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?

Wong-Baker Faces Scale

Numeric Rating Scale

FLACC

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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

A. Infants, especially those under 6 months, may present with apnea and cyanosis during coughing paroxysms instead of the classic “whoop,” as their respiratory muscles are immature. This is a common severe manifestation in young infants.

B. Inspiratory stridor and a barking cough are characteristic of croup, not pertussis. Croup is usually viral in origin and presents with hoarseness and upper airway obstruction, which differs from pertussis.

C. Wheezing with exertional dyspnea is more typical of asthma or bronchiolitis, not pertussis. While pertussis can cause hypoxia, wheezing is not a defining feature.

D. The paroxysmal stage of pertussis is characterized by repetitive coughing spells followed by a high-pitched inspiratory “whoop”. This is classic for older infants and children, though it may be absent in young infants.

E. In the catarrhal stage, pertussis often begins as a mild, dry cough resembling a common cold, which gradually progresses to severe paroxysms. Nighttime exacerbation is common.

A. "Your baby is demonstrating proximal-to-distal development, gaining control from the center outward" B. Your baby should use both hands equally at this age" C. "This is a sign of delayed fine motor development" D. "Your baby is skipping developmental milestones"

Correct Answer is A

Explanation

A. Infant motor development follows a proximal-to-distal pattern, meaning control develops from the center of the body outward. At 7 months, infants first gain control of shoulders and arms, allowing them to reach with the whole hand. Later, fine motor skills like the pincer grasp (using thumb and forefinger) develop around 9–12 months, enabling the child to pick up small objects. This progression is typical and expected.

B. At 7 months, infants are still developing bilateral coordination. It is normal for a baby to favor one hand or alternate hands inconsistently. Expecting equal use of both hands at this stage reflects a misunderstanding of normal motor development.

C. Fine motor skills, such as using the thumb and forefinger to grasp small objects, emerge later. Reaching with the whole hand at 7 months is part of normal development. Labeling it as delayed is incorrect and may cause unnecessary concern.

D. The infant is following the typical developmental sequence, progressing from gross motor to fine motor control. Reaching with one hand before using the pincer grasp does not indicate skipped milestones. Developmental milestones are achieved in a predictable order, and this behavior is within normal limits.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is assessing a 4-month-old infant who has suspected pertussis. Which of the following findings should the nurse identify as consistent with this diagnosis? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

During a well-child visit, a parent asks why their 7-month-old has started to reach for objects with one hand before picking up smaller items with the fingers. Which explanation should the nurse give?

Correct Answer is A

Explanation

The nurse is assessing a newborn who is 12 hours old. Which symptoms would indicate the newborn is experiencing respiratory distress?(Select all that apply)

The patient has an order for a single dose of ceftriaxone 400 mg IM. The final concentration is 500 mg/1.2 ml. How many milliliters will you administer? (Round to the nearest hundredth.)

A 6-year-old child in the pediatric ward has had a minor laceration sutured on the forearm. Vital signs are within normal limits but the child is quiet. withdrawn, and refuses to play. The nurse suspects pain. What action should the nurse take FIRST?

Which of the following characteristics of the pediatric respiratory system makes infants and young children more susceptible to respiratory distress compared to adults?

A mother is Rh-negative, and her fetus is Rh-positive. She delivered her first Rh-positive baby without receiving Rho(D) immune globulin. Which complication may occur in a future pregnancy if sensitization has occurred?

The nurse is caring for a pregnant client with preeclampsia who is receiving IV magnesium sulfate. The nurses assess the following symptoms: -Respiratory rate of 10 breaths/min Urine output 25ml during the last hour Absent deep tendon reflexes What medication should the nurse prepare to administer?

A 5.6 kg patient is receiving digoxin by mouth every 8 hours. The safe dose is 0.03-0.06 mg/kg/day. What is the maximum safe dose for this patient? (Round to the nearest hundredth.)