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?

A. Increased respiratory rate: An increased respiratory rate may indicate that the child is experiencing respiratory distress or discomfort, which could be a sign that suctioning was not effective or that it was too aggressive. Ideally, after suctioning, the child's respiratory rate should stabilize or decrease as they are able to breathe more comfortably with a clear airway.

B. Decreased oxygen saturation: A decreased oxygen saturation level may indicate that the child is not receiving enough oxygen, which could be a sign of ineffective suctioning or airway obstruction. Effective suctioning should improve oxygenation by removing secretions and allowing for better airflow. A decrease in oxygen saturation would suggest the need for further assessment and intervention.

C. Clear breath sounds: This is the correct option. Clear breath sounds indicate that the airway has been effectively cleared of excess secretions, allowing for clear airflow. After suctioning, the nurse should listen for clear breath sounds without any crackles, wheezes, or other abnormal sounds indicating obstruction or congestion.

D. Increased oral secretions: Increased oral secretions may suggest that suctioning was not effective in clearing secretions from the airway, leading to pooling of secretions in the mouth. Effective suctioning should remove excess secretions from the airway, reducing the need for excessive oral secretions.

A. "Schedule a time for your child to receive the pneumococcal vaccine within 2 weeks."

This statement is incorrect. Pharyngitis caused by group A beta-hemolytic streptococci (GABHS) is typically treated with antibiotics, but it does not necessitate pneumococcal vaccination. Pneumococcal vaccination is recommended for other purposes, such as preventing pneumonia and invasive pneumococcal disease.

B. "Provide your child with their own towel for drying their face and hands at home."

This statement is correct. Group A streptococci (GAS) can be transmitted through respiratory droplets or by direct contact with infected secretions. Providing the child with their own towel can help prevent the spread of the infection to other family members.

C. "Replace your child's toothbrush 24 hours after beginning antibiotic therapy."

This statement is correct. It is recommended to replace the child's toothbrush after starting antibiotic therapy to reduce the risk of re-infection with group A streptococci (GAS).

D. "Your child can return to school 24 hours after their first dose of antibiotics."

This statement is correct. After initiating antibiotic therapy for GABHS pharyngitis, the child is usually considered non-contagious and can return to school after completing 24 hours of antibiotic treatment.

E. "Replace your child's orthodontic appliances prior to beginning antibiotic therapy."

This statement is incorrect. There is no specific recommendation to replace orthodontic appliances before starting antibiotic therapy for GABHS pharyngitis unless otherwise advised by a dentist or healthcare provider.