A nurse is reinforcing teaching about a biophysical profile (BPP) with a client who is at 38 weeks of gestation. Which of the following statements should the nurse include in the teaching?

Choice A reason:

The FACES Scale is a visual pain scale typically used for children who can understand and verbalize their pain intensity. It consists of a series of faces with varying expressions, from smiling to crying, to help the child express their pain level. However, since the client in question is nonverbal and has cognitive and developmental delays, this scale may not be suitable as they might not be able to communicate using this tool effectively.

Choice B reason:

The Numerical Scale involves asking the patient to rate their pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable. While this scale is commonly used for older children and adults, it may not be appropriate for a nonverbal and developmentally delayed 9-year-old client, as they may not understand or be able to use numbers effectively to express their pain.

Choice C reason:

The FLACC pain assessment scale is designed for nonverbal or preverbal individuals, including children and those with cognitive impairments. FLACC stands for Face, Legs, Activity, Cry, and Consolability. Each category is scored from 0 to 2 or 0 to 3, depending on the version used, based on specific observed behaviors. The scores are then totaled to give an overall pain assessment. This scale is particularly suitable for the current client's condition as it focuses on observable behaviors rather than verbal communication.

Choice D reason:

The Visual Analog Scale (VAS) requires the patient to mark a point along a line that represents their pain intensity, with one end indicating no pain and the other end indicating the worst pain. Although this scale is useful for older children and adults, it may not be appropriate for a 9-year-old client with cognitive and developmental delays who might not fully comprehend the concept of the scale.

Choice A reason:

The nurse should not initiate contact precautions for a child with suspected epiglottitis. Epiglottitis is primarily caused by Haemophilus influenzae type B, and it spreads through respiratory droplets. Contact precautions are not necessary as the transmission occurs through droplets, and standard precautions should be sufficient.

Choice B reason:

The nurse should monitor pulse oximetry. Epiglottitis is a condition where the epiglottis becomes inflamed and swollen, potentially blocking the airway. Monitoring the child's pulse oximetry helps assess their oxygen saturation levels, which is crucial in determining if there is adequate oxygenation. If the oxygen saturation drops significantly, immediate intervention might be needed to maintain the child's airway and prevent hypoxia.

Choice C reason:

Obtaining a throat culture is not an appropriate intervention for suspected epiglottitis. In cases of suspected epiglottitis, the priority is to ensure the child's airway is maintained and that they receive appropriate medical attention promptly. Throat culture collection involves swabbing the throat to identify the infectious agent and is not a priority in this urgent situation.

Choice D reason:

Administering epinephrine IM is not indicated for suspected epiglottitis. Epinephrine is typically used to treat severe allergic reactions (anaphylaxis) and not for managing epiglottitis. The primary focus in epiglottitis is securing the airway and providing appropriate medical treatment, which might include antibiotics and respiratory support.