The nurse is caring for a client during a prolonged second stage of labor.

The nurse observes that the fetal head retracts against the client's perineum immediately following the delivery of the head, known as the turtle sign.

Which of the following actions will the nurse anticipate in this situation?

The scenario requires an understanding of obstetric assessment and monitoring. Knowledge of prenatal diagnostics, physical assessment techniques for neurological and gestational health, and laboratory screening for infection or metabolic changes is necessary to identify appropriate nursing interventions within a comprehensive care plan.

Choice A rationale

Glucose tolerance tests screen for gestational diabetes mellitus by measuring blood glucose response to sugar loads. Normal fasting glucose is < 95 mg/dL. This monitors metabolic status and prevents maternal or neonatal complications during the pregnancy.

Choice B rationale

Assessing deep tendon reflexes evaluates neuromuscular irritability. It is crucial for clients at risk of preeclampsia or those receiving magnesium sulfate. Normal reflexes are 2+. Abnormal findings can indicate impending seizures or magnesium toxicity.

Choice C rationale

The non-stress test monitors fetal heart rate patterns in response to fetal movement. A reactive test shows two or more accelerations in twenty minutes. This non-invasive procedure assesses fetal well being and placental oxygenation.

Choice D rationale

A complete blood count monitors hemoglobin and hematocrit levels to detect anemia. Normal hemoglobin in pregnancy is > 11 g/dL. It also assesses white blood cell counts for infection and platelets for clotting disorders.

Choice E rationale

Vaginal examinations determine cervical dilation, effacement, and fetal station during labor. This assessment helps the nurse track labor progression. It is also used to evaluate for the rupture of membranes or presence of vaginal bleeding.

Choice F rationale

Urine dipsticks screen for proteinuria, glycosuria, and ketones. Proteinuria ≥ 1+ can indicate preeclampsia. Glucose in the urine may suggest diabetes. This bedside test provides immediate data regarding the client's renal and metabolic status.

Priority assessment in obstetrics focuses on fetal well-being and identifying life-threatening complications. Clinical knowledge regarding fetal kick counts and placental perfusion must be applied to differentiate between normal physiological changes of pregnancy and signs of impending fetal compromise or demise.

Choice A rationale

Back pain is a common discomfort in pregnancy caused by shifts in the center of gravity and lumbar lordosis. While uncomfortable, it is not a priority finding compared to indicators of direct fetal distress or placental issues.

Choice B rationale

Decreased fetal movement is a critical sign of potential fetal hypoxia or distress. Fetal activity typically remains consistent, and a quiet baby requires immediate assessment via non-stress testing or ultrasound to ensure the fetus is still viable.

Choice C rationale

Varicosities in the lower extremities are common due to increased venous pressure from the enlarging uterus. While they require management like compression stockings, they do not pose an immediate threat to the life of the mother or fetus.

Choice D rationale

Increased fundal height can indicate polyhydramnios or macrosomia but is generally assessed over time. It does not carry the same immediate urgency as a sudden change in fetal movement, which suggests an acute oxygenation problem.