A nurse is assisting with the care of a client who is verbalizing their desire for natural family planning as a method of contraception. Which of the following responses should the nurse make?

A. Changing a sterile dressing for a client who is postoperative: Changing a sterile dressing requires the use of sterile technique and nursing judgment, making it a task that must be performed by a licensed nurse, not delegated to assistive personnel.

B. Performing a gastrostomy feeding on a stable client: While assistive personnel can assist with feeding in general, administering a gastrostomy feeding requires specific assessment and verification of tube placement, which must be done by a licensed nurse.

C. Observing the patency of an intravenous catheter on a stable client: Observing and assessing IV catheter patency is a nursing responsibility. It requires assessment skills and cannot be delegated to assistive personnel.

D. Providing postmortem care to a client: Providing postmortem care, such as bathing, positioning, and preparing the body, is a task that can be safely delegated to assistive personnel, following proper facility protocols and respectful handling of the deceased.

• Lung assessment: The client's lungs are clear bilaterally with no signs of respiratory distress or abnormal breath sounds. There is no indication of pulmonary complications, so no further immediate action is needed regarding the lung assessment.
• Vertigo: Vertigo is a common complication following a stapedectomy due to disturbance of the inner ear structures. However, it still requires monitoring because severe or worsening vertigo can increase the risk of falls and indicate inner ear trauma or dysfunction.
• Facial nerve assessment: The presence of left facial droop and asymmetrical smile indicates possible injury to the facial nerve during surgery. This finding is abnormal and requires immediate provider notification for further neurological evaluation and management.
• Pain rating: A pain rating of 5 out of 10 is moderate and, following ear surgery, it should be addressed. Proper pain control is important not only for comfort but also to reduce the risk of increased intracranial pressure from straining or agitation.
• Diminished hearing: Some decrease in hearing can occur temporarily after a stapedectomy due to packing or swelling, but it still needs further monitoring. Persistent or worsening hearing loss could suggest a surgical complication, such as prosthesis dislocation.
• Pupils: The pupils are equal, smaller postoperatively but still reactive to light, which is expected following anesthesia and is not concerning. No immediate intervention is necessary based on pupil assessment findings.