A nurse is planning care for a child who has mumps.
Which of the following instructions should the nurse include in the plan?

The correct answer is Choice A.

Choice A rationale

The FLACC scale (Face, Legs, Activity, Cry, Consolability) is suitable for assessing pain in infants and young children who cannot verbally communicate their pain. It evaluates five criteria to determine the level of pain.

Choice B rationale

The FACES scale is more appropriate for children aged 3 years and older who can point to the face that best represents their pain level.

Choice C rationale

The OUCHER scale is also designed for older children who can understand and use the photographic or numerical scale to indicate their pain.

Choice D rationale

The PANAD scale is used for assessing pain in patients with advanced dementia and is not suitable for infants.

The correct answer is Choice B.

Choice A rationale

Restraining the child’s arms during a seizure is not recommended. Restraint can cause injury to the child and does not prevent the seizure from occurring. Instead, the focus should be on ensuring the child’s safety by removing any nearby objects that could cause harm.

Choice B rationale

Positioning the child laterally (on their side) is the correct action. This position helps maintain an open airway and allows any secretions to drain out of the mouth, reducing the risk of aspiration. It also facilitates better breathing and prevents the tongue from obstructing the airway.

Choice C rationale

Attempting to stop the seizure is not advisable. Seizures typically run their course and attempting to stop them can cause more harm than good. The nurse should focus on ensuring the child’s safety and monitoring the seizure’s duration and characteristics.

Choice D rationale

Using a padded tongue blade is outdated and not recommended. Inserting any object into the mouth during a seizure can cause injury to the teeth, gums, or airway. It is better to ensure the child’s safety by positioning them laterally and monitoring their airway.