A nurse is caring for a 24-week-old infant whose mother requests additional information about sudden infant death syndrome (SIDS). Which of the following responses should the nurse make?

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.

Choice A rationale: Soft and flat fontanels are normal in healthy infants. In hydrocephalus, increased intracranial pressure causes bulging fontanels due to excess cerebrospinal fluid accumulation.

Choice B rationale: Proteinuria is a renal finding and not associated with hydrocephalus. Hydrocephalus affects the central nervous system, not kidney filtration or protein excretion.

Choice C rationale: Dilated scalp veins occur due to elevated intracranial pressure from cerebrospinal fluid buildup. Venous distension is a visible sign in infants with hydrocephalus.

Choice D rationale: Hypertension is not a typical sign of hydrocephalus in infants. The condition primarily presents with neurological and cranial changes, not systemic blood pressure elevation.