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?

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Quizplus · Accepted Answer

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.

A Nurse Is Caring for a Woman Who Gave Birth