1.
Anatomically, the best position for the client
to assume is the squatting position because this
enhances pelvic diameters and allows gravity to
assist the expulsion stage of labor.
2. Contraindications to the procedure include
multiple gestation because of the potential for
fetal injury or uterine injury, severe
oligohydramnios, contraindications to a vaginal
birth, and unexplained third trimester bleeding.
3. Assessing for signs and symptoms associated
for cardiac decompensation is the priority. Class
III heart disease during pregnancy has a 25%-
50% mortality.
4. The obese pregnant client is more susceptible
to soft tissue dystocia, which can impede the
progress of labor. Symptoms of soft tissue
dystocia would include an arrest of labor,
prolonged labor, or an arrest of the descent of
the fetus.
5. An expression of tears is a normal reaction.
Cultural factors, exhaustion, and anxieties over
the new role can affect all maternal responses,
so the nurse must be sensitive to the client’s
emotional expressions.
6. The most reliable sign that the placenta has
detached from the uterine wall is lengthening of
the cold outside of the vagina. Other signs
include a change of the shape of the uterus
from discoid to globular and a sudden gush of
vaginal blood.
7. Light stroking of the skin, or effleurage, is
often used with the Lamaze method of
childbirth preparation.
8. To determine fetal lung maturity, the sample
of amniotic fluid will be tested for the L/S ratio.
When fetal lungs are mature, the ratio should
be 2:1.
9. According to the gate-control theory of pain,
a closed gate means that the client should feel
no pain. The gate-control theory of pain refers
to the gate-control mechanisms in the
substantia-gelatinosa that are capable of halting
an impulse at the level of the spinal cord so the
impulse is never perceived at the brain level as
pain.
10. The bladder status should be monitored
throughout the labour process, but especially
before the client begins pushing. A full bladder
can impede the progress of labour and may
result in injury to the client.
11. If the fetus is hypoxis, the pH will fall below
7.2 and be indicative of fetal distress. This
finding typically requires immediate vaginal or
caesarean delivery.
12. A small trickle of bright red vaginal bleeding
may indicate a laceration. The nurse should
notify the physician immediately of these
findings, because uterine atony may occur and
the laceration, if present, needs to be repaired
to prevent further blood loss.
13. A chill shortly after delivery is common and
normal occurrence. Warm blankets can help
provide comfort for the client. It has been
suggested that the shivering response is caused
by a difference between internal and external
body temperatures.
14. After an amniotomy, the nurse should plan
to first assess the fetal heart rate for 1 full
minute. One of the complications of amniotomy
is cord compression and/or prolapsed cord, and
a fetal heart rate of 100 bpm or less should be
promptly reported to the the physician.
15. Neonatal scalp edema is common after the
use of a vacuum extractor to assist the client’s
expulsion efforts. This edema may persist up to
7 days.
16. After spontaneous rupture of the amniotic
fluid, the gushing fluid may carry the umbilical
cord out of the birth canal. Sudden deceleration
of the fetal heart rate often signifies cord
compression and/or prolapsed of the cord,
which would require immediate delivery. This
client is particularly at risk because the fetus is
preterm and the fetal head may not be
engaged. Turning the client to the right side is
not a priority action. However, changing the
client’s position would be appropriate if
variable decelerations are present. The nurse
should assess the colour, amount, and odor of
the fluid, but this can be done once the fetal
heart rate is assessed and no problems are
detected. Cervical dilation should be checked
but only after the fetal heart rate pattern is
assessed.
17. A neonate in good condition needs to be
kept warm. This reduces cold stress and
potential respiratory problems. Cold stress
causes the neonate to burn much needed
brown fat. The infant can be evaluated under a
radiant warmer or wrapped in dry, warm
blankets on the mother’s abdomen.

18. Client’s who are pregnant with two or more

gestations are at greater risk for pregnancy
induced hypertension, hydramnios, placenta
previa, preterm labor and anemia. During
delivery, occasionally the placenta of the
second twin separates before that twin is
delivered, causing profound bleeding.

19. Neonates born to mothers who smoke tend

to have lower than average birth weights.
Maternal smoking is not related to higher
neonatal hyperirritability, hyperbilirubinemia,
or hypocalcemia.

20. Because delivery occurs so rapidly and the

fetus is propelled quickly through the birth
canal, the major complication of a precipitous
delivery is a boggy fundus or uterine atony. The
neonate should be put to breast, if the mother
permits, to allow for the release of natural
oxytocin.