A 5-month-old girl’s arms are encased in elbow restraints following facial surgery. Which of the following situations would warrant removal of the restraints?

Narcotic medication has been administered, and the child’s pain rating has dropped.

Infant has been put to sleep for the night in her crib lying on her back.

The infant’s hands are pink with spontaneous movement and capillary refill of two seconds.

A responsible adult is holding the baby and preventing her from touching the operative site.

Answer and Explanation

The Correct Answer is B

Elbow restraints are commonly used in infants after facial or cleft palate surgery to prevent them from touching or disrupting the operative site. However, restraints should never be used continuously; they must be removed periodically to allow for skin checks, circulation assessment, range of motion, and bonding with caregivers.

Rationale for correct answer:

D. The purpose of elbow restraints after facial surgery (e.g., cleft lip/palate repair) is to prevent the infant from touching or disrupting the operative site. Restraints should only be used when necessary, and they should be removed when a responsible adult can directly supervise and protect the child. This reduces risk of complications while allowing the infant comfort, mobility, and bonding time.

Rationale for incorrect answers:

A. Pain relief does not eliminate the risk of the infant reaching for or rubbing the operative site. Restraints are still necessary unless directly supervised.

B. Even while asleep, infants may reflexively move their hands to their mouth or face, risking injury to the surgical site. Restraints must remain in place if the infant is unsupervised.

C. The infant’s hands being pink with spontaneous movement and capillary refill of two seconds indicates good circulation and neurovascular status, which is important to monitor while restraints are on, but it is not a reason for removal.

Take home points

Elbow restraints are used post-facial surgery to protect the operative site.
They should be removed only when a responsible adult is directly supervising the infant and preventing self-injury.
Nurses must perform regular neurovascular checks (color, warmth, movement, sensation, cap refill) to ensure restraint safety.
Restraints should be used as minimally as possible and alternated with supervised periods of freedom to promote comfort and bonding.

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Correct Answer is C

Explanation

Pain control post-surgery refers to the strategies and treatments used to manage discomfort and promote healing after a surgical procedure. It’s a critical part of recovery that affects mobility, emotional well-being, and risk of complications.

Rationale for correct answer:

C. Administering morphine to the child based on the child’s rating of the pain is correct. The gold standard for pain assessment is the child’s self-report, as long as the child is developmentally capable of using a numeric pain scale (which an 8-year-old is). Even though the child appears to be playing, this does not negate the reported pain score. Children can sometimes distract themselves with play but still experience significant pain.

Rationale for incorrect answers:

A. Reporting the child’s pain level to the child’s primary health-care provider is not necessary at this point. The provider has already prescribed pain medications, and the nurse has the autonomy to administer them according to the child’s needs.

B. Administering acetaminophen to the child based on the child’s behavior undermines the child’s self-report. Behavior (playing) is not always a reliable indicator of pain severity. Acetaminophen alone would likely be insufficient for reported severe pain.

D. Querying the child about how the child is able to play with such severe pain could make the child feel disbelieved or dismissed. Nurses should validate, not question, the child’s reported pain level.

Take home points

Self-report is the most reliable indicator of pain in children who can use numeric or other validated pain scales.
Children may still engage in play despite experiencing significant pain.
Nurses should trust the child’s pain rating and treat accordingly.
Opioids like morphine are indicated for severe postoperative pain, while acetaminophen may be used for mild pain or as part of multimodal therapy.

A. Read a book to the child. B. Hold and cuddle with the child. C. Put an ice pack on the child’s knee. D. Have the child watch a favorite program on television. E. Perform passive range of motion exercises on the injured knee.

Correct Answer is ["A","B","C","D"]

Explanation

Nonpharmacological pain interventions in children are non-drug strategies used to reduce pain, anxiety, and distress, especially during medical procedures or recovery. These approaches are developmentally tailored, often family-centered, and can be just as powerful as medications when used appropriately.

Rationale for correct answers:

A. Distraction through storytelling and reading a book to the child engages the child’s attention and helps divert focus away from pain.

B. Comforting touch and physical closeness such as cuddling provide security and reduce anxiety, which enhances pain relief.

C. Cold therapy reduces inflammation, numbs pain, and is an appropriate adjunct for musculoskeletal injuries in children.

D. Distraction via television provides sensory engagement, diverting attention from pain and supporting the pharmacological intervention.

Rationale for incorrect answer:

E. Performing passive range of motion exercises on the injured knee is inappropriate during acute injury and pain because it can worsen pain, aggravate tissue damage, and delay healing. Movement should only be initiated when prescribed during rehabilitation, not as an immediate comfort measure.

Take home points

Nonpharmacological pain interventions for children include distraction (books, TV, play), comfort (cuddling, holding), and physical measures (ice/heat as appropriate).
These interventions are adjuncts to medication and can reduce the required analgesic dose.
Avoid interventions that exacerbate pain or cause harm, such as unnecessary movement of the injured area.
Combining pharmacological and nonpharmacological approaches is best practice in pediatric pain management.

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A 5-month-old girl’s arms are encased in elbow restraints following facial surgery. Which of the following situations would warrant removal of the restraints?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

To enhance the effectiveness of the pharmacological pain intervention administered to a 4-year-old child with an injured knee, the nurse plans to add a nonpharmacological pain intervention. Which of the following actions would be appropriate for the nurse to perform? Select all that apply

Correct Answer is ["A","B","C","D"]

Explanation

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