MIDTERM Flashcards
Question: What is a key role of the pediatric nurse in providing care to children?
A. Prescribing medications for chronic illnesses
B. Educating families about child health and development
C. Diagnosing medical conditions
D. Performing surgery on infants
Answer: B. Educating families about child health and development
Rationale: Pediatric nurses focus on educating families to promote the child’s health, development, and well-being.
Which action demonstrates the pediatric nurse’s role in health promotion?
A. Administering vaccines according to the CDC schedule.
B. Treating children with RSV.
C. Monitoring vital signs post-surgery.
D. Performing developmental screenings only when parents request them.
Answer: A
Rationale: Health promotion includes activities like immunizations to prevent disease.
A nurse assesses a 10-year-old child. Which growth milestone is expected?
A. Concrete operational thinking.
B. Puberty onset.
C. Sensorimotor reflexes.
D. Solitary play.
Answer: A
Rationale: School-aged children develop logical thinking (concrete operational stage).
What is the first pubertal change in boys?
A. Voice deepening.
B. Development of pubic hair.
C. Testicular enlargement.
D. Growth spurt.
Answer: C
Rationale: Testicular enlargement is the first sign of puberty in boys.
When assessing a toddler, which technique ensures the most accurate findings?
A. Perform a head-to-toe assessment.
B. Begin with invasive procedures.
C. Allow the child to sit on a caregiver’s lap.
D. Use a systematic adult-focused assessment.
Answer: C
Rationale: Allowing toddlers to sit on a caregiver’s lap reduces anxiety.
When teaching parents about SIDS prevention, the nurse should include:
A. Place the baby on their stomach to sleep.
B. Avoid breastfeeding.
C. Keep soft bedding out of the crib.
D. Share a bed with the infant.
Answer: C
Rationale: Keeping soft bedding out reduces suffocation risk.
What is the primary stressor for a preschool-aged child in the hospital?
A. Separation from caregivers.
B. Fear of body mutilation.
C. Fear of strangers.
D. Lack of autonomy.
Answer: B
Rationale: Preschoolers fear body mutilation due to a developing body image.
Which pain scale is most appropriate for a 5-year-old child?
A. FLACC scale.
B. Numeric rating scale.
C. Wong-Baker FACES scale.
D. Visual analog scale.
Answer: C
Rationale: The FACES scale is suitable for young children who can point to a face that represents their pain.
At what age should the first dose of MMR vaccine be administered?
A. 2 months
B. 6 months
C. 12 months
D. 15 months
Answer: C
Rationale: The MMR vaccine is administered at 12-15 months for the first dose.
A child weighs 20 kg and needs maintenance fluids. How many mL/hr should the nurse administer?
A. 50 mL/hr
B. 62.5 mL/hr
C. 70 mL/hr
D. 100 mL/hr
Answer: B
Rationale: Maintenance fluids for a child weighing 20 kg are calculated as 100 mL/kg for the first 10 kg + 50 mL/kg for the next 10 kg = 1500 mL/day = 62.5 mL/hr.
A child with croup presents with stridor. What is the priority intervention?
A. Administer racemic epinephrine.
B. Provide cool mist therapy.
C. Place the child in prone position.
D. Offer oral hydration.
Answer: A
Rationale: Racemic epinephrine reduces airway swelling in severe cases.
A child with cystic fibrosis has thickened respiratory secretions. Which treatment is most effective?
A. Oral antibiotics.
B. High-flow oxygen therapy.
C. Chest physiotherapy.
D. IV corticosteroids.
Answer: C
Rationale: Chest physiotherapy aids in mobilizing secretions.
Where should the nurse place the stethoscope to auscultate a child’s mitral valve?
A. 4th left intercostal space.
B. 2nd right intercostal space.
C. 3rd right intercostal space.
D. 5th left midclavicular line.
Answer: A
Rationale: The mitral valve is best heard at the 4th left midclavicular line.
What is the primary concern for a child with acute glomerulonephritis?
A. Proteinuria
B. Dehydration
C. Hypertension
D. Hypokalemia
Answer: C
Rationale: Hypertension is a critical complication of glomerulonephritis due to fluid retention.
Which assessment finding is most concerning in a child with a head injury?
A. A Glasgow Coma Score (GCS) of 14.
B. A fixed and dilated pupil.
C. Vomiting once after injury.
D. A headache.
Answer: B
Rationale: A fixed and dilated pupil indicates increased intracranial pressure or brain herniation.
A child presents with a second-degree burn. What is the nurse’s first priority?
A. Apply a topical antibiotic.
B. Cover the burn with sterile gauze.
C. Administer IV fluids.
D. Administer analgesics.
Answer: B
Rationale: Protecting the wound from infection is the initial priority.
A nurse notes wheezing in a child with asthma. What is the first action?
A. Administer albuterol.
B. Increase oxygen flow rate.
C. Notify the provider.
D. Perform chest physiotherapy.
Answer: A
Rationale: Albuterol is a first-line treatment to relieve bronchospasm in asthma.
A child weighs 15 kg and requires a fluid bolus of 20 mL/kg. How much fluid should the nurse administer?
A. 200 mL
B. 300 mL
C. 400 mL
D. 600 mL
Answer: B
Rationale: 15 kg × 20 mL = 300 mL.
A nurse is counseling a family about a new diagnosis of Type 1 diabetes in their child. Which statement by the parent indicates a need for further teaching?
A. “We will check blood sugars before each meal.”
B. “My child can skip insulin if they skip a meal.”
C. “We will work with a dietitian to create meal plans.”
D. “It’s important to monitor for low blood sugar during exercise.”
Answer: B
Rationale: Insulin should never be skipped, even if meals are skipped, as it is needed to regulate blood glucose levels.
Which developmental milestone is expected for a 6-month-old infant?
A. Sitting up unsupported.
B. Saying two-word phrases.
C. Rolling over in both directions.
D. Pulling to a standing position.
Answer: C
Rationale: By 6 months, infants should be able to roll over in both directions.
The parents of a 3-year-old are concerned their child is not sharing with other children. What should the nurse explain?
A. “Your child should be evaluated for developmental delays.”
B. “Sharing typically develops during the preschool years.”
C. “Encourage more group play to teach sharing skills.”
D. “This behavior is unusual for their age.”
Answer: B
Rationale: Sharing behaviors typically develop during the preschool years as children become more social.
The nurse is administering an IM injection to an infant. What is the preferred site?
A. Dorsogluteal
B. Ventrogluteal
C. Vastus lateralis
D. Deltoid
Answer: C
Rationale: The vastus lateralis is the preferred site for IM injections in infants due to its large muscle mass.
Which clinical sign indicates dehydration in an infant?
A. Bulging fontanelles
B. Capillary refill >2 seconds
C. Increased tear production
D. Strong peripheral pulses
Answer: B
Rationale: A capillary refill time >2 seconds is a sign of poor perfusion, indicating dehydration.
A child presents with a “slapped cheek” rash. What is the most likely diagnosis?
A. Measles
B. Rubella
C. Fifth disease (erythema infectiosum)
D. Roseola
Answer: C
Rationale: Fifth disease, caused by parvovirus B19, is characterized by a “slapped cheek” rash.
A child diagnosed with varicella (chickenpox) can return to school when:
A. All lesions are crusted over.
B. The fever has resolved for 24 hours.
C. The rash is no longer visible.
D. Antibiotic therapy is completed.
Answer: A
Rationale: Children with chickenpox are no longer contagious once all lesions are crusted over.
A nurse is teaching parents about introducing solid foods to their infant. What is the first food they should introduce?
A. Mashed vegetables
B. Iron-fortified cereal
C. Pureed meat
D. Yogurt
Answer: B
Rationale: Iron-fortified cereal is typically the first solid food introduced to infants around 4-6 months.
A nurse is assessing a child with suspected meningitis. Which finding is most concerning?
A. Positive Kernig’s sign
B. Irritability
C. Purpuric rash
D. Headache
Answer: C
Rationale: A purpuric rash may indicate meningococcemia, a life-threatening complication of meningitis.
A child with Type 1 diabetes has fruity-smelling breath. What does this indicate?
A. Hypoglycemia
B. Diabetic ketoacidosis (DKA)
C. Hyperosmolar hyperglycemic state
D. Dehydration
Answer: B
Rationale: Fruity breath is a classic sign of ketoacidosis caused by the breakdown of fatty acids.
A child with a new cast reports tingling and numbness in the fingers. What is the nurse’s priority action?
A. Elevate the limb.
B. Perform a neurovascular assessment.
C. Apply ice to the cast.
D. Administer pain medication.
Answer: B
Rationale: Tingling and numbness may indicate compartment syndrome, requiring immediate evaluation.
A child with sickle cell anemia presents with severe abdominal pain. What is the most likely cause?
A. Splenic sequestration crisis
B. Acute chest syndrome
C. Pain crisis due to vaso-occlusion
D. Iron overload
Answer: C
Rationale: Vaso-occlusive crises cause severe pain due to blocked blood flow, commonly affecting the abdomen.
A nurse is educating parents about atopic dermatitis (eczema). Which statement indicates understanding?
A. “We should use scented lotions to keep the skin moisturized.”
B. “Daily baths with hot water will reduce flare-ups.”
C. “We’ll apply emollients immediately after bathing.”
D. “Antibiotics are needed during every flare-up.”
Answer: C
Rationale: Emollients help retain moisture and should be applied immediately after bathing.
A child with burns over 30% of their body is at risk for which complication within the first 24 hours?
A. Hypovolemia
B. Sepsis
C. Hypertension
D. Hyperkalemia
Answer: A
Rationale: Burn injuries can lead to significant fluid loss and hypovolemia.
A nurse caring for a child with a tracheostomy notes thick secretions. What is the priority intervention?
A. Administer humidified oxygen.
B. Perform suctioning immediately.
C. Increase the child’s fluid intake.
D. Replace the tracheostomy tube.
Answer: A
Rationale: Humidified oxygen helps loosen thick secretions, making suctioning more effective.
Which finding indicates developmental delay in a 2-year-old?
A. Unable to jump with both feet.
B. Not combining two words.
C. Preferring solitary play.
D. Not drawing a circle.
Answer: B
Rationale: By 2 years, children should combine two words to form simple phrases.
Which behavioral sign is most consistent with pain in a neonate?
A. Smiling
B. Grimacing
C. Increased eye contact
D. Sucking on a pacifier
Answer: B
Rationale: Neonates often display nonverbal cues like grimacing when in pain.
A child with cancer is receiving opioid analgesics for pain. What is the most appropriate nursing intervention to prevent a common side effect?
A. Administer an antiemetic.
B. Monitor respiratory rate every 15 minutes.
C. Encourage a high-fiber diet and adequate hydration.
D. Assess for tinnitus and hearing changes.
Answer: C
Rationale: Opioids commonly cause constipation, which can be minimized with dietary adjustments and hydration.
A child with asthma is experiencing an acute exacerbation. Which clinical finding indicates respiratory distress?
A. Oxygen saturation of 95%.
B. Subcostal retractions.
C. Mild wheezing.
D. Respiratory rate of 20 breaths/min.
Answer: B
Rationale: Retractions suggest increased respiratory effort and distress.
A child is having a tonic-clonic seizure. What is the nurse’s priority action?
A. Restrain the child to prevent injury.
B. Turn the child onto their side.
C. Insert a tongue blade to prevent biting.
D. Administer lorazepam.
Answer: B
Rationale: Turning the child onto their side prevents airway obstruction and aspiration.
A nurse is caring for a child with pyloric stenosis. What clinical finding is most characteristic of this condition?
A. Frequent loose stools.
B. Projectile vomiting.
C. Abdominal distention with visible peristalsis.
D. Bloody stools.
Answer: B
Rationale: Projectile vomiting after feeding is a hallmark of pyloric stenosis.
A nurse is caring for a dehydrated infant with sunken fontanelles. Which is the priority intervention?
A. Offer small, frequent feedings.
B. Administer IV fluids.
C. Provide oral rehydration salts.
D. Encourage breastfeeding.
Answer: B
Rationale: IV fluids are needed for severe dehydration to restore hydration quickly.
A child with juvenile idiopathic arthritis is prescribed NSAIDs. What is an important nursing consideration?
A. Administer the medication on an empty stomach.
B. Assess for abdominal pain or GI bleeding.
C. Avoid concurrent use of corticosteroids.
D. Discontinue therapy if pain persists.
Answer: B
Rationale: NSAIDs can cause GI irritation and bleeding, so monitoring for these effects is crucial.
A child with hemophilia is bleeding after a minor fall. What is the nurse’s first action?
A. Administer factor VIII.
B. Apply firm pressure to the site.
C. Elevate the affected limb.
D. Administer an analgesic.
Answer: B
Rationale: Applying firm pressure helps control bleeding in hemophilia before further treatment.
A child with impetigo is prescribed antibiotics. What should the nurse include in the teaching plan?
A. “Your child can return to school immediately after starting treatment.”
B. “Do not touch or pick at the lesions.”
C. “The condition is not contagious after crusting forms.”
D. “Avoid bathing until lesions have healed.”
Answer: B
Rationale: Picking at lesions can spread the infection and delay healing.
A nurse is educating parents about hand-foot-mouth disease. What statement indicates understanding?
A. “The rash is contagious even after it scabs over.”
B. “It is caused by the Varicella-zoster virus.”
C. “We should avoid sharing utensils with our child.”
D. “Antibiotics will help reduce the symptoms.”
Answer: C
Rationale: Hand-foot-mouth disease spreads through direct contact, including shared utensils.
A parent of a 6-month-old asks why the child needs multiple doses of the same vaccine. What is the best response?
A. “It ensures complete immunity.”
B. “It is required by law.”
C. “It prevents adverse effects.”
D. “It reduces the risk of allergic reactions.”
Answer: A
Rationale: Multiple doses are needed to build full immunity over time.
A child with hypothyroidism is prescribed levothyroxine. What should the nurse include in teaching?
A. “Take the medication at bedtime.”
B. “Do not skip doses, even if symptoms improve.”
C. “Administer the medication with meals.”
D. “Avoid dairy products while on this medication.”
Answer: B
Rationale: Consistent dosing is necessary to maintain thyroid hormone levels.
A child with pertussis has paroxysmal coughing. What is the priority nursing intervention?
A. Administer an antibiotic.
B. Provide humidified oxygen.
C. Place the child in Trendelenburg position.
D. Encourage oral hydration.
Answer: B
Rationale: Humidified oxygen alleviates coughing and promotes easier breathing.
A child undergoing chemotherapy for leukemia has a WBC count of 1,000/µL. What is the nurse’s priority action?
A. Restrict all visitors.
B. Monitor for signs of infection.
C. Administer prophylactic antibiotics.
D. Provide a high-protein diet.
Answer: B
Rationale: A low WBC count (neutropenia) significantly increases infection risk.
Which finding is most concerning in a child after a tonsillectomy?
A. Mild throat pain.
B. Frequent swallowing.
C. White patches in the throat.
D. Low-grade fever.
Answer: B
Rationale: Frequent swallowing may indicate bleeding, which requires immediate intervention.
A nurse is preparing a 7-year-old for surgery. What approach is most appropriate?
A. Use age-appropriate words to describe the procedure.
B. Avoid discussing the surgery to reduce anxiety.
C. Use complex medical terminology for explanation.
D. Involve the parents only in preparation.
Answer: A
Rationale: Age-appropriate explanations reduce fear and increase understanding.
A nurse is caring for a child in isolation for measles. What is the most appropriate infection control measure?
A. Contact precautions
B. Airborne precautions
C. Droplet precautions
D. Standard precautions
Answer: B
Rationale: Measles requires airborne precautions due to its highly contagious nature.
A child is admitted with diarrhea and vomiting. Which lab result requires immediate intervention?
A. Sodium 138 mEq/L
B. Potassium 2.8 mEq/L
C. Chloride 101 mEq/L
D. Bicarbonate 23 mEq/L
Answer: B
Rationale: Hypokalemia (<3.5 mEq/L) can lead to cardiac arrhythmias and requires prompt correction.
Which sign suggests fluid overload in a child receiving IV fluids?
A. Dry mucous membranes
B. Peripheral edema
C. Tachycardia
D. Sunken fontanel
Answer: B
Rationale: Peripheral edema is a key indicator of fluid overload.
A nurse caring for a child with rubella notes petechiae on the soft palate. What is the priority nursing intervention?
A. Notify the health department.
B. Administer antibiotics as prescribed.
C. Encourage oral hydration.
D. Initiate seizure precautions.
Answer: A
Rationale: Rubella is a notifiable disease, and petechiae (Forchheimer spots) are a characteristic finding.
A nurse educates parents about hand hygiene to prevent spreading conjunctivitis. Which statement indicates a need for further teaching?
A. “We should avoid touching our eyes.”
B. “We should use separate towels for each family member.”
C. “Antibiotics will prevent spreading conjunctivitis.”
D. “We’ll wash our hands before and after applying eye drops.”
Answer: C
Rationale: Antibiotics treat bacterial conjunctivitis but do not prevent transmission.
Which intervention is most appropriate for pain relief in a 2-month-old infant after immunization?
A. Acetaminophen
B. Ibuprofen
C. Cold compress
D. Oral sucrose
Answer: D
Rationale: Oral sucrose is effective in managing minor pain in neonates and infants.
A parent refuses the varicella vaccine for their child, stating the disease is mild. What is the best response by the nurse?
A. “Varicella can lead to severe complications like pneumonia and encephalitis.”
B. “It’s required for school attendance in most states.”
C. “It’s important to protect other children from exposure.”
D. “Mild cases of chickenpox don’t require immunization.”
Answer: A
Rationale: Education on potential complications helps parents understand the importance of vaccination.
A child with epiglottitis is drooling and leaning forward. What is the priority intervention?
A. Prepare for emergency intubation.
B. Obtain a throat culture.
C. Administer oral antibiotics.
D. Encourage the child to lie supine.
Answer: A
Rationale: Drooling and tripod positioning indicate airway obstruction, requiring immediate preparation for intubation.
What is the first action for a child experiencing an acute asthma attack?
A. Administer a corticosteroid.
B. Administer a short-acting bronchodilator.
C. Place the child in high-Fowler’s position.
D. Start an IV line for fluids.
Answer: B
Rationale: Short-acting bronchodilators, like albuterol, are first-line treatments for acute asthma exacerbations.
A nurse auscultates a murmur in a newborn. What is the nurse’s best action?
A. Notify the provider immediately.
B. Document the finding as normal.
C. Prepare for an echocardiogram.
D. Reassess after feeding.
Answer: C
Rationale: Murmurs in newborns may indicate congenital heart defects and should be evaluated further.
Which finding in a child with Kawasaki disease requires immediate intervention?
A. Strawberry tongue
B. Peeling of the hands and feet
C. Gallop rhythm on auscultation
D. Fever persisting for 3 days
Answer: C
Rationale: A gallop rhythm suggests myocardial dysfunction, a severe complication of Kawasaki disease.
A nurse is educating parents about insulin administration for their child with Type 1 diabetes. Which statement indicates understanding?
A. “We’ll rotate injection sites to prevent lipodystrophy.”
B. “We’ll inject insulin into a vein for faster absorption.”
C. “We should only inject insulin in the morning.”
D. “It’s okay to skip a dose if our child eats fewer carbohydrates.”
Answer: A
Rationale: Rotating sites prevents tissue damage and ensures consistent absorption.
- A child with celiac disease should avoid which of the following foods?
A. Rice
B. Corn
C. Barley
D. Potatoes
Answer: C
Rationale: Gluten-containing grains like barley, wheat, and rye must be avoided in celiac disease.
Which is a priority finding in a child with appendicitis?
A. Severe right lower quadrant pain
B. Sudden relief of pain
C. Low-grade fever
D. Nausea and vomiting
Answer: B
Rationale: Sudden relief of pain may indicate appendix rupture, a surgical emergency.
Which intervention is appropriate for a child in traction?
A. Encourage frequent repositioning.
B. Ensure weights hang freely.
C. Remove the traction weights to perform skin care.
D. Elevate the child’s affected limb.
Answer: B
Rationale: Traction weights must hang freely to maintain proper alignment and therapeutic effect.
A child undergoing chemotherapy develops oral mucositis. What is the nurse’s priority action?
A. Encourage oral intake of acidic juices.
B. Provide saline mouth rinses.
C. Apply alcohol-based mouthwash.
D. Offer hard candies to reduce discomfort.
Answer: B
Rationale: Saline rinses help soothe mucositis and reduce infection risk without causing irritation.
A nurse is teaching a parent about ringworm (tinea corporis). Which statement indicates effective teaching?
A. “We’ll keep the area covered with tight bandages.”
B. “We’ll apply topical antifungal cream as directed.”
C. “We’ll avoid using antifungal medication until symptoms worsen.”
D. “Ringworm is caused by worms, so antibiotics are needed.”
Answer: B
Rationale: Topical antifungals are the treatment of choice for ringworm.
A child has a mild cold but is scheduled for routine immunizations. What is the nurse’s best action?
A. Administer the vaccines as scheduled.
B. Postpone the vaccines until the child is symptom-free.
C. Notify the provider for further instructions.
D. Administer only half the vaccine dose.
Answer: A
Rationale: Mild illnesses are not contraindications for routine immunizations.
A child with scoliosis is prescribed a thoracolumbosacral orthosis (TLSO). What is the most important teaching point?
A. “Wear the brace only at night.”
B. “Remove the brace for at least 12 hours each day.”
C. “Wear the brace over a thin shirt to protect the skin.”
D. “Apply lotion to prevent irritation under the brace.”
Answer: C
Rationale: A thin shirt under the brace prevents skin irritation without compromising fit.
. A parent asks how to prevent diaper dermatitis. What should the nurse recommend?
A. “Use baby powder with each diaper change.”
B. “Avoid using barrier creams.”
C. “Change diapers frequently and apply barrier cream.”
D. “Let the infant go without a diaper for 24 hours.”
Answer: C
Rationale: Frequent diaper changes and barrier creams protect the skin from irritation.
A nurse observes a child using their fingers to repeatedly poke at their ears. What is the priority assessment?
A. Assess for signs of otitis media.
B. Ask if the child has hearing loss.
C. Assess the child’s balance.
D. Inspect the child’s teeth for cavities.
Answer: A
Rationale: Ear poking is a common sign of otitis media in young children.
A nurse is assessing pain in a nonverbal toddler. Which assessment tool is most appropriate?
A. FLACC Scale
B. Wong-Baker FACES Scale
C. Numeric Rating Scale
D. Visual Analog Scale
Answer: A
Rationale: The FLACC Scale is used to assess pain in nonverbal children based on facial expression, leg movement, activity, cry, and consolability.
Which patient would benefit most from the FLACC pain assessment scale?
A. A 10-year-old who rates their pain as 5/10.
B. A 4-month-old infant after an immunization.
C. A 7-year-old with cerebral palsy who uses a communication device.
D. A 15-year-old post-surgery experiencing mild pain.
Answer: B
Rationale: The FLACC scale is specifically designed for infants, preverbal children, or children with cognitive impairments who cannot verbalize their pain. It assesses pain through behavioral cues.
A child with bronchiolitis is receiving humidified oxygen. What additional intervention can help alleviate symptoms?
A. Administering antibiotics
B. Performing chest physiotherapy
C. Suctioning nasal secretions
D. Starting a corticosteroid inhaler
Answer: C
Rationale: Suctioning nasal secretions helps clear the airway and improves breathing in children with bronchiolitis.
A child with spina bifida is at risk for which complication?
A. Hydrocephalus
B. Seizures
C. Cerebral palsy
D. Asthma
Answer: A
Rationale: Hydrocephalus is a common complication of spina bifida due to the disruption of cerebrospinal fluid flow.
A child with a new diagnosis of Duchenne muscular dystrophy asks why they have difficulty walking. What is the best response?
A. “Your muscles are inflamed, which makes movement painful.”
B. “You have a condition that weakens your muscles over time.”
C. “You’ll regain your strength with physical therapy.”
D. “This is caused by a problem with the bones, not the muscles.”
Answer: B
Rationale: Duchenne muscular dystrophy causes progressive muscle weakness due to genetic mutations affecting muscle protein.
A nurse is caring for a child with leukemia who develops bruising and petechiae. What is the most likely cause?
A. Thrombocytopenia
B. Neutropenia
C. Anemia
D. Hemophilia
Answer: A
Rationale: Thrombocytopenia (low platelet count) is common in leukemia and increases the risk of bruising and bleeding.
A 6-month-old infant is crying steadily, arching their back, pulling their legs up, and inconsolable despite soothing attempts. Based on the FLACC scale, what is the appropriate score?
A. 5
B. 7
C. 10
D. 12
Answer:C
Rationale:
Face: 2 (frequent frown, quivering chin).
Legs: 2 (legs drawn up).
Activity: 2 (arched back).
Cry: 2 (crying steadily).
Consolability: 2 (difficult to console).
Total score = 10, indicating severe pain.
A nurse is assessing a nonverbal 3-year-old using the FLACC scale. The child is grimacing, restless, whimpering occasionally, and calms with parental reassurance. What is the FLACC score?
A. 2
B. 4
C. 6
D. 8
Answer: B
Rationale:
Face: 1 (grimacing).
Legs: 1 (restless).
Activity: 0 (no rigid or jerking movements).
Cry: 1 (occasional whimpering).
Consolability: 1 (calms with reassurance).
Total score = 4, indicating moderate pain.
