A nurse is evaluating an 8-month-old infant's pain level following the administration of hydrocodone. Which of the following pain scales would the nurse use?

A) Position the client on their left side.
This is the most appropriate action. The client's symptoms (dizziness, racing heart, and paleness) are consistent with supine hypotensive syndrome, which occurs when the pregnant uterus compresses the inferior vena cava while lying on the back, reducing venous return to the heart. Positioning the client on their left side relieves the pressure on the vena cava, restores normal blood flow, and alleviates these symptoms. This is a common intervention during pregnancy to prevent such complications.

B) Check the client's temperature.
While checking the client’s temperature may be necessary if an infection is suspected, the symptoms described are more indicative of supine hypotensive syndrome rather than an infection. Therefore, checking the temperature is not the priority action in this scenario.

C) Instruct the client to take a brisk walk.
Encouraging the client to take a brisk walk is not an appropriate response to the symptoms described. In fact, moving or exerting oneself might worsen dizziness or lead to further complications. The priority is to relieve the pressure on the vena cava by changing the client's position, not by physical activity.

D) Provide the client with a glass of orange juice.
Although providing orange juice might help if the client is experiencing hypoglycemia, there is no indication from the symptoms described that the client has low blood sugar. The client's symptoms are more likely due to positional changes that affect circulation during pregnancy, and the best immediate action is to change the client's position rather than offering food or drink.

A) Can you tell me about the stresses in your life?: While identifying stressors is important in understanding the context of the client’s feelings, the priority in the context of suicidal ideation is to assess the immediacy of danger to the client. Understanding the plan and means for suicide is the first step in evaluating the severity of the situation.

B) "Do you have a plan for harming yourself?": This is the priority question because it directly assesses the immediacy and seriousness of the client’s suicidal ideations. Knowing whether the client has a specific plan allows the nurse to determine the level of risk and take appropriate action, such as ensuring the client is safe and arranging for immediate intervention, including hospitalization if necessary.

C) Do you have someone to discuss your feelings with?: While social support is important, this question does not immediately address the severity of the suicidal ideation. If the client is at high risk, the nurse must first assess the immediate danger posed by the suicidal thoughts and actions before discussing coping strategies or support systems.

D) Has anyone in your family ever died by suicide?: Although a family history of suicide can increase risk, this question is secondary to directly assessing the client's current risk. The focus should first be on evaluating the client’s immediate safety, such as whether they have a plan and the means to harm themselves.