A nurse is collecting data from a 3-month-old infant who is 6 hr postoperative following a cleft palate repair.
Which of the following pain rating tools should the nurse use?
FACES Scale
FLACC Scale
Color tool
Numeric scale
The Correct Answer is B
b. FLACC Scale.
Explanation: The FLACC (Face, Legs, Activity, Cry, Consolability) Scale is a pain assessment tool commonly used for infants and young children who are unable to self-report their pain. It assesses five categories of behavior: facial expression, leg movement, activity level, cry, and consolability. Each category is scored from 0 to 2 or 0 to 3, depending on the specific scale used. The scores are then totaled to provide an overall pain assessment.
The FACES Scale, also known as the Wong-Baker FACES Pain Rating Scale, is a tool commonly used for children who can understand and self-report their pain. It consists of a series of faces with different expressions representing varying degrees of pain.
The Color tool is not a recognized pain rating tool. It may refer to an assessment of skin color, which can be used to assess oxygenation or circulation but not specifically for pain.
The Numeric scale is a pain rating tool that involves asking the individual to rate their pain on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain imaginable. However, this scale may not be suitable for a 3-month-old infant who is unable to comprehend numbers or communicate effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When a mother states that she should have her baby latch on to both the nipple and areola during breastfeeding, it demonstrates an understanding of the correct latch technique. A proper latch involves the baby taking in not just the nipple but also a portion of the surrounding areola. This ensures effective milk transfer and helps prevent nipple soreness or damage.
"My baby should breastfeed 5 to 10 minutes on each breast": This statement is not entirely accurate. It is important to understand that breastfeeding duration can vary among infants, and there is no fixed timeframe for how long a baby should breastfeed on each breast. Some infants
may nurse for shorter periods, while others may take longer. The focus should be on ensuring that the baby is effectively nursing and getting enough milk rather than adhering strictly to a specific time limit.
"I should keep my baby on a strict feeding schedule": This statement is incorrect. Breastfeeding on demand, also known as responsive feeding, is generally recommended for newborns.
Newborns should be fed whenever they show signs of hunger, such as rooting, sucking motions, or increased alertness. Strict feeding schedules can interfere with the baby's natural feeding cues and hinder milk supply establishment.
"I should not wake my baby during the night to breastfeed": This statement is not accurate, especially for a 5-day-old newborn. Newborns typically need frequent feeding, including during the night, to meet their nutritional needs and support proper growth and development. It is generally recommended to wake a sleeping newborn every 2-3 hours during the night to ensure adequate feeding and prevent excessive weight loss.
Correct Answer is C
Explanation
Ciprofloxacin is an antibiotic commonly prescribed for the treatment of various bacterial infections. It belongs to a class of medications known as fluoroquinolones. One potential side effect of ciprofloxacin is increased sensitivity to sunlight, which can lead to a higher risk of sunburn. Therefore, it is important for the client to take precautions, such as using sunscreen, wearing protective clothing, and avoiding excessive sun exposure while taking this medication.
"Take an antacid if the medication causes gastrointestinal upset": Ciprofloxacin can be taken with or without food, but it should not be taken with antacids, calcium supplements, or other products containing aluminum, magnesium, or calcium, as they can interfere with the absorption of the medication. If gastrointestinal upset occurs, it is generally recommended to take the medication with food to minimize this side effect.
"Restrict your daily fluid intake while taking this medication": There is no need to restrict fluid intake while taking ciprofloxacin unless specifically instructed by the healthcare provider.
Adequate hydration is important to maintain overall health and prevent potential complications.
"Expect to experience diarrhea while taking this medication": Diarrhea can be a potential side effect of ciprofloxacin, but it is not a universal experience for all individuals taking the medication. It is more appropriate to inform the client about the potential side effects of ciprofloxacin, including gastrointestinal upset, and to encourage them to report any significant or persistent symptoms to their healthcare provider
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