A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect?

Choice A: A decreased heart rate is not a sign of pain in an infant, as pain usually causes an increased heart rate due to sympathetic nervous system activation. A decreased heart rate may indicate other problems, such as hypothermia, hypoxia, or bradycardia.

Choice B: A decreased respiratory rate is not a sign of pain in an infant, as pain usually causes an increased respiratory rate due to sympathetic nervous system activation. A decreased respiratory rate may indicate other problems, such as hypothermia, hypoxia, or respiratory depression.

Choice C: An increased formula consumption is not a sign of pain in an infant, as pain usually causes a decreased appetite and oral intake due to discomfort and distress. An increased formula consumption may indicate other factors, such as growth spurt, hunger, or thirst.

Choice D: An increased crying episode is a sign of pain in an infant, as crying is one of the most common and reliable indicators of pain in infants who cannot verbalize their feelings. An increased crying episode may also be accompanied by other signs of pain, such as facial grimacing, body tensing, or inconsolability.

Choice A: Loosening restrictive clothing is not the priority action, but rather a secondary action for a child who is having a tonic-clonic seizure and vomiting. A tonic-clonic seizure is a type of seizure that involves the stiffening of muscles (tonic phase) followed by jerking movements (clonic phase). Loosening restrictive clothing can prevent injury or discomfort to the child during or after the seizure.

Choice B: Placing a pillow under the child's head is not the priority action, but rather an inappropriate action for a child who is having a tonic-clonic seizure and vomiting. A pillow under the head can obstruct the airway or cause aspiration of vomitus into the lungs. The nurse should remove any pillows or objects from around the head and neck area and support the head with their hands or on a flat surface.

Choice C: Clearing the area of hazards is not the priority action, but rather a secondary action for a child who is having a tonic-clonic seizure and vomiting. Clearing the area of hazards can prevent injury or harm to the child or others during or after the seizure. The nurse should remove any sharp, hard, or flammable objects from near or under the child and move any furniture or equipment away.

Choice D: Positioning the child side-lying is the priority action for a child who is having a tonic-clonic seizure and vomiting, as it can protect the airway and prevent aspiration of vomitus into the lungs. Aspiration can cause pneumonia, which is an infection of the lungs that can cause fever, cough, difficulty breathing, or death. The nurse should turn the child's head to one side and place them on their side with their knees bent and one arm under their head. The nurse should also suction any vomitus from their mouth and nose if needed.