An 8-month-old infant is restrained to prevent interference with the IV infusion. The nurse's action is to:
a. remove the restraints once a day to allow movement.
b. keep the restraints on constantly.
c. keep the restraints secure so infant remains supine.
d. remove restraints whenever possible.
ANS: D
The nurse should remove the restraints whenever possible. When parents or staff are present, the restraints can be removed and the IV site protected. Restraints must be checked and documented every 1 to 2 hours. They should be removed for range of motion on a periodic basis. The child should not be securely restrained in the supine position because of risks of aspiration.
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