After a tonsillectomy, a 7-year-old girl begins to swallow excessively.
Which intervention is most important for the practical nurse to implement?
Inform the registered nurse about the vital signs and swallowing.
Offer the child fluids to soothe the throat.
Administer supplemental oxygen per prescription.
Elevate the child's head to promote drainage.
The Correct Answer is A
Choice A rationale
Excessive swallowing after a tonsillectomy is a critical sign of postoperative hemorrhage, as blood pooling in the pharynx triggers the swallowing reflex. Promptly informing the registered nurse allows for immediate assessment, potential intervention to control bleeding, and prevention of airway compromise or hypovolemic shock.
Choice B rationale
Offering fluids to soothe the throat is contraindicated in suspected hemorrhage as it may increase the risk of aspiration or obscure the amount of blood being swallowed. It also delays the critical assessment and intervention required for active bleeding.
Choice C rationale
Administering supplemental oxygen per prescription is a supportive measure for respiratory distress. While potentially necessary if the child's oxygen saturation drops, it does not address the underlying cause of excessive swallowing, which is likely hemorrhage, and should not be prioritized over reporting the cardinal sign.
Choice D rationale
Elevating the child's head to promote drainage is a general comfort measure and may help with swelling. However, it does not directly address active bleeding. In a suspected hemorrhage, the primary concern is to identify and manage the source of bleeding, not merely to promote drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A soft, spongy fundus, often described as boggy, indicates uterine atony. This condition means the uterine muscles are not contracting effectively, which is abnormal postpartum and significantly increases the risk of postpartum hemorrhage due to inadequate compression of uterine blood vessels.
Choice B rationale
Unilateral lower leg pain, especially accompanied by warmth, redness, or swelling, is an abnormal finding and can be indicative of a deep vein thrombosis (DVT). Postpartum women are at an increased risk for DVT due to hypercoagulability and venous stasis, making this a critical assessment requiring immediate attention.
Choice C rationale
Saturating two perineal pads per hour is an excessive amount of lochia and suggests postpartum hemorrhage. Normal lochia flow should not saturate more than one pad per hour in the immediate postpartum period, indicating that the uterus is not contracting adequately to control bleeding.
Choice D rationale
A heart rate of 56 beats/minute, also known as puerperal bradycardia, is considered a normal physiological finding for a primigravida client 12 hours postpartum. This transient bradycardia often occurs due to the increased stroke volume and cardiac output that result from the significant decrease in uterine blood flow after delivery.
Correct Answer is B
Explanation
Choice A rationale
Elevating the head of the examination table would not effectively alleviate supine hypotensive syndrome. This condition occurs due to compression of the vena cava by the gravid uterus, reducing venous return to the heart. While elevating the head might provide some comfort, it does not directly address the underlying circulatory compromise.
Choice B rationale
Assisting the client to a lateral position, particularly the left lateral position, is the most effective intervention. This maneuver displaces the gravid uterus off the inferior vena cava, increasing venous return to the heart, thereby improving cardiac output and uteroplacental perfusion, which alleviates symptoms of faintness and dizziness.
Choice C rationale
Placing the examination table in Trendelenburg position involves lowering the head and raising the foot of the bed. This position would further exacerbate vena caval compression in a pregnant client, potentially worsening supine hypotensive syndrome and increasing the risk of aspiration, making it an contraindicated intervention.
Choice D rationale
Stepping out of the room to notify the healthcare provider (HCP) before addressing the immediate physiological distress is inappropriate. The PN should first implement immediate interventions to stabilize the client's condition, such as repositioning, and then promptly inform the HCP about the event and the interventions performed.
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