A nurse is assessing a school-age child who is 2 hours postoperative and has a chest tube in place. The nurse notes sanguineous drainage in the collection chamber. Which of the following actions should the nurse take?

This scenario requires the application of postoperative thoracic care principles and understanding normal drainage progression after surgery. The nurse must distinguish between expected findings and complications while adhering to protocols for maintaining chest tube patency and preventing tension pneumothorax through safe intervention. Choice A rationale Sanguineous drainage is expected within the first few hours following chest surgery. The nurse must document the volume to establish a baseline for monitoring output trends. Normal drainage for children should stay below 5 to 10 mL/kg/hr. Choice B rationale The drainage system must always remain below the level of the patient's chest to facilitate gravity-assisted drainage. Raising the system can cause backflow of fluid or air into the pleural space, potentially causing a collapsed lung or infection. Choice C rationale Stripping or milking chest tubes creates high negative pressure within the pleural space, which can damage lung tissue or cause bleeding. Current clinical standards prioritize gently checking for kinks rather than vigorous manipulation of the chest tube. Choice D rationale Clamping a chest tube is contraindicated unless specifically ordered for tube removal or during brief system changes. Clamping increases the risk of a tension pneumothorax because air and fluid cannot escape the pleural cavity.