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

Infrequent or inconsistent feedings lead to milk stasis, providing an environment conducive to bacterial growth, which can result in mastitis. Proper breastfeeding frequency ensures milk drainage, reducing stasis and infection risk. Milk stasis is a primary contributor to the development of mastitis, emphasizing the importance of regular feeding practices.

Choice B rationale

Nipple cracks and fissures are a direct portal for bacterial entry, increasing the likelihood of infection in the lactiferous ducts. Staphylococcus aureus, commonly present on the skin, can invade through damaged tissue, resulting in mastitis. Proper nipple care and hygiene are essential in prevention.

Choice C rationale

Gradual weaning allows for a decrease in milk production, preventing engorgement and stasis, which reduces the risk of mastitis. Gradual weaning gives the mammary glands time to adapt. Mastitis is more commonly associated with abrupt changes in feeding patterns or milk stasis rather than controlled weaning processes.

Choice D rationale

Engorgement from oversupply creates increased intraductal pressure, which can lead to blocked ducts and milk stasis, creating conditions favorable for bacterial growth. Engorgement needs prompt management to prevent secondary infections such as mastitis, particularly in lactating individuals.

Choice A rationale

Assessing the baseline fetal heart rate (FHR) over a 10-minute period ensures accurate measurement by capturing rate fluctuations due to fetal activity or maternal factors. This duration is a standardized method to establish a representative baseline. Variability is excluded during this time, focusing on a stable resting rate.

Choice B rationale

Baseline FHR can be obtained using ultrasound or auscultation, both being reliable non-invasive methods for assessing fetal well-being. These tools accurately detect cardiac activity and provide real-time data, allowing consistent monitoring during labor.

Choice C rationale

Baseline FHR cannot be obtained during contractions due to transient accelerations or decelerations caused by uterine compression. These changes do not represent the resting heart rate. Accurate baseline assessments require a period without uterine activity to avoid skewed results.

Choice D rationale

A normal FHR of 110-160 bpm indicates adequate oxygenation and neural regulation. This range reflects the fetal cardiovascular system's ability to adapt to in utero conditions. Values outside this range might suggest hypoxia, infection, or other abnormalities.