A nurse is assisting with the care of a 3-month-old infant following a surgical procedure.
Which of the following pain scales should the nurse use to determine the infant’s pain level?
FACES.
Word-Graphic Rating Scale.
FLACC.
Oucher.
The Correct Answer is C
Choice A rationale
The FACES pain scale is typically used for children who are at least 3 years old. It requires the child to compare their pain to a series of faces ranging from smiling to crying.
Choice B rationale
The Word-Graphic Rating Scale is typically used for older children and adolescents who can read and understand the descriptive words associated with each level of pain.
Choice C rationale
The FLACC pain scale, which stands for Face, Legs, Activity, Cry, and Consolability, is appropriate for assessing pain in a 3-month-old infant. It is often used for children under 3 years old or those who are unable to verbally communicate their pain.
Choice D rationale
The Oucher pain scale is typically used for children aged 3 to 13 years. It includes a series of photographs of children’s faces and a numerical scale for older children.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Applying lotion to the newborn’s skin twice per day is not necessary during phototherapy. The main goal of phototherapy is to reduce the level of bilirubin in the newborn’s blood. Applying lotion can interfere with the effectiveness of the light therapy and can cause the newborn’s skin to overheat.
Choice B rationale
Monitoring the newborn’s blood glucose level hourly is not necessary during phototherapy unless the newborn has a specific condition that requires close monitoring of blood glucose levels. Phototherapy does not directly affect blood glucose levels.
Choice C rationale
Encouraging the newborn to breastfeed every 2 hours is an important part of the care plan for a newborn undergoing phototherapy. Frequent feeding can help to promote the excretion of bilirubin through the newborn’s stool.
Choice D rationale
Maintaining the newborn in a prone position is not necessary during phototherapy. The newborn should be placed in a variety of positions to ensure that all areas of the skin are exposed to the light.
Correct Answer is D
Explanation
Choice A rationale
Removing elbow restraints while the infant is sleeping is not a recommended intervention following cleft palate repair. Elbow restraints are used to prevent the infant from touching the surgical site and potentially causing injury or infection. Therefore, they should not be removed while the infant is sleeping.
Choice B rationale
Keeping the infant in a side-lying position is not a specific recommended intervention following cleft palate repair. The position of the infant following surgery will depend on various factors, including the infant’s comfort and the surgeon’s instructions.
Choice C rationale
Feeding the infant half-strength formula for the first 48 hours is not a specific recommended intervention following cleft palate repair. The infant’s feeding regimen following surgery will depend on various factors, including the infant’s age, weight, and overall health, as well as the surgeon’s instructions.
Choice D rationale
Administering pain medication PRN (as needed) for the first 48 hours is a recommended intervention following cleft palate repair. Pain management is an important part of postoperative care, and appropriate pain medication can help ensure the infant’s comfort and promote healing.
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