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

FACES

FLACC

Visual Analog Scale

Oucher

Answer and Explanation

The Correct Answer is B

A. FACES. The Wong-Baker FACES scale is used for children aged 3 years and older who can understand and select a face representing their pain level.

B. FLACC. The FLACC scale (Face, Legs, Activity, Cry, Consolability) is used for infants and nonverbal children to assess pain through observation of behaviors.

C. Visual Analog Scale. The Visual Analog Scale (VAS) requires the client to point on a numeric pain scale, which is inappropriate for infants who cannot communicate pain verbally.

D. Oucher. The Oucher scale is similar to FACES and is used in children aged 3–12 years. It relies on self-report, which is not feasible for a 6-month-old infant.

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Correct Answer is B

Explanation

A. Maintenance of good posture. While good posture can promote better bowel motility, it is not a primary intervention for constipation.

B. Increased fiber and fluid in the diet. Increasing dietary fiber (whole grains, fruits, vegetables) and fluid intake softens stool and promotes regular bowel movements, making this the best recommendation.

C. Regular use of a laxative. Frequent use of stimulant laxatives can lead to dependence, making it an inappropriate first-line intervention.

D. Regular use of glycerin suppositories. Glycerin suppositories are used for occasional relief of constipation but are not recommended for routine use as they do not address the underlying cause.

A. Assess respiratory rate and rhythm B. Pulse oximetry reading C. Assess bowel sounds D. Auscultate lung sounds E. Determine two touch discrimination in the lower extremities

Correct Answer is ["A","B","D"]

Explanation

A. Assess respiratory rate and rhythm. Changes in breathing pattern may indicate hypoxia, respiratory distress, or metabolic acidosis.

B. Pulse oximetry reading. Measures oxygen saturation, which is critical in assessing oxygenation and ventilation status.

C. Assess bowel sounds. While anxiety and stress can affect the gastrointestinal system, bowel sounds are not directly relevant in this situation.

D. Auscultate lung sounds. Important for identifying wheezing, crackles, or diminished breath sounds, which may indicate bronchospasm, fluid overload, or airway obstruction.

E. Determine two-point discrimination in the lower extremities. This test assesses neurological function, which is not a priority in a client presenting with respiratory distress and anxiety.

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

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