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
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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Related Questions
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.
Correct Answer is A
Explanation
A. Erb-Duchenne palsy involves injury to the upper brachial plexus, resulting in weakness or paralysis of the affected arm and an absent Moro reflex on that side.
B. Cleft palate is unrelated to Erb-Duchenne palsy.
C. The Babinski reflex is a neurological test of the lower limbs and is not affected by this condition.
D. Difficulty sucking and swallowing is not typical of Erb-Duchenne palsy but may be related to other cranial nerve injuries.
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