A nurse is caring for an 18-month-old infant who is 12 hr postoperative following a myringotomy. Which of the following pain rating scales should the nurse use?

A. Wiping from the outer corner of the eye to the inner canthus is incorrect because this can introduce bacteria from the outer part of the eye into the inner part, which could exacerbate the infection. The proper technique is to wipe from the inner canthus to the outer canthus to prevent contamination.

B. Cleaning the eye with a moist cloth is appropriate for conjunctivitis as it helps remove secretions and crusts that accumulate. Using a clean, moist cloth minimizes irritation to the eye.

C. Keeping the eye covered with a compress is not recommended unless directed by a provider. Compresses could increase irritation or harbor bacteria if not kept clean.

D. Applying eye ointment in the morning is not optimal because ointment should generally be applied at night to prevent blurred vision during the day. The nurse should advise applying it as prescribed by the healthcare provider.

A. Increased blood pressure is typically not associated with dehydration. In fact, dehydration often causes hypotension or low blood pressure, especially in severe cases.

B. Distended jugular veins are usually a sign of fluid overload or heart failure, not dehydration. In dehydration, the veins may appear flat due to decreased fluid volume.

C. A flat anterior fontanel is generally expected in a well-hydrated child. A sunken fontanel would indicate dehydration in infants and young toddlers.

D. Increased pulse (tachycardia) is a common sign of dehydration. As the body loses fluid, the heart compensates by increasing the heart rate to maintain adequate perfusion of organs.