A nurse is caring for a woman who gave birth to a term infant an hour ago. The chart notes that the baby was born after demonstrating a positive turtle sign. What assessment finding by the nurse warrants immediate action?
A.
Lochia rubra is noted an hour after birth.
B.
Maternal blood pressure is 90/42 mm Hg.
C.
Maternal heart rate is 68 beats/minute.
D.
Patient saturates one perineal pad in 2 hours.
ANS: B
A turtle sign describes a situation where the fetal head retracts during contractions after crowning. This is a clinical indicator of possible shoulder dystocia. Maternal complications of shoulder dystocia include hemorrhage and soft tissue trauma. A blood pressure as low as this woman's blood pressure measurement could be an indicator of hemorrhage, and the nurse needs to assess the woman further. The finding of lochia rubra 1 hour after birth is normal, as is a maternal heart rate of 68 beats/ minute. The finding of one saturated perineal pad within 2 hours is also normal.
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