A nurse manager is updating protocols for the use of belt restraints.
Which of the following guidelines should the nurse manager include?

Request a PRN restraint prescription for clients who are aggressive.

Document the client's condition every 15 min.

Attach the restraint to the bed's side rails.

Remove the client's restraint every 4 hr.

Answer and Explanation

The Correct Answer is B

Answer is: b. Document the client's condition every 15 min.

Explanation: The nurse manager should include the guideline to document the client's condition every 15 minutes while using belt restraints. This is to ensure close monitoring of the client's physical and psychological well-being and to evaluate the ongoing need for restraint use.

Choice a. is wrong because requesting a PRN restraint prescription for clients who are aggressive might not be appropriate. The use of restraints should be based on a thorough assessment of the client's condition and should be the least restrictive method possible.

Choice c. is wrong because attaching the restraint to the bed's side rails poses a safety risk to the client, as the side rails can be lowered accidentally or intentionally, leading to potential injury.

Choice d. is wrong because removing the client's restraint every 4 hours might not be appropriate, as it depends on the client's specific needs, facility policies, and state regulations. The nurse should follow appropriate guidelines for removing restraints and reassess the client's need for continued restraint use.

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Correct Answer is D

Explanation

Choice A rationale:

Maintaining eye contact with the newborn during feedings is a general caregiving practice and is not specific to managing neonatal abstinence syndrome. While eye contact and bonding are important for newborns, it does not address the symptoms of neonatal abstinence syndrome.

Choice B rationale:

Swaddling the newborn with his legs extended is not a specific action for managing neonatal abstinence syndrome. However, swaddling can provide comfort to some infants, but the positioning of the legs is not directly related to managing symptoms of withdrawal.

Choice C rationale:

Administering naloxone to the newborn is not a standard practice for managing neonatal abstinence syndrome. Naloxone is an opioid antagonist used to reverse opioid overdose in adults and is not typically used in newborns unless there are specific indications, which are rare.

A. Maternal hypoglycemia. B. Fetal anemia. C. Chorioamnionitis. D. Maternal fever.

Correct Answer is A

Explanation

The correct answer is choice a. Maternal hypoglycemia.

Choice A rationale:

Maternal hypoglycemia can lead to decreased glucose availability for the fetus, which can result in fetal bradycardia due to reduced energy supply.

Choice B rationale:

Fetal anemia typically causes fetal tachycardia rather than bradycardia, as the fetus compensates for the lack of oxygen-carrying capacity by increasing the heart rate.

Choice C rationale:

Chorioamnionitis, an infection of the fetal membranes, usually causes fetal tachycardia due to the inflammatory response and fever.

Choice D rationale:

Maternal fever is more likely to cause fetal tachycardia rather than bradycardia, as the increased maternal temperature can lead to an increased fetal heart rate.

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A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

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A nurse manager is updating protocols for the use of belt restraints.
Which of the following guidelines should the nurse manager include?