The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.

RationaleA. Clenched fists can be a sign of pain in infants. Infants may reflexively clench their fists as a response to discomfort or pain. This behavior is commonly observed during painful procedures or when experiencing pain.B. While fever can sometimes accompany pain due to inflammation or stress response, it is not typically a reliable indicator of pain in the absence of other signs. Therefore, fever alone is not a specific indicator of pain post-pyloromyotomy.C. Restlessness or increased agitation can indicate pain in infants. They may squirm, move their arms and legs, or have difficulty settling down. Restlessness is a non-verbal cue that infants use to communicate discomfort or distress.D. Peripheral pallor could indicate decreased peripheral perfusion, which might occur due to various factors post-operatively, but it is not a direct indicator of pain.E. Increased respiratory rate can be associated with pain.F. An increased pulse rate (tachycardia) is a physiological response to pain in infants. Pain activates the sympathetic nervous system, leading to an increased heart rate as the body prepares to respond to stress or discomfort.