A nurse is speaking with a client who called the provider's office to report chest pain and requests clarification about how to take their sublingual nitroglycerin. Which of the following statements should the nurse make?

A. "My baby has a yellowish layer covering their circumcision.": A thin yellow exudate on a circumcision site is a normal part of the healing process and represents the formation of a protective scab. It is not a sign of infection and does not require immediate reporting to the provider.

B. "My baby has crusty drainage in both eyes.": Bilateral eye crusting in a newborn may indicate conjunctivitis, which can be bacterial or viral and requires prompt evaluation. Newborn conjunctivitis can progress rapidly and may lead to complications if untreated, so the nurse should report this finding to the provider for timely intervention.

C. "My baby has loose stools that are greenish-yellow.": Loose, greenish-yellow stools are common in breastfed newborns due to the digestibility of breast milk and normal meconium transition. This finding is expected and does not indicate pathology.

D. "My baby's umbilical cord is still attached.": The umbilical cord typically detaches between 1–3 weeks of age. At 3 days old, it is normal for the cord to remain attached and requires only routine care and monitoring for signs of infection.

A. Plan of care: The plan of care is developed and updated by licensed nursing staff and other providers. Assistive personnel (AP) are not authorized to document assessments, interventions, or changes in the plan of care, as this requires professional judgment and accountability.

B. Graphic record: APs can document routine, objective data such as vital signs, intake and output, and other measurable observations in the graphic or flow sheet section of the EHR. This allows for accurate tracking of trends while remaining within their scope of practice.

C. Nurses' notes: Nurses’ notes require professional assessment, analysis, and evaluation of client responses to care. APs do not have the licensure to make these judgments, so they should not document in this section.

D. Discharge teaching: Documentation of discharge teaching reflects the nurse’s evaluation of client understanding and education provided, which is a licensed nursing responsibility. APs can reinforce teaching but are not authorized to document it as part of the official discharge record.