A nurse is giving an intramuscular injection to a newborn who was delivered at 38 weeks of gestation. Which of the following pain scales should the nurse use to assess the newborn's pain?
Natal Infant Pa Scale PS
FACES pain rating scale
Premature infant Pain Profile (PIPP)
visual analog scale (VAS)
The Correct Answer is A
Choice A reason:
A. Natal Infant Pain Scale (NIPS): The NIPS is a behavioral assessment tool designed for both preterm and full-term neonates. It evaluates six behavioral indicators in response to painful procedures. These indicators include changes in facial expression (such as grimacing, brow bulge, and eye squeeze), body movements (such as fisting, tremulousness, and limb withdrawal), and other signs of distressChoice B reason:
FACES pain rating scale The FACES pain rating scale should not be used because it is a visual scale that uses facial expressions to assess pain in children who can communicate using pictures of faces displaying different emotions. It is generally used for older children and not appropriate for newborns.
Choice C reason
Premature Infant Pain Profile (PIPP): The PIPP is another pain assessment tool specifically developed for preterm infants. It considers physiological and behavioral parameters, including facial expressions, heart rate, oxygen saturation, and gestational age. While useful for preterm infants, it may not be the best choice for full-term newborns.Since the newborn in this scenario was delivered at 38 weeks of gestation, the PIPP would be an appropriate pain assessment tool to use. It considers specific physiological and behavioural indicators of pain in newborns and helps healthcare providers evaluate and manage pain in this vulnerable population.
Choice D reason:
Visual analog scale (VAS) should not be used because the visual analog scale is a pain assessment tool typically used for older children, adolescents, and adults who can understand and provide a subjective rating of their pain intensity along a linear scale. It involves marking a point on the line corresponding to the level of pain experienced. Since newborns cannot communicate in this way, the VAS is not suitable for their pain assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A.PRN (as needed) restraint prescriptions are not appropriate because restraints should only be used in situations where there is an immediate need for safety and all other methods of de-escalation have failed. Restraint use must be based on a current assessment of the client's behavior, and a specific prescription should be obtained each time restraints are applied.
B.Restraints should be removed every 2 hours to assess the client's skin, circulation, and range of motion, and to provide an opportunity for toileting, hydration, and movement. Prolonged use without breaks increases the risk of complications such as skin breakdown or impaired circulation.
C.Attach the restraint to the bed's side rails. Restraints should not be attached to the bed's side rails because it can lead to serious injuries if the client attempts to climb over the side rails while restrained. Instead, restraints should be attached to specific restraint ties or straps that are part of the bed frame.
D.The client's condition, including circulation, skin integrity, and behavior, should be monitored and documented every 15 minutes while restraints are in use. This frequent assessment helps ensure the client’s safety and comfort, and allows for early identification of potential complications.
Correct Answer is A
Explanation
A. Correct. The nurse should initiate continuous cardiac monitoring because a magnesium level of 2.7 mEq/L indicates hypermagnesemia, which can cause cardiac dysrhythmias, hypotension, and bradycardia.
B. Incorrect. The nurse should not administer potassium chloride to a client who has hypermagnesemia because it can worsen the condition by increasing the intracellular magnesium level and decreasing the serum calcium level.
C. Incorrect. The nurse should not provide a diet rich in legumes, nuts, and green vegetables to a client who has hypermagnesemia because these foods are high in magnesium and can increase the serum magnesium level.
D. Incorrect. The nurse should not monitor the client for tetany because tetany is a sign of hypomagnesemia, not hypermagnesemia. Hypomagnesemia can cause neuromuscular excitability, muscle spasms, and positive Chvostek's and Trousseau's signs.
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