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

The statement “My baby will be placed under special lights if the test is elevated” indicates a need for further teaching. This statement is incorrect because phototherapy (special lights) is not used to treat phenylketonuria (PKU). PKU is a genetic disorder that results in the body’s inability to metabolize the amino acid phenylalanine. If left untreated, it can lead to intellectual disability and other serious health problems. The treatment for PKU involves a special diet that is low in phenylalanine. Therefore, the parent’s statement about using special lights for treatment indicates a misunderstanding about the nature of PKU and its treatment.

Choice B rationale

The statement “Sometimes the test is repeated in the doctor’s office at the 2-week check-up” is correct. PKU is usually diagnosed through a routine newborn screening test, and if the initial test results are positive or unclear, the test may be repeated.

Choice C rationale

The statement “My baby must take formula or breast milk before the test is done” is correct. For accurate results, the PKU test is done after the baby is 24 hours old and after the baby has had some protein in the diet.

Choice D rationale

The statement “This test checks for a genetic disorder that can be corrected by diet” is correct. PKU is a genetic disorder that can be managed with a special diet low in phenylalanine.

Choice A rationale

While rest is important for a child, suggesting that the child needs to rest does not address the parents’ concern about their child crying when they leave.

Choice B rationale

This is the correct answer. It is normal for an 8-month-old child to show signs of separation anxiety when their parents leave. This is a part of their normal development where they start to understand object permanence - the concept that things and people exist even when they’re out of sight. This can make them upset when their parents leave as they understand their parents are somewhere else, but they don’t know when they’ll return.

Choice C rationale

Notifying the provider about a normal developmental behavior is not necessary. It’s important for parents to understand that this behavior is a normal part of their child’s development.

Choice D rationale

While an overstimulating environment can cause distress in children, in this case, the child is upset because of their parents leaving, not because of the environment.