The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.

Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate.

Each row must have one option selected.

Choice A rationale

While encouraging quiet activities like watching television can provide some distraction and temporary relief, it does not address the underlying need for consistent pain management in juvenile idiopathic arthritis. Distraction techniques should be used as an adjunct to proper pain medication rather than a replacement for it. This condition can cause chronic pain, which may negatively impact the child's quality of life if not managed appropriately.

Choice B rationale

Resting when experiencing pain is a common recommendation, but for juvenile idiopathic arthritis, it's essential to balance rest with physical activity to maintain joint mobility and muscle strength. Only encouraging rest can lead to muscle atrophy and joint stiffness, which can exacerbate the condition in the long term. Regular pain management can help the child stay more active.

Choice C rationale

Hot baths can help to some extent by relaxing muscles and reducing stiffness, but they are not sufficient as a sole method for managing pain in juvenile idiopathic arthritis. The condition often requires consistent medication to control inflammation and pain. Non-pharmacological methods like hot baths should be used in conjunction with prescribed medication rather than as an alternative.

Choice D rationale

Giving pain medication around the clock helps control the pain effectively by maintaining a steady level of medication in the body, preventing breakthrough pain. Consistent pain management allows the child to participate in daily activities and physical therapy, which is essential for maintaining joint function and overall quality of life.

Choice A rationale

Giving zidovudine 6 to 12 hours after birth is crucial as it helps prevent mother-to-child transmission of HIV. Early administration of antiretroviral medication reduces the risk of the newborn acquiring HIV significantly.

Choice B rationale

Administering antibiotics for 7 to 10 days is not standard practice for newborns of HIV-positive mothers unless there is an indication of infection. The primary intervention is antiretroviral therapy.

Choice C rationale

Delaying the initial bath for 1 to 2 days is not standard practice for preventing HIV transmission. It is important to bathe the newborn shortly after birth to remove any potential HIV-containing fluids.

Choice D rationale

Encouraging breastfeeding every 2 to 3 hours is not advised for HIV-positive mothers as HIV can be transmitted through breast milk. Alternatives such as formula feeding are recommended to prevent transmission. .