A nurse is caring for a 5-week-old infant who has just returned from a PACU following surgery.

Exhibits

The nurse is planning care for a 5-week-old infant who is postoperative. For each intervention, click to specify if the intervention is expected or unexpected for the infant. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Rationale:

A. Clarify the source of the referral: Before taking any action, the nurse must first clarify the referral source to understand why the visit is needed, the client’s health status, and any specific concerns or priorities. This ensures the nurse has accurate and complete information to plan the visit safely and effectively.

B. Contact the family by phone: While contacting the family is necessary to arrange the visit, it should occur only after the nurse understands the purpose of the referral and any special considerations to communicate relevant information.

C. Implement the nursing process: Implementing the nursing process requires assessment and planning. The nurse cannot proceed to intervention without first obtaining information about the referral and preparing appropriately.

D. Schedule a time for the home visit: Scheduling is important for logistics, but it should occur after clarifying the referral and understanding the family’s needs to ensure the visit is purposeful and safe.

Rationale:

A. Maintain sensory stimulation for the client: While in restraints, minimizing overstimulation is important to reduce agitation and prevent further aggressive behavior. Excessive sensory input can increase stress and escalate the situation rather than support safety.

B. Identify stressors that caused the client's aggression: Understanding triggers is important for long-term behavior management, but it is not the priority while the client is physically restrained. Immediate safety and monitoring take precedence over retrospective analysis.

C. Observe the client's range of movement: Continuous monitoring of the client’s range of motion is essential while restraints are in place to prevent injury, nerve damage, or impaired circulation. Regular checks ensure the restraints are applied safely and that the client maintains mobility as much as possible within safety limits.

D. Hold a critical incident debriefing about the client: Debriefing is important for staff learning and emotional processing after the event, but it occurs after the client is safe and restraints are removed. It is not an action to be performed while the client is restrained.