A nurse is planning to collect data on the pain level of a 3-year-old child. Which of the following pain rating scales should the nurse plan to use?

Choice A reason:

The nurse should not remind the client to void every 4 hours because epidural anesthesia can cause temporary loss of bladder sensation, making it difficult for the client to know when to void. Instead, the nurse should use a bladder scanner to assess for urinary retention and encourage the client to void regularly.

Choice B reason:

Encouraging the client to alternate from side to side every 2 hours is not directly related to the administration of epidural anesthesia. This action is commonly advised for clients who are on bed rest to prevent pressure ulcers and promote circulation. However, it is not specifically necessary for the client receiving epidural anesthesia for pain management during labor.

Choice C reason:

Raising the four side rails on the client's bed is not necessary in this situation. The use of side rails should be based on the client's mobility and risk assessment for falls. If the client is receiving epidural anesthesia, they may experience reduced mobility, but the decision to use side rails should be made on an individual basis, not solely based on the anesthesia.

Choice D reason:

Monitoring the client's blood pressure is a crucial action when a client is receiving epidural anesthesia. Epidural anesthesia can cause a drop in blood pressure, leading to hypotension. By regularly monitoring the client's blood pressure, the nurse can detect any significant changes and take appropriate actions to maintain hemodynamic stability.

Choice C reason: The infant makes babbling sounds. At 6 months of age, it is typical for infants to engage in babbling sounds. Babbling is a significant milestone in language development during infancy. It involves the repetition of consonant-vowel combinations (e.g., "ba-ba,”. "ma-ma") and is an essential precursor to later language skills, such as forming words and sentences. The nurse should expect the 6-month-old infant to be making these babbling sounds as part of their normal development.

Choice A reason:

The infant has a pincer grasp. A pincer grasp is the ability to pick up small objects using the thumb and index finger. This fine motor skill typically develops around 9 to 12 months of age. At 6 months old, infants have not yet acquired the pincer grasp. Therefore, the nurse should not expect the 6-month-old infant to demonstrate this skill during the assessment.

Choice D reason:

The infant crawls on their hands and knees. Crawling is a gross motor skill that usually emerges between 7 to 10 months of age. While some infants may start crawling earlier or later, it is not a skill that is typically present in a 6-month-old. Therefore, the nurse should not anticipate the 6-month-old infant to be crawling on their hands and knees during the assessment.

Choice B reason:

The infant drops objects with the expectation of someone picking them up. This behavior, known as "object permanence,”. is a cognitive milestone that develops around 8 to 12 months of age. At 6 months old, infants have not yet fully developed this concept. They might drop objects as part of their exploratory behavior, but they do not yet understand the expectation of someone picking them up. Therefore, the nurse should not expect the 6- month-old infant to exhibit this specific behavior during the assessment.