NORCET-5 Prelims (Sh…: Following tonsillectomy an infant is swallowing frequently and looking like restlessness, which is a priority…

NORCET-5 Prelims (Shift-2)

Child Health Nursing (Pediatrics)

Hard

Appeared in: NORCET-5 Prelims (Shift-2)

Explanation

The primary risk after tonsillectomy is hemorrhage, which can lead to airway obstruction from blood aspiration.
Frequent swallowing and restlessness are early, subtle signs of active bleeding in the pharynx.
Positioning the infant prone with the head turned to the side is the immediate priority. This action uses gravity to promote drainage of blood and secretions out of the mouth, keeping the airway clear.
This intervention directly addresses the 'Airway' component of the ABCs (Airway, Breathing, Circulation), which is always the highest priority in an emergency.

Option A: While informing the doctor is essential, it is not the first action. The nurse must first perform an immediate, life-saving intervention to secure the patient's airway. Notifying the provider should happen immediately after positioning the patient safely.
Option C: Placing the infant in a sideline (lateral) position is also an acceptable practice to promote drainage. However, the prone position with the head turned to the side is often considered more effective for maximizing drainage from the mouth and pharynx, especially in an infant.
Option D: Starting IV fluids addresses the 'Circulation' aspect of the ABCs by preparing for volume replacement due to blood loss. However, protecting the 'Airway' is a more immediate and higher priority. An obstructed airway can be fatal within minutes.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Post-Tonsillectomy Hemorrhage Management in the correct sequence, documenting the action clearly, and monitoring for the expected response.
Recognizing subtle signs of post-tonsillectomy bleeding, like frequent swallowing, is a critical nursing skill. Overt signs like vomiting bright red blood appear later.
The nurse's ability to act quickly by positioning the patient can prevent a life-threatening aspiration event and stabilize the patient while awaiting medical intervention.
What if? If the patient was an older, cooperative child, the nurse might first ask them to sit up and lean forward to allow blood to drain from the mouth, in addition to positioning them on their side.

How to Approach the Question

First, identify the clinical scenario: a post-tonsillectomy infant.
Recognize the significance of the key symptoms: 'frequent swallowing' and 'restlessness' are classic signs of hemorrhage, a major complication.
Apply the ABCs (Airway, Breathing, Circulation) framework to prioritize actions. The most immediate threat is blood aspiration, which compromises the airway.
Evaluate each option against the ABCs. Option A (notify) is an important communication step but not an immediate intervention. Option D (IV fluids) addresses circulation, which is secondary to airway.
Compare the two positioning options (B and C). Both address the airway. Recall or deduce that positioning to facilitate drainage is the goal. The prone position with the head to the side is a standard and effective method for this.
Select the option that provides the most direct and immediate protection for the airway.

Concept Tested & Keywords

Concept Tested: Post-Tonsillectomy Hemorrhage Management
Stem keywords: tonsillectomy, infant, swallowing frequently, restlessness
Lead-in keywords: priority nursing action
Clinical cues: Frequent swallowing post-tonsillectomy is a classic sign of bleeding.
Clinical cues: Restlessness is an early sign of hypoxia or hypovolemia.