A nurse is caring for a 10-month-old child who has had surgery for a cleft palate. The child is put in elbow restraints. The mother comes and asks the nurse to remove the restraints
Which of the following is the most appropriate action for the nurse to take? A) Remove a restraint from one extremity.
B) Remove both the restraints from the elbows for the remainder of the day.
C) Loosen the restraints without removing them.
D) Tell the mother that the restraints are important.
A
Feedback:
The nurse should remove a restraint from one elbow. The elbow restraint in the child is used to prevent the child from touching the incision site. One restraint at a time can be removed to provide movement in the child, but the mother should be told to supervise the child. Removing both the restraints, not removing the restraints, and loosening the restraints are inappropriate nursing actions.
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