A nurse is caring for a woman who gave birth to a term infant an ...

[EAugust]

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.

Question 2

A nurse is caring for a patient with abruptio placentae. What assessment findings would indicate that the woman is hemodynamically stable?
 
  A.
  Fetal heart rate: 108 beats/minute
  B.
  Hematocrit: 33
  C.
  Oxygen saturation: 90
  D.
  Urine output: 20 mL/hour

[Tonny]

Answer to Question 1

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.

Answer to Question 2

ANS: B
Hemorrhage is a significant possibility with placental abruption. A hematocrit less than 30 is indicative of maternal hemodynamic stability; the presence of fetal bradycardia, maternal hypoxia, and urine output less than 30 mL/hour are indicative of an unstable state.