A charge nurse in a newborn nursery is providing information to a group of nurses about risk factors for hypoglycemia. Which of the following risk factors should the charge nurse include? (Select all that apply)

Choice A reason: Using a cane provides stability and reduces fall risk for clients with multiple sclerosis, who often experience muscle weakness or balance issues. This assistive device promotes safe mobility, aligning with evidence-based safety strategies, making it the correct precaution for home care.
Choice B reason: Walking with feet close together decreases stability, increasing fall risk in multiple sclerosis due to impaired coordination. A wider stance is recommended for balance, making this precaution incorrect and potentially dangerous for the client’s safety.
Choice C reason: Avoiding orthotics is not advisable, as they can support mobility and prevent foot drop in multiple sclerosis. Orthotics improve safety and function, so discouraging their use is counterproductive, making this an incorrect recommendation for home safety.
Choice D reason: A rigorous range-of-motion exercise plan may cause fatigue or injury in multiple sclerosis, where moderated exercise is preferred. Overexertion exacerbates symptoms, so this plan is unsafe and inappropriate, making it incorrect for promoting client safety.

Choice A reason: Removing restraints immediately risks safety, as the client’s calm state may not be sustained. Restraints require gradual removal after ensuring sustained behavioral stability, per facility policy and safety standards. Frequent monitoring is needed to assess ongoing safety, making this action premature and potentially unsafe.
Choice B reason: Encouraging group therapy is inappropriate while the client remains in restraints, as it does not address the immediate need to evaluate their behavior for safe restraint removal. Therapy may be beneficial later, but ongoing monitoring is the priority to ensure safety and compliance with restraint protocols.
Choice C reason: Continuing to monitor the client every 15 minutes ensures safety while assessing sustained calm and cooperative behavior. This adheres to restraint protocols, which require frequent checks to evaluate the need for continued restraint, prevent complications, and plan for safe removal, making it the correct action.
Choice D reason: Administering a sedative to maintain calm behavior is inappropriate without a current medical order or ongoing aggression. Sedatives carry risks like oversedation or respiratory depression. Monitoring the client’s behavior is the priority to determine if restraints can be safely discontinued, making this action unnecessary and potentially harmful.