A community health nurse is performing a home visit for a client and is evaluating the home environment for safety. Which of the following findings would indicate to the nurse that the client has a proper understanding of safety in the home?

A single light fixture hangs along the sidewalk to the house.

A small area rug is placed at the front door.

The batteries in the smoke alarms are changed annually.

The water heater is set at 54° C (129.2° F).

Answer and Explanation

The Correct Answer is D

Rationale:
A. A single light fixture hangs along the sidewalk to the house: Proper home safety requires adequate lighting to prevent falls, particularly along walkways. A single light fixture may not provide sufficient illumination and poses a risk.

B. A small area rug is placed at the front door: Loose rugs increase the risk of slips and falls. Safe home practices include securing rugs with nonslip backing or removing them entirely.

C. The batteries in the smoke alarms are changed annually: Smoke alarm batteries should be checked and replaced more frequently, typically every 6 months, to ensure proper function. Annual replacement alone may not be sufficient.

D. The water heater is set at 54° C (129.2° F): Setting the water heater at or below 54° C helps prevent scald injuries while providing adequate hot water. This demonstrates the client’s understanding of home safety measures.

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Correct Answer is ["C","D"]

Explanation

Rationale for Correct Choices

• Intravenous antibiotic: The client shows classic signs of postpartum endometritis, including fever, uterine tenderness, boggy fundus, and foul-smelling lochia. IV antibiotics are the primary treatment to target the uterine infection and prevent progression or sepsis.

• Increase in daily fluid intake: Adequate hydration supports circulation, helps maintain uterine tone, and assists in reducing the risk of complications such as hypotension or dehydration from infection. Fluids also support antibiotic therapy by promoting renal clearance and overall recovery.

Rationale for Incorrect Choices

• Kleihauer-Betke test: This test identifies fetal-to-maternal hemorrhage, which is not indicated here because the client’s hemoglobin is stable and there is no evidence of significant postpartum hemorrhage.

• Tocolytic medication: Tocolytics are used to suppress preterm labor, which is irrelevant for this postpartum client whose uterus has already delivered the fetus.

• Intrauterine tamponade balloon: This intervention is used for severe postpartum hemorrhage to mechanically control bleeding. The client’s bleeding is moderate and the uterus is firm after massage, so this is not indicated at this time.

A. Discourage the client from allowing friends to see the newborn. B. Offer to take pictures of the newborn for the client. C. Assure the client that she can have additional children. D. Avoid talking to the client about the newborn.

Correct Answer is B

Explanation

Rationale:
A. Discourage the client from allowing friends to see the newborn: Restricting contact can hinder the grieving process. Allowing the client and close family or friends to see and hold the baby can help them acknowledge the loss, express emotions, and begin healthy mourning.

B. Offer to take pictures of the newborn for the client: Offering photographs provides the family with tangible memories that can support the grieving and healing process. Many parents later find comfort in having keepsakes, even if they initially decline them.

C. Assure the client that she can have additional children: Statements about future pregnancies minimize the client’s current grief and loss. The nurse should focus on supporting the client’s emotional needs in the present rather than redirecting attention.

D. Avoid talking to the client about the newborn: Avoiding discussion invalidates the client’s feelings and may intensify emotional isolation. Talking about the newborn by name, if known, acknowledges the baby’s existence and validates the parents’ grief, which is essential for emotional healing.

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A community health nurse is performing a home visit for a client and is evaluating the home environment for safety. Which of the following findings would indicate to the nurse that the client has a proper understanding of safety in the home?

Nursing Test Bank

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