A nurse is assessing a 12-month-old infant who is immediately postoperative following hernia repair surgery. Which of the following pain measurement tools should the nurse use to determine if the infant is experiencing pain?

FACES

COMFORT

CRIES

FLACC

Answer and Explanation

The Correct Answer is D

A. FACES: The FACES pain scale is a visual analog scale commonly used with older children who can point to or select a facial expression that best represents their pain level. It may not be suitable for infants who may not have the cognitive or motor skills to use the scale effectively.

B. COMFORT: The COMFORT scale assesses pain in infants and young children based on behaviors such as crying, facial expressions, and body movements. It evaluates parameters such as alertness, calmness, respiratory response, physical movement, and muscle tone. The COMFORT scale is suitable for assessing pain in infants and young children, including those who are postoperative.

C. CRIES: The CRIES scale is a neonatal pain assessment tool that evaluates crying, oxygen saturation, vital signs, expression, and sleeplessness. While it is designed for newborns and infants up to 6 months of age, it may not be as appropriate for a 12-month-old infant who is postoperative and beyond the neonatal period.

D. FLACC: The FLACC scale assesses pain in infants and young children based on five behavioral categories: facial expression, leg movement, activity level, cry, and consolability. It is commonly used in pediatric settings and is suitable for assessing pain in infants who are postoperative.

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Correct Answer is C

Explanation

A. Visual acuity 20/30 bilaterally: Visual acuity of 20/30 bilaterally indicates relatively good vision in both eyes, but it does not necessarily indicate strabismus. Strabismus is related to eye alignment rather than visual acuity.

B. Peripheral vision 70° downward: Peripheral vision refers to the ability to see objects outside the direct line of vision. While changes in peripheral vision can occur in various eye conditions, such as glaucoma, it is not specific to strabismus.

C. Movement of the uncovered eye during a cover test: This is the correct option. During a cover test, one eye is covered while the other eye fixates on an object. If the uncovered eye moves to try to align with the covered eye, it may indicate strabismus or a misalignment of the eyes.

D. Light reflects symmetrically within each pupil during a corneal light reflex test: A corneal light reflex test assesses the alignment of the eyes by observing the reflection of light on the corneas. While asymmetry in the corneal light reflex can indicate strabismus, the description provided in this option suggests that the light reflects symmetrically within each pupil, which is a normal finding.

A. Temperature of 38° C (100.4° F) B. Family history of sudden unexpected infant death (SUID) C. Taking an antihistamine for seasonal allergies D. Receiving prednisone for nephrotic syndrome

Correct Answer is D

Explanation

A. Temperature of 38°C (100.4°F):A mild fever is not a contraindication for the MMR vaccine. In fact, a low-grade fever is common after immunizations and does not warrant withholding the vaccine.

B. Family history of sudden unexpected infant death (SUID): While a family history of SUID may be concerning, it is not a contraindication for administering the MMR vaccine. This history would not directly impact the safety or effectiveness of the vaccine.

C. Taking an antihistamine for seasonal allergies: Taking an antihistamine for seasonal allergies does not typically contraindicate the administration of the MMR vaccine. Antihistamines are generally safe to use with vaccines, and they do not interfere with the immune response to the vaccine.

D. Receiving prednisone for nephrotic syndrome:Prednisone is an immunosuppressive medication. Children receiving high-dose corticosteroids (such as prednisone) should avoid live vaccines like MMR

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A nurse is assessing a 12-month-old infant who is immediately postoperative following hernia repair surgery. Which of the following pain measurement tools should the nurse use to determine if the infant is experiencing pain?

Nursing Test Bank

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