A nurse is completing a pain assessment of an infant. Which of the following pain scales should the nurse use?
FLACC
Symptom log
Oucher
FACES
The Correct Answer is A
A. FLACC: The FLACC scale (Face, Legs, Activity, Cry, Consolability) is specifically designed for assessing pain in infants and young children who are unable to communicate their pain. It is based on observing physical and behavioral indicators of pain.
B. Symptom log: A symptom log is a tool typically used by older children or adults to track symptoms over time. It is not suitable for assessing pain in infants, as they cannot self-report or track symptoms.
C. Oucher: The Oucher scale is designed for children aged 3-12 years who are able to understand and use the scale, which involves comparing pain intensity to pictures of facial expressions. It is not suitable for infants.
D. FACES: The FACES pain scale is typically used for older children who can point to or choose a facial expression to indicate their pain level. Infants are too young to use this scale effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. G4 T2 P2 A1 L1: The client had one preterm birth at 26 weeks (P1), not two, and the miscarriage counts as an abortion (A1), not as a preterm or term birth. The classification for preterm births should be adjusted to P1, not P2. There is also one term delivery (T1) not two.
B. G4 T1 P1 A1 L1: The client has had 4 pregnancies (G4): one live birth at 38 weeks (T1), one preterm birth at 26 weeks that did not survive (P1), one miscarriage at 8 weeks (A1), and one living child (L1). This is the correct classification.
C. G3 T2 P1 A1 L1: This option is incorrect because the client has had 4 pregnancies, not 3. The correct count should be G4.
D. G3 T2 P1 A2 L1: This option is incorrect because the miscarriage counts as one abortion (A1), not A2, and the client has had 4 pregnancies, not 3. The client has also had one term delivery (T1) not two.
Correct Answer is ["A","B","C","D"]
Explanation
A. Fetal tone: Fetal tone is a key component of the BPP. This assessment evaluates the fetus's muscle tone by observing spontaneous extension and flexion of an extremity or the trunk. A normal score indicates good neurological function and fetal well-being.
B. Fetal breathing movement: Fetal breathing movement in BPP involves observing episodes of fetal breathing movements over a certain period, typically at least one episode lasting 30 seconds within 30 minutes. Normal breathing movements indicates a mature and healthy central nervous system.
C. Amniotic fluid volume: The amniotic fluid volume (AFV) is assessed as part of the BPP, usually by measuring the amniotic fluid index (AFI) or the single deepest pocket. Adequate amniotic fluid indicates good renal perfusion and placental function, reflecting long-term fetal well-being.
D. Non-stress test: The non-stress test evaluates fetal heart rate and its response to fetal movements, which provides information about fetal well-being. A reactive NST, characterized by accelerations of the fetal heart rate, indicates a healthy, well-oxygenated fetus with an intact neurological system.
E. Fetal gender: Fetal gender is not part of the biophysical profile, it can often be determined during an ultrasound examination. The BPP focuses on fetal health and well-being, not gender identification.
F. Fetal neck translucency: Fetal neck translucency (also known as nuchal translucency) is measured during the first trimester screening for Down syndrome, not during the BPP. The BPP does not include this component.
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