Question

A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2-3 mins apart, each lasting 80-90 sec, and vaginal exam reveals the cervix is dilated to 9 cm. The nurse should identify the client is in which phase of labor?

a) Latent phase
b) Active phase
c) Transition phase
d) Expulsion phase

Answer 1

The client is in the transition phase of labor, marked by intense contractions and a cervix dilated to 9 cm, the last phase before reaching full dilation at 10 cm.

Step-by-step explanation:

The client who is in labor and reports increasing rectal pressure, experiencing contractions 2-3 minutes apart, each lasting 80-90 seconds, and whose vaginal exam reveals the cervix is dilated to 9 cm is in the transition phase of labor. This is the final phase of the first stage of labor, where the cervix dilates from 7 cm to its full dilation at 10 cm. The transition phase is often the most intense and painful part of labor, as contractions come quickly and last longer.

The nurse should identify the client as being in the transition phase of labor. During this phase, the cervix dilates from 8 to 10 cm. The contractions are closer together, lasting around 80-90 seconds and occurring 2-3 minutes apart. The increasing rectal pressure is a common sign that the client is transitioning from the active phase to the pushing phase of labor