A nurse is collecting data from an infant who is postoperative. Which of the following pain scales should the nurse use to evaluate the infant's pain level?

FACES

FLACC

Oucher

Visual analog

Answer and Explanation

The Correct Answer is B

A. FACES: The FACES pain scale uses facial expressions that correspond to numeric ratings, but it is designed for children who are typically 3 years of age or older and can cognitively associate faces with levels of pain. Infants cannot reliably use this tool because they lack the developmental ability to self-report.

B. FLACC: The FLACC scale (Face, Legs, Activity, Cry, Consolability) is validated for assessing pain in infants and young children who cannot verbally communicate. It evaluates observable behaviors such as facial grimacing, limb movement, activity level, crying, and consolability, providing an objective measure of pain intensity in nonverbal populations.

C. Oucher: The Oucher scale is a self-report tool that uses photographs of children’s faces to represent pain intensity, appropriate for children around 3 to 12 years old. Infants cannot use this scale reliably because they cannot interpret or select images to indicate their pain level.

D. Visual analog: The visual analog scale requires the child or adult to mark a point along a line to represent pain intensity. It relies on abstract reasoning and self-reporting and is not suitable for infants or nonverbal children, as they cannot understand or accurately use this method.

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Correct Answer is B

Explanation

A. Terbutaline: Terbutaline is a beta-agonist used to relax the uterus in cases of preterm labor or to manage uterine hyperstimulation, which would worsen postpartum bleeding. It is contraindicated in postpartum hemorrhage because it inhibits uterine contractions needed to control bleeding.

B. Methylergonovine: Methylergonovine is a uterotonic medication that stimulates sustained uterine contractions, promoting uterine tone and helping to control postpartum hemorrhage. It is used when hemorrhage results from uterine atony and is contraindicated in clients with hypertension or preeclampsia due to vasoconstrictive effects.

C. Magnesium sulfate: Magnesium sulfate is used primarily for seizure prophylaxis in preeclampsia and for tocolysis in preterm labor. It relaxes smooth muscle, including the uterus, which would exacerbate postpartum bleeding rather than treat it.

D. Nifedipine: Nifedipine is a calcium channel blocker used as a tocolytic to inhibit preterm labor. It decreases uterine contractions and is therefore inappropriate for managing postpartum hemorrhage, as it would reduce uterine tone and increase bleeding risk.

A. "I will share my decision to quit smoking with my friends." B. "I will ask for a prescription for alprazolam to reduce my withdrawal symptoms." C. "I'm not going to set a target date for quitting." D. "Unfortunately, even if I stop smoking now, my lung function will not improve."

Correct Answer is A

Explanation

A. "I will share my decision to quit smoking with my friends.": Social support is a key factor in successful smoking cessation. Sharing the decision to quit with friends and family can provide encouragement, accountability, and reinforcement during withdrawal and cravings, which increases the likelihood of maintaining abstinence.

B. "I will ask for a prescription for alprazolam to reduce my withdrawal symptoms.": Alprazolam is a benzodiazepine and is not indicated for nicotine withdrawal. Nicotine replacement therapy or medications like bupropion and varenicline are evidence-based options for managing withdrawal symptoms. Using alprazolam does not address nicotine addiction.

C. "I'm not going to set a target date for quitting.": Setting a specific quit date is an important component of effective smoking cessation plans. A clear target date helps the client prepare mentally, plan coping strategies, and increase commitment. Avoiding a quit date reduces the likelihood of successful cessation.

D. "Unfortunately, even if I stop smoking now, my lung function will not improve.": Smoking cessation can slow disease progression and improve symptoms such as cough, sputum production, and shortness of breath even in clients with chronic bronchitis. Lung function may partially recover, and quitting still provides significant long-term health benefits.

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A nurse is collecting data from an infant who is postoperative. Which of the following pain scales should the nurse use to evaluate the infant's pain level?

Nursing Test Bank

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