A nurse is collecting data from a client who has diabetic ketoacidosis.
Which of the following findings should the nurse expect?

The correct answer is a. Plan to remove the restraints as soon as the client is calm.

Choice A reason: The primary goal after applying restraints is to ensure the safety of the client and others. Once the client is calm, planning for the removal of restraints is essential to maintain the client’s dignity and to adhere to ethical standards of minimizing restraint use.

Choice B reason: While offering snacks is part of general care, it is not specifically related to the immediate action required following the application of restraints. Nutritional needs should be addressed, but they do not take precedence over the assessment and potential removal of restraints.

Choice C reason: Ensuring that a prescription for restraints is signed within 48 hours is a legal requirement, but it is not the immediate action to be taken following the application of restraints. The focus should be on the client’s current state and reassessing the need for continued restraint.

Choice D reason: Monitoring the client’s range of motion every 60 minutes is important to prevent complications from restraint, such as contractures or muscle atrophy. However, this is secondary to the immediate reassessment of the need for restraint and planning for its removal as soon as the client is calm.

The correct answer is: a. Remove bibs when the infant is going to sleep.

Choice A reason: Removing bibs when an infant is going to sleep is a critical safety measure to prevent suffocation and strangulation risks. Infants should have a sleep environment free of any loose objects that could cover their face and interfere with breathing. The American Academy of Pediatrics recommends keeping the crib clear of items like bibs, pillows, blankets, and toys to reduce the risk of Sudden Infant Death Syndrome (SIDS) and other sleep-related infant deaths.

Choice B reason: Using a highchair for feedings is not recommended for a 3-month-old infant because they typically cannot sit up unsupported at this age. Highchairs are generally used when an infant can sit up well without support and has good head control, usually around 6 months old. Until then, infants should be held or placed in an appropriate reclined feeding position.

Choice C reason: A soft crib mattress is not advisable for infants. A firm mattress is essential to provide a safe sleep surface. Soft mattresses and other soft surfaces increase the risk of SIDS and suffocation because they can create pockets that may cause an infant’s face to sink in and restrict breathing.

Choice D reason: Placing pillows in the crib, even one small pillow, is unsafe for infants. Pillows can pose a suffocation hazard and increase the risk of SIDS. The crib should be kept bare, with only a firm mattress and a fitted sheet, to ensure a safe sleep environment for the infant.