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?

Choice A rationale:
Correct Answer. Placing the medication along the side of the child's tongue is a recommended technique for administering oral medication to infants. This helps prevent the infant from spitting out the medication and encourages swallowing. Placing the medication directly on the center of the tongue might trigger the gag reflex.
Choice B rationale:
Putting small bits of ice on the child's tongue prior to administering the medication is not a standard technique and is not necessary for giving liquid medication. This could potentially create discomfort for the infant and may not contribute to effective medication administration.
Choice C rationale:
Positioning the child on their back during administration of the medication is not ideal. This position might increase the risk of choking. Placing the child in an upright or slightly inclined position is generally recommended to aid in swallowing and prevent choking.
Choice D rationale:
Adding the medication to the child's formula prior to feeding is not advisable without consulting a healthcare provider. Mixing medication with formula can alter the medication's effectiveness or interactions. It's important to administer medications separately from formula to ensure accurate dosing. The correct answer is choice C. Document the infant's respiratory rate every 2 hr. The correct answer is choice D. Adopted. The correct answer is choice A. "You should place the medication along the side of your child's tongue during administration."

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.