A nurse is caring for an 18-month-old infant who is 12 hr postoperative following a myringotomy. Which of the following pain rating scales should the nurse use?

A. Repositioning the pulse oximetry probe every 2 hours is unnecessary unless there is a concern about skin integrity or the accuracy of the reading. Continuous monitoring generally requires the probe to be in place for longer periods.

B. Taping the wire to the palm of the hand is not recommended because it may cause skin irritation or pressure injury. The sensor should be placed on a finger or toe, where blood flow is easily accessible.

C. Applying the sensor to the index fingernail is not ideal. Pulse oximetry is most accurate when applied to a finger or toe, but not directly on the nail itself. It should be placed on the skin near the nail.

D. Warming the skin prior to probe placement is recommended to ensure better circulation and accurate pulse oximetry readings, especially in children or individuals with poor peripheral circulation.

A. Infants with heart failure may experience fatigue during feeding, so smaller, more frequent feedings are recommended to prevent exhaustion and ensure adequate nutrition. Feedings every 3 hours are typically recommended to maintain a steady intake without overexertion.

B. Diluting formula to half strength is not recommended for an infant with heart failure, as it can lead to malnutrition and insufficient caloric intake. The formula should be provided at normal strength.

C. Placing the infant in a lateral position during feeding could be unsafe, as it may increase the risk of aspiration. The infant should generally be fed in an upright or semi-upright position to reduce aspiration risk and promote optimal digestion.

D. Bolus gavage feedings are typically used for infants who are unable to feed orally due to medical conditions, but for a child with heart failure who is feeding orally, more frequent and smaller feedings would be preferable.