Health Promotion and Maintenance
83. A client, who is gravida 2, para 1, is admitted to a birthing center. A nurse is using a Doppler to check fetal heart tones. The nurse finds fetal heart tones of 160 to 170 bpm. A vaginal examination reveals that the cervix is 4 cm dilated, with intact membranes and a –1 station. The nurse decides to apply an external fetal monitor rather than an internal monitor. Which is the best rationale for this decision?
. The cervix is closed.
. The membranes are still intact.
. The fetal heart tones are within normal limits.
. The contractions are intense enough for insertion of an internal monitor.
Test-Taking Tip
Think about the purpose of fetal monitoring and the difference between external and internal monitoring. The membranes must be ruptured to place an internal monitor. This client has intact membranes, so only an external monitor can be used on this client.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Health Promotion and Maintenance
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Answer 1 is incorrect because the cervix is 4 cm dilated, not closed. Answer 2 is correct because the nurse cannot artificially rupture the amniotic membranes in order to apply an internal fetal monitor. The only choice for continuous fetal monitoring is an external fetal monitor. Answer 3 is incorrect because the fetal heart tones show tachycardia, which is an indicator that continuous fetal monitoring is needed to ensure fetal well-being. Answer 4 is incorrect because, when the contractions are intense enough, there is no need for insertion of an internal monitor. The purpose of an internal uterine monitor is to ensure the strength of the contractions.