A nurse is caring for a client who is 39 weeks gestation and in active labor.
Your assessment findings reveal G1P0, BMI of 41, and completely dilated.
The nurse observes a turtle sign after the head has delivered.
What is the priority action by the nurse?

The newborn most likely has Brachial plexus injury (B) as evidenced by Left arm remains at the side during Moro reflex (B).

Choice A rationale:

Congenital cardiac defect is less likely since the newborn has a normal heart rate and oxygen saturation. There are no signs of respiratory distress beyond mild acrocyanosis, which is common in newborns and usually resolves without intervention.

Choice B rationale:

Brachial plexus injury is suggested by the newborn's inability to move the left arm during the Moro reflex. This type of injury is often associated with shoulder dystocia and vacuum-assisted delivery, which can stretch or damage the brachial plexus nerves.

Choice C rationale:

Fractured clavicle could be a possibility due to the shoulder dystocia, but it is less likely given that the only noted abnormal finding is the lack of movement in the left arm. Typically, a fractured clavicle would present with crepitus, swelling, or a palpable fracture.

Choice D rationale:

Neonatal sepsis is less likely as the newborn appears to be active, has a normal temperature, and no signs of systemic infection. The only abnormal findings are related to the left arm movement and caput succedaneum, which are more consistent with a birth injury rather than an infection.

D.

Choice A rationale

Initiating an IV fluid bolus is a common intervention in labor, particularly if there are signs of maternal hypotension or fetal distress. However, it may not be the priority action in every situation, and the decision should be based on the specific clinical context.

Choice B rationale

Discontinuing oxytocin infusion is crucial if there are signs of fetal distress, uterine hyperstimulation, or tachysystole. Oxytocin, while useful for inducing and augmenting labor, can sometimes lead to excessive uterine contractions that compromise fetal oxygenation.

Choice C rationale

Notifying the provider is essential when any complication or unexpected situation arises during labor. The provider needs to be informed to make timely decisions regarding the management of labor and ensure the safety of both mother and baby.

Choice D rationale

Repositioning the client to a lateral position can improve uteroplacental blood flow and enhance fetal oxygenation. This simple intervention can be particularly beneficial if there are concerns about fetal heart rate patterns.

Choice E rationale

Titrating oxytocin infusion to 8 mu/min per order is an appropriate intervention if the goal is to maintain adequate uterine contractions. However, if there are signs of fetal or maternal distress, this action should be reconsidered.