The nurse is ordered to apply restraints to a toddler who keeps pulling at the tubes in his arm. Which of the following criteria must occur to ensure proper use of these restraints? Select all answers that apply.
A) The nurse must check the restraints every 15 minutes while they are in place.
B) Secure the restraints with ties to the side rails, not the bed or crib frame.
C) Assess the temperature of the affected extremities, pulses, and capillary refill every 15 minutes after placement.
D) Use a clove-hitch type of knot to secure the restraints with ties.
E) Remove the restraint every 2 hours to allow for range of motion and repositioning.
F) Encourage parent participation, providing continuous explanations about the reasons and time frame for restraints.
Question 2
Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem?
a. Group all care activities together to provide long periods of rest.
b. While giving your report to the next nurse, stand in front of the incubator and talk softly about how the infant responds to stimulation.
c. Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers.
d. Keep charts on top of the incubator so the nurses can write on them there.
The nurse is using Standard Precautions to draw blood.
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