A nurse is caring for a full term client in labor who is prescribed continuous fetal monitoring. On examination, the nurse determines the client's membranes are intact. Which of the following assessment methods should the nurse implement?

Transvaginal fetal Doppler probe

External ultrasound transducer monitor

DeLee Hillis fetoscope

Internal fetal scalp electrode

Answer and Explanation

The Correct Answer is B

A. A transvaginal fetal Doppler is not commonly used for continuous monitoring and is typically reserved for early pregnancy.
B. An external ultrasound transducer is appropriate for continuous fetal monitoring when the membranes are intact. It is noninvasive and safe for use during labor.
C. A DeLee Hillis fetoscope is used for intermittent auscultation, not continuous monitoring.
D. An internal fetal scalp electrode requires ruptured membranes and cervical dilation; it is contraindicated with intact membranes.

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Correct Answer is C

Explanation

A. The vacuum cup is positioned on the fetal head, over the flexion point, not in front of the ears.
B. Continuous fetal monitoring should be maintained during vacuum-assisted delivery.
C. The nurse should encourage the client to push during contractions to assist with the delivery.
D. A full bladder can obstruct delivery; the bladder should be emptied prior to the procedure.

A. Assess for cervical dilation. B. Obtain a vaginal swab to test for ferning C. Administer oxytocin IV every hour D. Monitor fetal heart rate tracings

Correct Answer is D

Explanation

A. Assessing cervical dilation is contraindicated due to risk of worsening bleeding with abruptio placenta.
B. Vaginal swabs for ferning test are used to assess rupture of membranes, not abruptio placenta.
C. Administering oxytocin can increase uterine contractions and worsen placental separation, so it is contraindicated.
D. Monitoring fetal heart rate tracings is essential to assess fetal well-being in cases of abruptio placenta.

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A nurse is caring for a full term client in labor who is prescribed continuous fetal monitoring. On examination, the nurse determines the client's membranes are intact. Which of the following assessment methods should the nurse implement?

Nursing Test Bank

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