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A nurse is caring for a 2-year-old toddler who is postoperative and nonverbal due to sedation. The child is grimacing and pulling at their IV site. Which pain assessment tool is MOST appropriate?

A.

Wong-Baker Faces Scale

B.

Numeric Rating Scale

C.

FLACC

D.

Visual Analog Scale

Answer and Explanation

The Correct Answer is C

A. This scale uses a series of faces ranging from a happy face (no pain) to a crying face (worst pain) and requires the child to identify which face best represents their pain level. It is suitable for children approximately 3 years and older who are verbal and cognitively able to associate facial expressions with their own pain. A sedated, nonverbal 2-year-old cannot reliably communicate using this method, making it inappropriate.

B. This scale asks the patient to rate their pain on a scale of 0 to 10. It requires verbal communication, abstract thinking, and the ability to quantify pain, which toddlers, especially a sedated 2-year-old, are unable to do. Therefore, this scale is not suitable in this context.

C. FLACC (Face, Legs, Activity, Cry, Consolability) is specifically designed for infants and young children (typically 2 months to 7 years) who are nonverbal or unable to self-report pain. It relies on observable behaviors, making it the most appropriate tool for a sedated postoperative toddler.

D. This scale asks the patient to mark a point on a line that represents their pain intensity from “no pain” to “worst pain.” It requires cognitive understanding, fine motor skills, and self-reporting, making it inappropriate for a sedated toddler who cannot comprehend or mark the scale.


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Related Questions

Correct Answer is B

Explanation

A. This option is incorrect because it describes Rh incompatibility, not ABO incompatibility. ABO incompatibility does not depend on Rh status and cannot be prevented with Rh immunoglobulin (Rho(D) immune globulin). Additionally, ABO incompatibility commonly causes jaundice, not just mild anemia.

B. This statement is correct. ABO incompatibility occurs when maternal IgG antibodies (anti-A or anti-B), most commonly in a type O mother, cross the placenta and attack fetal red blood cells that carry A or B antigens. This can result in hemolysis, leading to neonatal jaundice and mild anemia. ABO incompatibility is more common than Rh incompatibility, although it is usually less severe.

C. This option is incorrect because ABO incompatibility does not require prior blood transfusions or sensitization. Mothers with type O blood naturally have anti-A and anti-B antibodies, which can affect the fetus even during a first pregnancy.

D. This statement is incorrect because ABO incompatibility occurs when the mother and infant have different blood types, not the same blood type. Severe hemolysis and kernicterus requiring exchange transfusion are more characteristic of severe Rh incompatibility, not typical ABO incompatibility, which is usually mild and managed with phototherapy.

Correct Answer is D

Explanation

A. The behaviors described including initial clinginess, crying, and gradual adjustment, are typical variations in temperament, not indicators of a social developmental delay. Most 3-year-olds show a range of responses when exposed to new environments.

B. A difficult temperament is characterized by intense reactions, irregular routines, and high sensitivity, but the child in this scenario eventually warms up and engages with others, indicating the child is not persistently difficult.

C. Children with an easy temperament adjust rapidly, show positive mood, and require minimal guidance, which does not match the initial clinginess and crying observed in this child.

D. Slow-to-warm-up children are cautious in unfamiliar situations, may initially withdraw or cling, and gradually adapt once they feel safe. The child’s behavior of crying, clinging, and taking several minutes to engage aligns with this temperament type.

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