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When the mother is blood type A and the fetus is also blood type A, the red blood cell antigens are the same. Because the mother does not have antibodies against her own blood type, there is no risk for ABO incompatibility in this situation.

A mother with blood type AB has both A and B antigens and therefore does not produce anti-A or anti-B antibodies. Since ABO incompatibility depends on maternal antibodies attacking fetal red blood cells, this combination does not place the fetus at risk.

If both the mother and fetus are blood type B, the maternal immune system recognizes the fetal red blood cells as “self.” No antibody-mediated hemolysis occurs, so ABO incompatibility is not a concern.

This option is incorrect because it describes Rh incompatibility, not ABO incompatibility. ABO incompatibility does not depend on Rh status and cannot be prevented with Rh immunoglobulin (Rho(D) immune globulin). Additionally, ABO incompatibility commonly causes jaundice, not just mild anemia.

This option is incorrect because ABO incompatibility does not require prior blood transfusions or sensitization. Mothers with type O blood naturally have anti-A and anti-B antibodies, which can affect the fetus even during a first pregnancy.

This statement is incorrect because ABO incompatibility occurs when the mother and infant have different blood types, not the same blood type. Severe hemolysis and kernicterus requiring exchange transfusion are more characteristic of severe Rh incompatibility, not typical ABO incompatibility, which is usually mild and managed with phototherapy.

This scale uses a series of faces ranging from a happy face (no pain) to a crying face (worst pain) and requires the child to identify which face best represents their pain level. It is suitable for children approximately 3 years and older who are verbal and cognitively able to associate facial expressions with their own pain. A sedated, nonverbal 2-year-old cannot reliably communicate using this method, making it inappropriate.

This scale asks the patient to rate their pain on a scale of 0 to 10. It requires verbal communication, abstract thinking, and the ability to quantify pain, which toddlers, especially a sedated 2-year-old, are unable to do. Therefore, this scale is not suitable in this context.

This scale asks the patient to mark a point on a line that represents their pain intensity from “no pain” to “worst pain.” It requires cognitive understanding, fine motor skills, and self-reporting, making it inappropriate for a sedated toddler who cannot comprehend or mark the scale.

These are symptoms of upper respiratory tract infections, such as the common cold, and are not indicative of epiglottitis, which presents more acutely and severely.

Wheezing and cough are more typical of lower airway diseases like croup or bronchiolitis, not epiglottitis. Difficulty swallowing alone is not sufficient without drooling and tripod positioning.

These are classic for viral croup, which affects the larynx and trachea. Epiglottitis differs because it progresses rapidly, causes drooling, and children often refuse to lie down.

This scale requires the child to understand numbers and quantify pain. A 5-year-old who has difficulty with numbers cannot reliably use this scale, making it inappropriate.

While FLACC is excellent for observational assessment of nonverbal or pre-verbal children, it does not allow the child to self-report pain. Since the nurse wants the child to self-report, this is not the best choice.

This scale requires the child to mark a point on a line representing their pain intensity. It also requires abstract thinking and fine motor skills, which may be challenging for a 5-year-old, especially if they can’t reliably understand numbers or gradients.

This scale asks the child to verbally rate their pain on a scale from 0 (no pain) to 10 (worst pain). It requires understanding of numbers, abstract thinking, and the ability to quantify pain, which is beyond the cognitive level of most 5-year-old preschoolers. Since the child in this scenario has difficulty understanding numbers, using the NRS would likely lead to inaccurate or unreliable pain assessment.

The VAS requires the child to mark a point along a continuous line representing pain intensity, usually anchored with “no pain” at one end and “worst pain” at the other. This tool requires abstract thinking, spatial awareness, and fine motor skills, which preschoolers may not have fully developed. A 5-year-old may not comprehend the concept of a continuous gradient or how to place a mark accurately, making this scale inappropriate.

The FLACC scale assesses pain based on observational behaviors: Face, Legs, Activity, Cry, and Consolability. It is designed for infants, toddlers, or children who are nonverbal or unable to self-report. While effective for behavioral assessment, FLACC does not allow the child to self-report pain, which is considered the gold standard whenever possible. Since this child can speak, the nurse should use a tool that allows self-expression rather than relying solely on observation.

Vital signs may not always reflect pain, especially in children. Behavioral and psychological cues are often more sensitive indicators of pain than vital signs in pediatric patients. Assuming the child is fine could lead to undertreatment of pain.

While offering food or drink may provide comfort, it does not address the underlying pain. Without assessment, the nurse cannot determine if the child’s withdrawal is due to pain or another cause. This is not the first or priority action.

Relying on self-report alone may delay pain recognition and treatment, particularly if the child is quiet, withdrawn, or fearful. Children often do not verbalize pain immediately, so proactive assessment is crucial.

While cold compresses can reduce local pain and inflammation, they do not address the systemic risk of tetanus. Given the child’s symptoms (stiff jaw, muscle spasms, difficulty swallowing) 10 days after stepping on a rusty nail, tetanus is suspected, and simply treating the wound locally is insufficient.

Muscle stiffness and spasms in tetanus are caused by neurotoxin effects on the nervous system, not inactivity. Ambulation does not prevent the progression of tetanus and could increase the risk of falls or injury.

Antibiotics like metronidazole or penicillin are used to reduce bacterial load, but they do not neutralize circulating tetanus toxin and are secondary to immediate immunotherapy. Delaying TIG while focusing only on antibiotics could be fatal.

An Rh-positive mother already has the D antigen, so she will not form antibodies against an Rh-negative baby. RhoGAM is not needed.

The mother is Rh-positive and cannot develop antibodies against Rh-positive fetal blood cells. No RhoGAM is required.

Both mother and baby are Rh-negative, so there is no risk of maternal sensitization. RhoGAM is not indicated.