A nurse is assisting with the plan of care for an infant who has heart failure. Which of the following actions should the nurse recommend to include in the plan of care?

The correct answer is choice C. 6.8 to 7.7 kg (15 to 17 lb).

Choice A rationale:

This weight range is above the average for a 6-month-old infant. According to growth charts, the 50th percentile weight for a 6-month-old male is approximately 7.9 kg (17 lb 8 oz), and for a female, it’s about 7.3 kg (16 lb 1 oz). Therefore, 8.6 to 9.5 kg would be considered above average and not the anticipated weight for most infants.

Choice B rationale:

This weight range is below the average for a 6-month-old infant. The average weight at 6 months is significantly higher than 4.1 to 5 kg, as infants are expected to double their birth weight by 5 months of age. Therefore, an infant weighing between 9 to 11 lb at 6 months would be considered underweight.

Choice C rationale:

This weight range is within the average for a 6-month-old infant. As mentioned, the 50th percentile weights for 6-month-old infants are approximately 7.9 kg for males and 7.3 kg for females. This choice falls within the expected weight gain trajectory where an infant is anticipated to double their birth weight by 5 months and then gain an additional pound or so by 6 months.

Choice D rationale:

This weight range is significantly above the average for a 6-month-old infant. It is well above the 95th percentile for this age group and would be considered unusual without underlying health conditions that could contribute to such a weight at this age. An infant weighing between 23 to 25 lb at 6 months would be exceptionally rare and likely indicative of an abnormal growth pattern.

Choice A rationale:
The FLACC (Face, Legs, Activity, Cry, Consolability) scale is a pain assessment tool commonly used for infants and young children who cannot verbalize their pain. It assesses different behavioral and physiological indicators of pain, such as facial expressions, leg movement, activity level, crying, and response to consoling. Given that the infant is only 18 months old, this scale is appropriate for evaluating their postoperative pain.
Choice B rationale:
The Color tool is not a recognized pain assessment tool. It's essential to use validated and standardized pain assessment scales, and the Color tool does not fit this criterion.
Choice C rationale:
The Poker Chip Tool is not typically used for pain assessment in infants. It's often used with older children to assess pain intensity using a poker chip set that corresponds to different levels of pain. However, for an 18-month-old infant, behavioral assessments like the FLACC scale would be more suitable.
Choice D rationale:
The Numeric scale involves asking the patient to rate their pain on a numerical scale, often from 0 to 10. However, this scale is not appropriate for an 18-month-old infant who is likely unable to comprehend or use numbers to express their pain. The FLACC scale provides a more comprehensive assessment of pain in non-verbal or preverbal children.