A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant's pain level?

Choice A reason: This choice is correct because providing a latex-free environment is an essential intervention for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Spina bifida is a congenital defect in which the spinal cord and its coverings do not close properly, resulting in a protrusion of the meninges (meningocele) or the meninges and spinal cord (myelomeningocele). Children who have spina bifida are at a high risk of developing a latex allergy, which can cause severe reactions such as anaphylaxis or death. Therefore, avoiding exposure to latex products such as gloves, catheters, balloons, or bandages is crucial to prevent complications.

Choice B reason: This choice is incorrect because initiating contact precautions is not necessary for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Contact precautions are infection control measures that prevent the transmission of microorganisms that can be spread by direct or indirect contact with the client or their environment. They may be indicated for clients who have multidrug-resistant organisms, clostridium difficile, or scabies, but they are not required for clients who have spina bifida unless they have a concurrent infection.

Choice C reason: This choice is incorrect because limiting visitors to immediate family members is not indicated for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Limiting visitors may be indicated for clients who have immunosuppression, isolation, or terminal illness, but it may not be beneficial for clients who have spina bifida. Allowing visitors may provide emotional and social support for the client and their family, as long as they follow standard precautions and do not pose any risk of infection or injury.

Choice D reason: This choice is incorrect because maintaining the infant in the supine position is not an appropriate intervention for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac.
Maintaining the infant in the supine position may cause pressure or trauma to the sac, which can lead to rupture, infection, or nerve damage. Therefore, positioning the infant in a prone or side-lying position with the hips flexed and knees abducted can help to protect the sac and prevent complications.

Choice A: Irregular respiratory rate is not a reliable indicator of mild dehydration, as it can be affected by many factors such as fever, infection, pain, or anxiety. An irregular respiratory rate can also indicate more severe dehydration or shock, which requires immediate intervention.

Choice B: Good skin integrity is not a reliable indicator of mild dehydration, as it can be maintained even in moderate dehydration. Good skin integrity does not reflect the fluid status of the body, as skin turgor and elasticity depend on other factors such as age, nutrition, and hydration.

Choice C: Blood pressure elevation is not a reliable indicator of mild dehydration, as it can be caused by other conditions such as stress, anxiety, pain, or hypertension. Blood pressure elevation can also indicate more severe dehydration or shock, which requires immediate intervention.

Choice D: Body weight is the most reliable indicator of mild dehydration, as it reflects the fluid loss or gain of the body. A loss of 5% or more of body weight indicates mild dehydration in infants. Body weight should be measured daily and compared with the baseline weight to monitor the fluid status of the infant.