A nurse is planning care for 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?
FLACC scale
FACES scale
OUCHER scale
PANAD scale
The Correct Answer is A
Rationale:
A. The FLACC scale (Face, Legs, Activity, Cry, Consolability) is designed for infants and young children who cannot verbally communicate their pain, making it suitable for a 2-month-old.
B. The FACES scale is used for older children who can point to or choose faces that represent their pain level and is not suitable for a 2-month-old.
C. The OUCHER scale is used for children aged 3 to 13 years and includes pictures representing pain, so it is not appropriate for a 2-month-old.
D. The PANAD scale is not a standard pain rating scale used for infants and is less commonly used than the FLACC scale.
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Correct Answer is D
Explanation
Rationale:
A. The Doll's eye reflex is expected to be negative in older infants. It is present in newborns but should be absent by 2 months of age.
B. The Crawl reflex, which involves the infant moving forward when placed on their stomach, should disappear by 6-8 months. A negative reflex at 9 months is expected.
C. The Babinski reflex, where the toes fan out when the sole of the foot is stroked, is normal in infants up to 12-18 months.
D. The Moro reflex, or startle reflex, should disappear by 4-6 months of age. A positive Moro reflex at 9 months indicates a delay in neurological development and requires further evaluation.
Correct Answer is C
Explanation
Rationale:
A. Reading a story is beneficial but does not directly support the toddler's developmental task of autonomy and initiative.
B. Feeding the toddler is a basic need but does not support the development of independence.
C. Allowing the toddler to pull a talking-duck toy supports their developmental task of autonomy and initiative by promoting physical activity and exploration.
D. Watching a puppet show is a passive activity and does not foster the active exploration needed for this developmental stage.