A nurse is collecting data from an infant who has otitis media.
Which of the following findings should the nurse identify as manifestations of pain in an infant? (Select all that apply)

Choice A rationale

At 10 months, it is normal for an infant to not be able to recognize objects by name. Language development varies greatly among children, and many do not start to understand and respond to simple requests and recognize common objects until around 12 months.

Choice B rationale

The ability to turn pages in a book is a fine motor skill that typically develops around 12 to 18 months. Therefore, it is normal for a 10-month-old infant to not have this ability.

Choice C rationale

Peek-a-boo is a common game that many infants enjoy. However, not all infants may show interest in this game. Lack of interest in peek-a-boo is not necessarily a cause for concern.

Choice D rationale

By 10 months, most infants can sit without support. If a 10-month-old infant does not sit steadily without support, it could indicate a delay in motor development and should be reported to the provider.

Choice A rationale

Applying lotion to the newborn’s skin twice per day is not necessary during phototherapy. The main goal of phototherapy is to reduce the level of bilirubin in the newborn’s blood. Applying lotion can interfere with the effectiveness of the light therapy and can cause the newborn’s skin to overheat.

Choice B rationale

Monitoring the newborn’s blood glucose level hourly is not necessary during phototherapy unless the newborn has a specific condition that requires close monitoring of blood glucose levels. Phototherapy does not directly affect blood glucose levels.

Choice C rationale

Encouraging the newborn to breastfeed every 2 hours is an important part of the care plan for a newborn undergoing phototherapy. Frequent feeding can help to promote the excretion of bilirubin through the newborn’s stool.

Choice D rationale

Maintaining the newborn in a prone position is not necessary during phototherapy. The newborn should be placed in a variety of positions to ensure that all areas of the skin are exposed to the light.