A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant's pain level?

Choice A: Oliguria is a condition of reduced urine output, which can indicate dehydration, kidney failure, or urinary tract obstruction. It is not associated with a CNS infection, which affects the brain and spinal cord.

Choice B: A negative Brudzinski sign is a normal finding that indicates no meningeal irritation. It is elicited by flexing the neck of a supine patient and observing no involuntary flexion of the hips and knees. A positive Brudzinski sign, on the other hand, is a sign of meningitis, which is a type of CNS infection.

Choice C: A bulging fontanel is an abnormal finding that indicates increased intracranial pressure, which can be caused by a CNS infection, such as meningitis or encephalitis. A fontanel is a soft spot on the skull of an infant that allows for brain growth and development.

Choice D: Jaundice is a condition of yellowing of the skin and eyes, which can indicate liver disease, hemolytic anemia, or neonatal hyperbilirubinemia. It is not associated with a CNS infection, which affects the brain and spinal cord.

Choice A: Urinary incontinence is a condition of involuntary loss of urine control, which can be caused by various factors, such as nerve damage, bladder dysfunction, or medication side effects. It is not always caused by neuroblastoma, which is a type of cancer that arises from immature nerve cells.

Choice B: Blood-fed is not a term that describes a neuroblastoma. Neuroblastoma is a type of cancer that arises from immature nerve cells, which can form tumors in various parts of the body, such as the adrenal glands, abdomen, chest, or spine.

Choice C: Tiny is not a term that describes a neuroblastoma. Neuroblastoma can vary in size and shape depending on the location and stage of the tumor. Some neuroblastomas can be very large and cause compression of nearby organs or structures.

Choice D: Unfortunately, much of the time, by the time a diagnosis has been made, metastasis has already occurred. This statement describes a neuroblastoma accurately. Neuroblastoma is a type of cancer that arises from immature nerve cells, which can spread rapidly to other parts of the body, such as the bones, liver, lymph nodes, or skin.
Metastasis is the process of cancer cells breaking away from the original tumor and forming new tumors elsewhere. Neuroblastoma often has no specific symptoms until it has metastasized, making it difficult to diagnose early and treat effectively.