A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?

A) Assist the client with range-of-motion exercises of the hands:
This task is appropriate for the assistive personnel (AP) as it is a routine, non-invasive intervention that can help maintain mobility and prevent contractures in the hands. The AP can assist with range-of-motion exercises, following proper technique, and reporting any abnormalities to the nurse. This falls within the AP's scope of practice and can be delegated to them effectively.

B) Determine the circulation status of the affected extremities every hr:
Assessing circulation is a nursing responsibility and requires clinical judgment to identify signs of impaired circulation, such as color changes, pulse, or temperature of the skin. This task cannot be delegated to an AP, as it requires a nurse’s skill to interpret findings and take appropriate action.

C) Instruct the client's family about the purpose of mitten restraints:
Educating the client's family about the use of mitten restraints is a responsibility of the nurse, not the AP. This involves assessing the family’s understanding, providing relevant information, and answering any questions they may have. Only licensed healthcare professionals are responsible for providing education about the purpose and use of restraints.

D) Evaluate the need for the client to remain in mitten restraints:
Evaluating the necessity of restraints involves assessing the client's condition, safety, and overall care needs. This requires critical thinking and professional judgment and should be performed by the nurse, not the AP. The nurse must determine if the restraints continue to be necessary or if they can be removed, ensuring the client’s safety and dignity.

A) "I will wash my baby’s head using a moist towelette": Using a moist towelette to wash a newborn’s head is not the best approach. Newborns should be bathed gently with warm water and mild soap, especially for sensitive areas like the scalp. A moist towelette could irritate the baby’s delicate skin or lead to unnecessary chemicals on the skin.

B) "I will give my baby a bath every day": Giving a newborn a bath every day is not typically necessary. Bathing a newborn 2-3 times per week is usually sufficient to keep the baby clean without drying out the skin. Daily baths can be too harsh on a newborn’s skin, especially in the first few weeks.

C) "I will bathe my baby under a faucet of running water": Bathing a newborn under running water can be dangerous, as it may be difficult to control the temperature of the water or the baby could be at risk of slipping. It is safer to use a basin of warm water and a soft washcloth to gently bathe the baby.

D) "I will wash my baby's face with a warm, wet washcloth without soap": This is the correct and safe approach to washing a newborn’s face. Newborns have very sensitive skin, and it’s best to wash the face with just warm water and a soft washcloth to avoid irritation. Using soap on the face may dry out or irritate their delicate skin.