A nurse is collecting data from an infant who has a large patent ductus arteriosus. Which of the following is clinical manifestations should the nurse expect?

A. Wrist: Wrist restraints are typically used to prevent older children or adults from pulling at medical devices or dressings. For an infant, wrist restraints can be too harsh and restrictive. They do not prevent the child from bending their arms, which could allow them to reach their face and potentially disrupt the surgical site.

B. Mummy: A mummy restraint involves wrapping the infant’s body tightly with a blanket to restrict movement, typically used for short periods during medical procedures to keep the child still. This type of restraint is too restrictive for postoperative care and does not allow any movement of the arms, making it uncomfortable and unsuitable for continuous use over extended periods.

C. Elbow: Elbow restraints, also known as no-no’s, are designed to prevent the infant from bending their arms. This type of restraint keeps the elbows straight, preventing the child from touching their face and disrupting the surgical site of the cleft lip and palate. It is effective in allowing the infant to move their arms while ensuring that they cannot interfere with the healing area. This method is less restrictive and more humane for postoperative care in an infant.

D. Jacket: Jacket restraints are used to secure the torso, usually to prevent a child from moving out of bed or a chair. This type of restraint is more restrictive and not specific to preventing arm movement. For an infant recovering from cleft lip and palate surgery, jacket restraints would not effectively prevent the child from reaching their face, and they can be excessively confining and distressing for an infant.

A. "I will notify the doctor if his temperature is not controlled with acetaminophen." Notifying the doctor if the temperature is not controlled with acetaminophen is appropriate, as persistent fever might indicate a more severe infection or other complications.

B. "I will continue to check his blood sugar two times every day." Checking blood sugar only twice a day is insufficient during illness, especially for a child with type 1 diabetes. Blood glucose levels can fluctuate significantly due to infection, and more frequent monitoring (at least 4 times a day or as recommended) is necessary.

C. "I will report changes in breathing or signs of confusion." Reporting changes in breathing or signs of confusion is essential, as these can be signs of worsening infection, respiratory distress, or diabetic ketoacidosis, which requires immediate medical attention.

D. "I will encourage him to drink a half a cup of water or sugar-free fluid every 30 minutes." Encouraging fluid intake is important to prevent dehydration and help manage blood glucose levels during illness. Ensuring adequate hydration with water or sugar-free fluids is appropriate.