A nurse is caring for a client who is at 14 weeks of gestation. Which of the following statements should the nurse identify as the client being emotionally prepared for pregnancy?

A. "I will wipe away yellow crusts that form around the incision." Yellow crusting at the incision site is a normal part of the healing process. It should not be wiped away, as doing so could disrupt healing and cause irritation or bleeding. Instead, the area should be kept clean and allowed to heal naturally.
B. "I will apply antibiotic ointment to my baby's penis." The Plastibell technique does not require the application of antibiotic ointment. Unlike other circumcision methods, the Plastibell ring remains in place and falls off on its own within 5 to 8 days, reducing the need for additional topical treatments.
C. "I will make sure that my baby's diaper is applied snugly." The diaper should be applied loosely to prevent excessive pressure or friction on the healing area. A snug diaper can cause discomfort and increase irritation, potentially delaying healing.
D. "I will apply pressure with gauze if I see bleeding." Minor bleeding may occur after circumcision, and applying gentle pressure with sterile gauze is the appropriate action to control it. If bleeding persists beyond a few minutes or is excessive, medical attention should be sought immediately.

A. Evaluate the need for the client to remain in mitten restraints. Assessing the necessity of restraints is a nursing responsibility that requires clinical judgment. Nurses must evaluate the client's condition and determine if restraints can be discontinued or if alternative measures are appropriate.
B. Assist the client with range-of-motion exercises of the hands. Assistive personnel (AP) can perform tasks that promote mobility, such as passive or active range-of-motion exercises. These exercises help prevent stiffness and maintain circulation in restrained extremities.
C. Determine the circulation status of the affected extremities every 2 hr. Assessing circulation involves evaluating capillary refill, skin color, temperature, and sensation, which requires nursing assessment skills. This task should be performed by a nurse rather than delegated to an AP.
D. Instruct the client's family about the purpose of mitten restraints. Educating the family on medical interventions falls within the nurse’s scope of practice. The nurse must explain the rationale, risks, and alternatives to ensure family members understand the need for restraints.