A nurse is planning care for a 2-month-old infant following a surgical procedure. Which of the following pain rating scales should the nurse plan to use to determine the infant's level of pain?
PANAD scale
OUCHER scale
FLACC scale
FACE Scale
The Correct Answer is C
The appropriate pain rating scale to use for a 2-month-old infant is the FLACC (Face, Legs, Activity, Cry, Consolability) scale. The FLACC scale is commonly used for infants and young children who are unable to self-report their pain. It assesses facial expression, leg movement, activity level, cry, and ability to be consoled. Each category is scored on a scale of 0 to 2, and the total score provides an indication of the infant's pain level.
The PANAD scale and OUCHER scale are more commonly used for older children, while the FACE scale is specific to assessing pain in individuals with cognitive impairments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
While the newborn's heart rate of 170 bpm is elevated, the respiratory rate of 44 breaths/min, blood pressure of 85/52 mmHg, and temperature of 99°F (37.2°C) are within the normal range for a newborn.
It is important for the nurse to explain to the parents that the newborn's heart rate may be elevated due to the vomiting and dehydration and that healthcare providers will monitor the vital signs closely to ensure the newborn's stability.
Correct Answer is D
Explanation
DDH refers to an abnormal development or alignment of the hip joint, which can lead to instability or dislocation of the hip. An asymmetric thigh fold is a common physical finding in DDH, where there is a difference in the skin fold between the affected and unaffected sides of the thigh. This occurs due to the malposition or displacement of the femoral head within the acetabulum.
While other findings may also be present in DDH, such as an inwardly turned foot on the affected side (also known as a positive Ortolani or Barlow test), absent plantar reflexes, or a lengthened thigh on the affected side, the asymmetric thigh fold is a key indicator of hip dysplasia in a newborn.
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