any actions that could exacerbate the bleeding.

Choice C rationale

Encouraging the child to cough can increase the risk of further bleeding. Coughing can dislodge clots and cause additional trauma to the surgical site. It is important to keep the child calm and avoid actions that could worsen the bleeding.

Choice D rationale

Suctioning the back of the throat can cause additional trauma to the surgical site and increase the risk of bleeding. It is important to avoid invasive procedures and continue to assess for bleeding. If the bleeding worsens, further medical intervention may be necessary.

Choice A rationale:

Evaluating the infant’s pain level using the FACES Scale is not appropriate for infants. The FACES Scale is typically used for children aged 3 years and older.

Choice B rationale:

Offering the infant small, frequent feedings of thickened liquids is not recommended in this scenario. The infant is on NPO (nothing by mouth) status due to the forceful vomiting and risk of aspiration.

Choice C rationale:

Measuring the infant’s head circumference is important to assess for any signs of increased intracranial pressure or hydrocephalus, which can be associated with vomiting.

Choice D rationale:

Implementing contact precautions is not necessary unless there is a known or suspected infectious cause for the vomiting.

Choice E rationale:

Weighing the infant is crucial to monitor for any significant weight loss, which can indicate dehydration or other underlying issues.

Choice F rationale:

Planning to administer a plain water enema to the infant is not appropriate in this scenario. The primary concern is the forceful vomiting, and an enema would not address this issue.