A nurse is reinforcing teaching with a client who has a new diagnosis of myasthenia gravis (MG) and a prescription for neostigmine. Which of the following information should the nurse include about the action of the medication?

A. A client who has cellulitis and is receiving oral antibiotics every 8 hr has a mild to moderate infection that can be managed at home with proper wound care and medication adherence. The client does not require hospitalization unless there are signs of systemic infection or complications.

B. A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex has a high risk of aspiration and airway obstruction due to impaired swallowing function. The client requires close monitoring and intervention until the gag reflex returns, which can take several hours or longer depending on the type and amount of anesthesia used.

C. A mother and their newborn 12 hr postdelivery have not completed the minimum recommended stay of 24 to 48 hours for uncomplicated vaginal deliveries or 72 to 96 hours for cesarean deliveries, according to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The mother and their newborn require assessment, education, support, and follow-up care to ensure their health and well-being.

D. A client who has lower extremity weakness and is newly admitted for observation has an undiagnosed condition that could indicate a serious neurological or vascular problem, such as stroke, spinal cord injury, or peripheral artery disease. The client requires diagnostic testing, evaluation, treatment, and rehabilitation to prevent further deterioration or complications.

- A. Discussing the suspicion of physical abuse with the provider is the appropriate action for the nurse to take. However, this should be done after the matter is reported to child protection services.

- B. Confronting the parents with the suspicion of physical abuse is not an appropriate action for the nurse to take, as it can escalate the situation and endanger the child or the nurse.

- C. Asking the hospital security to detain and question the parents is not an appropriate action for the nurse to take, as it violates the parents' rights and may interfere with the legal process.

- D.Contacting Child Protective Services is appropriate action for the nurse to take at this point as it is the nurse's legal responsibility to do so.