A nurse is caring for a 5-year-old child who is postoperative following a tonsillectomy.
Which of the following pain scales should the nurse use to determine the child's pain level?

Choice A rationale

A positive rubella serum antibody titer indicates immunity to rubella infection, which is protective during pregnancy. It is not an abnormal finding and does not require immediate reporting. Rubella immunity is important to prevent congenital rubella syndrome in the fetus, a severe condition causing defects such as deafness or cardiac anomalies.

Choice B rationale

Blood pressure of 144/94 mmHg is elevated and indicates gestational hypertension, which could progress to preeclampsia if not managed. Preeclampsia can lead to complications such as eclampsia, placental abruption, or maternal and fetal mortality. Normal blood pressure during pregnancy is less than 140/90 mmHg, making this finding critical to report.

Choice C rationale

Copious leukorrhea is a common physiological change in pregnancy due to increased estrogen levels and vascularity. It is usually benign and protective, preventing infections by maintaining a mildly acidic environment in the vagina. This finding does not warrant immediate concern unless associated with infection symptoms.

Choice D rationale

An O-negative blood type requires administration of Rh immunoglobulin to prevent Rh isoimmunization, but this is routinely managed in pregnancy. It is not an urgent issue unless there are concerns about fetomaternal hemorrhage or alloimmunization, which could harm an Rh-positive fetus.

Choice A rationale

The Oucher scale uses photographic images or numerical scales and is appropriate for older children who can visually correlate their pain level with the provided scale. It is not ideal for younger children or those unable to understand numerical or photographic representations.

Choice B rationale

The Visual Analog Scale requires a more mature understanding of concepts such as gradients and is suitable for older children and adults. It is not an appropriate tool for a 5-year-old as their cognitive development may limit the accurate use of this scale.

Choice C rationale

The FLACC scale assesses pain based on behavioral observations and is ideal for non-verbal or very young children. However, a 5-year-old can generally articulate their pain or utilize pictorial representations, making other scales more suitable.

Choice D rationale

The FACES scale, featuring cartoonish faces representing varying pain levels, is a validated tool for children as young as 3 years old. Its simplicity and visual clarity make it an effective and age-appropriate method for a 5-year-old to communicate their pain level.