Practice Question
A nurse is caring for a 6-month-old infant. Which of the following findings should indicate to the nurse that the client is experiencing pain following a procedure?
Answer Choices:
Correct Answer:
Increased crying episodes
Rationale:
🟢Crying is the most reliable behavioral indicator of pain in infants, especially those under 1 year who cannot verbalize discomfort.
🟢At 6 months of age, infants express pain through persistent, high-pitched, or inconsolable crying, which differs from normal fussiness.
🟢Pain stimulates the sympathetic nervous system, heightening distress behaviors such as crying, grimacing, and irritability.
🟢Tools such as the FLACC pain assessment scale validate crying intensity as a primary marker of infant pain.
🟢Following a procedure, an increase in crying episodes indicates acute discomfort, making this the most accurate cue among the options.
Decreased heart rate
🟢Pain does not cause decreased heart rate; instead, it activates the sympathetic nervous system, leading to tachycardia, not bradycardia.
🟢A low heart rate in an infant may indicate serious conditions such as hypoxia or medication effects, not typical post-procedural pain.
🟢Bradycardia is considered a danger sign, unrelated to normal physiologic pain responses.
🟢Using this finding to assess pain would lead to misinterpretation of clinical status.
🟢Because it contradicts known physiologic pain reactions, this option cannot indicate pain in a 6-month-old.
Increased formula consumption
🟢Infants in pain typically eat less, not more, due to discomfort and stress-related disruption in feeding patterns.
🟢Pain may reduce an infant’s ability to suck effectively, leading to poor feeding, not increased intake.
🟢Greater consumption usually suggests comfort, familiarity, and absence of distress, not pain.
🟢Feeding behaviors are sensitive indicators of infant well-being, and pain rarely stimulates appetite.
🟢Therefore, increased formula intake does not correlate with post-procedural pain.
Decreased respiratory rate
🟢Pain activates the fight-or-flight response, usually increasing respiratory rate, not decreasing it.
🟢A low respiratory rate is concerning for sedation, airway compromise, or neurologic suppression, not typical pain.
🟢Infants often cry vigorously when in pain, which increases respiratory effort, making decreased rate inconsistent with expected presentation.
🟢 Assessing pain through abnormal respiratory depression would be clinically inaccurate.
🟢Thus, decreased respiratory rate is not an appropriate indicator of acute pain in a 6-month-old.
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This question is from Custom: Peds Assessment one 2025 which contains 53 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Pediatrics
- Answer Choices: 4