The client at 39 weeks' gestation is undergoing a cesarean birth due to breech presentation. General anesthesia is being used. Which situation requires immediate intervention?

1. The baby's hands and feet are blue at 1 minute after birth.
2. The fetal heart rate is 70 prior to making the skin incision.
3. Clear fluid is obtained from the baby's oropharynx.
4. The neonate cries prior to delivery of the body.


2
Explanation: 2. Fetal bradycardia occurs when the fetal heart rate falls below 110 beats/minute during a 10-minute period of continuous monitoring. When fetal bradycardia is accompanied by decreased variability, it is considered ominous and could be a sign of fetal compromise.

Nursing

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