Exhibits

The nurse determines the client is in pain.

Which pain scales would be appropriate for this client? Select all that apply.

FLACC Postoperative Pain Scale

Riley Infant Pain Scale

Poker Chip Tool

Visual Analog Scale

Numeric

FACES

Answer and Explanation

Correct Answer : A,B

A.   FLACC Postoperative Pain Scale: The FLACC (Face, Legs, Activity, Cry, Consolability) Scale is commonly used for infants and young children who cannot verbally report their pain. It assesses behavioral cues such as facial expressions, leg movement, activity level, crying, and ability to be consoled, making it appropriate for this 4-month-old infant.
B.   Riley Infant Pain Scale: This scale is specifically designed for infants under 1 year of age. It evaluates facial expression, sleep patterns, movements, crying, and verbal cues to determine the level of discomfort. Since this infant is postoperative and unable to self-report pain, this scale is a useful tool.
C.   Poker Chip Tool: This tool is used for older children, typically 4 years and above, who can understand the concept of counting and associating poker chips with pain intensity. It is not appropriate for a 4-month-old infant who lacks the cognitive ability to use symbolic representation.
D.   Visual Analog Scale: This scale requires the client to mark pain intensity on a continuous line, making it appropriate only for older children (around 7 years and older) who understand abstract concepts. A 4-month-old infant cannot comprehend or use this scale.
E.   Numeric: The numeric pain scale (0–10) is used for older children and adults who can assign a number to their pain. Infants and young children cannot use this scale, making it inappropriate for this client.
F.   FACES: The Wong-Baker FACES Pain Rating Scale is designed for children 3 years and older who can recognize and correlate facial expressions with pain levels. A 4-month-old does not have the cognitive ability to use this scale reliably.

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Correct Answer is A

Explanation

A. 3.3mL: The correct dose for infants is 10–15 mg/kg every 4–6 hours. If the infant weighs 7 kg, the correct dose is:Minimum dose: 10 mg × 7 kg = 70 mg. Maximum dose: 15 mg × 7 kg = 105 mg. Since the standard concentration is 160 mg/5 mL, the correct volume for 105 mg is 3.3 mL, making it the most appropriate dose.
B. 1.9 mL: This provides only about 61 mg of acetaminophen, which is below the recommended 10 mg/kg minimum dose, making it potentially ineffective.
C. 5.0 mL: This equates to 160 mg of acetaminophen, which exceeds the safe dose range for most infants, increasing the risk of liver toxicity.
D. 0.8 mL: This would provide only about 26 mg of acetaminophen, which is severely underdosed and unlikely to provide adequate pain relief.

A. Pulse of 105 beats/minute B. Feeling chilled, achy, and fatigued C. Baby fed pumped breast milk D. Pain rating of 4 on a 0 to 10 scale E. Foul-smelling lochia rubra at 2 Weeks postpartum F. Temperature of 101.2° F (38.4°C)

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"C"}}

Explanation

Pulse of 105 beats/minute – Both mastitis and endometritis
Tachycardia (heart rate >100 bpm) is a systemic response to infection and inflammation, which can occur in both mastitis and endometritis. In mastitis, infection in the breast tissue triggers a systemic inflammatory response, while in endometritis, uterine infection can cause sepsis-related tachycardia.
Feeling chilled, achy, and fatigued – Both mastitis and endometritis
Both conditions can cause systemic flu-like symptoms, including chills, body aches, and fatigue, as the body mounts an immune response. Mastitis leads to generalized malaise due to localized infection and inflammation in the breast, while endometritis causes uterine infection, which can spread if untreated.
Baby fed pumped breast milk – Mastitis
Mastitis often develops due to milk stasis when the breasts are not fully emptied. The client was away from the baby for several hours while feeding pumped milk, which may have led to incomplete drainage of the breast, increasing the risk of bacterial overgrowth and mastitis.
Pain rating of 4 on a 0 to 10 scale – Mastitis
Pain in mastitis is usually localized to the affected breast, presenting as a red, firm, warm area. The uterine pain in endometritis is generally more cramp-like and associated with uterine tenderness, rather than a focal area of pain like in mastitis.
Foul-smelling lochia rubra at 2 weeks postpartum – Endometritis
Lochia should transition from rubra (red) to serosa (pink-brown) to alba (white/yellow) within 2 weeks postpartum. Foul-smelling, persistent lochia rubra is a hallmark sign of endometritis, indicating bacterial overgrowth in the uterus.
Temperature of 101.2° F (38.4°C) – Both mastitis and endometritis
Fever is a key symptom of both mastitis and endometritis as the body responds to infection. Mastitis causes localized breast infection with systemic symptoms, while endometritis results in uterine infection and systemic inflammatory response.

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Exhibits The nurse determines the client is in pain. Which pain scales would be appropriate for this client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse is reviewing the prescription and planning the appropriate pain management. Complete the following sentence by choosing from the lists of options. For best pain management, the nurse should give... of acetaminophen every 4 hours as scheduled.

Correct Answer is A

Explanation

Exhibits For each assessment finding, click to indicate whether findings from this client's assessment are generally associated with mastitis, endometritis, or could be a sign of both conditions. Each row must have only one response option selected.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"C"}}

Explanation

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Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

Exhibits Which description(s) by the client should help confirm that the mastitis has been resolved and breastfeeding/breast health is well maintained? Select all that apply.

Exhibits Which other assessment data would the nurse want to collect before implementing pain management strategies? Select all that apply.

The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?

Exhibits

The nurse determines the client is in pain.

Which pain scales would be appropriate for this client? Select all that apply.