A nurse is caring for a 4-year-old child who has dehydration. Which of the following findings should the nurse identify as the priority?

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. "Your newborn will receive the first DTaP vaccine during the initial well-baby visit.": The first dose of DTaP is typically given at 2 months, not at the newborn stage.

B. "Your newborn should receive an immunization for MMR at 6 months.": The MMR vaccine is usually administered at 12-15 months, not at 6 months.

C. "Your newborn is scheduled to have a hepatitis B vaccine prior to discharge.": Hepatitis B vaccine is recommended to be given within 24 hours of birth as the first dose of a series.

D. "Your newborn should receive the PCV vaccine two times prior to his first birthday.": The pneumococcal conjugate vaccine (PCV) schedule starts at 2 months with multiple doses, but not specifically "two times" before the first birthday.