# A 6-year-old client is on the pediatric surgical unit on postoperative day 1 following tonsillectomy and adenoidectomy (T&A). The nurse observes the child swallowing frequently while resting and notes that the child appears restless. Vital signs: T 37.2°C, HR 124, BP 96/58, RR 24, SpO2 98% on room air. Which is the priority nursing action?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=361812&lang=en  
> language: en  
> subject: System-Specific Assessments  
> category: ROR

## Question

A 6-year-old client is on the pediatric surgical unit on postoperative day 1 following tonsillectomy and adenoidectomy (T&A). The nurse observes the child swallowing frequently while resting and notes that the child appears restless. Vital signs: T 37.2°C, HR 124, BP 96/58, RR 24, SpO2 98% on room air. Which is the priority nursing action?

## Option

1. Offer the child a red popsicle to soothe throat pain and decrease postoperative swelling, encourage the child to rest in a semi-Fowler's position, and reassess swallowing frequency and pain level in 30 minutes.
2. Reassure the child and family that frequent swallowing is an expected response to throat soreness after surgery, administer the prescribed acetaminophen for pain, and continue to monitor vital signs every 4 hours as per unit protocol.
3. Inspect the back of the throat with a flashlight for blood, assess the child for bleeding signs (pallor, tachycardia, restlessness, vomiting bright red blood), and notify the surgeon immediately. **✔ Correct answer**
4. Encourage the child to gently cough and clear the throat to expel any blood, apply an ice pack to the neck for vasoconstriction, and monitor vital signs and swallowing pattern every 15 minutes.

**Correct answer: 3**

## Explanation

Frequent swallowing in a child after T&A is the classic and most reliable early sign of post-tonsillectomy hemorrhage — the child swallows the blood as it drains from the surgical site, often before any visible bleeding. Combined with tachycardia (HR 124 is at the upper end for a 6-year-old), restlessness (an early hypovolemia or hypoxia indicator), and the post-op timing, this is a red flag. The priority is direct visualization of the surgical site, a focused bleeding assessment, and immediate surgeon notification (with a possible return to OR). Option 2 is false reassurance and delays care. Option 1 — red popsicles are contraindicated because they can mask blood color, and a 30-minute delay is not appropriate. Option 4 — coughing or clearing the throat can dislodge clots and worsen bleeding; neck ice is not a standard intervention.

## In-depth explanation

Clinical Judgment
Apply NCJMM: Recognize cues (frequent swallowing + restlessness + HR 124 + T&A POD 1) → Analyze cues (frequent swallowing = swallowed blood; restlessness = early hypovolemia or hypoxia; tachycardia = compensatory) → Generate solutions (visualize the throat + bleeding assessment + surgeon notification) → Take action (flashlight throat exam, full assessment, notification) → Evaluate outcomes (early bleeding identification, possible return to OR before decompensation).

Memory Tip
Frequent swallowing = bleeding. After T&A, frequent swallowing is the most reliable early sign of hemorrhage. Children compensate well — they look stable until they decompensate. Tachycardia and restlessness are signs of compensatory hypovolemia.

KR vs US
Pediatric ENT wards in Korea sometimes interpret post-T&A frequent swallowing as a normal recovery and reassure the family. NCLEX treats this as the leading cue for post-op hemorrhage and requires immediate throat assessment + surgeon notification as the priority. Red popsicles, red Jell-O, and red Kool-Aid are always avoided on NCLEX because they mask the color of blood.

## Clinical scenario

Clinical Practice Guide
AAO-HNS post-tonsillectomy bleeding guidelines: primary hemorrhage occurs within 24 hours (rare), secondary hemorrhage at 5–10 days when the eschar separates (most common). Pediatric patients compensate well — vital sign changes appear LATE. Cues include frequent swallowing, throat clearing, vomiting bright red blood, pallor, restlessness, and tachycardia. Immediate management: surgeon notification, IV access, NPO, and possible return to OR.

Caution
NCLEX uses frequent swallowing as the most common cue. Red popsicles, red Jell-O, and red Kool-Aid are always avoided because they mask the color of blood. Children maintain BP through compensation, so a BP drop is a late sign.

## Key concepts

- **Tonsillectomy & Adenoidectomy (T&A)** — Surgical removal of the palatine tonsils and adenoids, commonly performed in children for recurrent infection or obstructive sleep apnea. Postoperative hemorrhage is the most serious complication and may occur primary (
- **Post-tonsillectomy hemorrhage** — Bleeding from the surgical bed after T&A. The most reliable early sign in children is frequent swallowing of blood. Other cues: restlessness, pallor, tachycardia, vomiting bright red or coffee-ground emesis. Immediate intervention: visualize the throat, IV access, NPO, surgeon notification, and possible return to OR.
- **Compensated shock in pediatrics** — Children maintain blood pressure longer than adults through tachycardia and vasoconstriction, often appearing stable until late decompensation. Tachycardia, capillary refill >3 seconds, and altered mental status (restlessness, irritability) are early warning signs.

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