A nurse is assisting in the care of a client.

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

A. Poor feeding: Newborns experiencing neonatal abstinence syndrome (NAS) often have neurologic irritability and gastrointestinal dysfunction caused by withdrawal from in utero exposure to opioids or other substances. Poor feeding, along with vomiting, diarrhea, and excessive sucking, is a common manifestation.

B. Weak cry: Infants with NAS typically have a high-pitched, shrill, or incessant cry due to central nervous system hyperactivity. A weak or soft cry is not characteristic and may suggest other neurologic conditions rather than withdrawal.

C. Hypotonia: NAS usually presents with hypertonia, jitteriness, and tremors. Hypotonia is not a typical finding; decreased muscle tone may indicate a different neurologic or metabolic disorder.

D. Absent Moro reflex: The Moro reflex is generally intact or exaggerated in infants with NAS because of increased neuromuscular irritability. An absent reflex is more consistent with severe neurologic impairment rather than substance withdrawal.

A. Position the seat of the wheelchair at a right angle to the bed: Proper wheelchair positioning is important to facilitate a safe pivot transfer and reduce the distance the client must move. However, ensuring environmental safety by stabilizing equipment must occur before positioning. The wheelchair can be placed correctly after confirming both surfaces are secure.

B. Lock the wheels on the bed: Safety is the priority before initiating any transfer. Locking the wheels on the bed prevents unintended movement that could result in loss of balance or falls, particularly in a client with unilateral weakness. Stabilizing the bed establishes a secure foundation prior to assisting the client to sit or stand.

C. Have the client sit at the edge of the bed: Dangling at the bedside allows assessment for orthostatic hypotension and balance, but this step should occur only after ensuring the bed is secure. Assisting the client to sit before locking the wheels increases fall risk if the bed shifts.

D. Place a gait belt around the client's waist: A gait belt enhances stability and control during transfer, especially for a client with left-sided weakness. However, it is applied after environmental safety measures, such as locking the bed and wheelchair, are completed.