A nurse is caring for a child who is several hours postoperative following a tonsillectomy. The child is restless, reports severe throat pain, has difficulty swallowing, and is frequently clearing secretions from the throat. After notifying the surgeon about the child’s condition, which action should the nurse perform first?

Choice A rationale: Hemoglobin of 11 g/dL is within the normal range for a 7-year-old child and does not indicate anemia or a coagulation disorder. While hemoglobin levels may decrease in cases of significant blood loss, this value is not suggestive of a bleeding or clotting abnormality.

Choice B rationale: Coagulation factor concentration of 35% is significantly below the normal range of 60% to 140%, indicating a potential coagulation disorder. Reduced coagulation factor levels impair the blood clotting process, leading to prolonged bleeding episodes, such as the persistent nosebleed observed in this child.

Choice C rationale: Persistent nosebleed despite pressure is a clinical sign of impaired hemostasis, which may be due to a coagulation disorder. Normal clotting mechanisms should stop bleeding with direct pressure; failure to do so suggests an underlying issue with clot formation or stability.

Choice D rationale: Platelet count of 165,000/mm³ is within the normal range (150,000 to 400,000/mm³) and does not indicate thrombocytopenia or a coagulation disorder. Platelets are essential for clot formation, but their normal count suggests that the bleeding is not due to platelet dysfunction.

Choice E rationale: A history of fall with nasal trauma explains the initial cause of the nosebleed but does not indicate a coagulation disorder. Trauma-induced bleeding is expected, but the persistence of bleeding despite pressure raises concern for an underlying clotting issue.

Choice F rationale: Hematocrit of 37% is within the normal range for a 7-year-old child and does not indicate anemia or a coagulation disorder. Hematocrit reflects the proportion of red blood cells in the blood and is not directly related to clotting factor levels or platelet function.

Choice A rationale

Passive range-of-motion exercises are contraindicated during an acute hemarthrosis episode. Movement can exacerbate bleeding within the joint and cause further pain and damage to the synovial tissue and cartilage. The scientific rationale is to immobilize the affected joint to stop the bleeding and allow the clotting factors to work effectively. Gentle range of motion is only introduced later, during the rehabilitation phase.

Choice B rationale

Administering aspirin is a dangerous and contraindicated choice for a child with hemophilia. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that inhibits platelet aggregation by irreversibly blocking cyclooxygenase-1 (COX-1) and COX-2 enzymes, thereby increasing the risk of bleeding. This can worsen the hemarthrosis. Acetaminophen or non-aspirin NSAIDs like ibuprofen are preferred for pain management in these patients.

Choice C rationale

Placing ice packs on the affected joints is the correct scientific intervention. Cold application, or cryotherapy, causes vasoconstriction, which helps to slow or stop the bleeding into the joint space. This reduces swelling, inflammation, and pain associated with hemarthrosis. The RICE acronym (rest, ice, compression, elevation) is a scientifically validated acute management strategy for joint bleeds in hemophilia.

Choice D rationale

Positioning the lower extremities below the level of the heart is scientifically incorrect. The affected extremity should be elevated above the level of the heart. Elevation uses gravity to reduce blood flow to the joint, which helps to decrease swelling, pain, and bleeding. Placing the extremity below the heart would increase blood flow and exacerbate the hemarthrosis, increasing intra-articular pressure and pain.