A nurse is caring for a woman who gave birth to a term infant an hour ago. The chart notes that the ...

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.