A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
A Active
B Transition
C Latent
D Descent
The Correct answer and Explanation is:
The correct answer is B. Transition.
Explanation:
In the context of labor, the transition phase is the final part of the first stage of labor and is characterized by specific signs and symptoms that differentiate it from the earlier phases. Here’s a detailed explanation of why the client is in the transition phase based on the provided information:
- Cervical Dilation: At 9 cm dilation, the client is nearing the end of the first stage of labor. The transition phase typically occurs from around 8 cm to 10 cm of dilation. This phase is marked by the cervix completing its dilation process, which prepares the woman for the second stage of labor.
- Contraction Frequency and Duration: The client is experiencing contractions every 2 to 3 minutes, each lasting 80 to 90 seconds. These contractions are more frequent and intense compared to earlier phases. In the transition phase, contractions become very strong, occurring every 1.5 to 3 minutes, and last around 60 to 90 seconds. This pattern indicates that the client is moving through the transition phase, where contractions are at their peak intensity.
- Rectal Pressure: Increasing rectal pressure is a common symptom during the transition phase. This pressure occurs as the fetal presenting part descends into the pelvis and applies pressure to the rectum. The client’s report of increased rectal pressure is consistent with the transition phase, where the fetus is making significant progress towards the birth canal.
- Phase Characteristics:
- Latent Phase: Occurs at the beginning of labor, where cervical dilation is from 0 to 3 cm. Contractions are generally mild to moderate and less frequent.
- Active Phase: Follows the latent phase, with dilation from 4 to 7 cm. Contractions become more regular, intense, and last longer, but not as frequent or intense as in the transition phase.
- Descent Phase: Refers to the second stage of labor, where the fetus descends into the birth canal. This phase starts after full cervical dilation (10 cm) and is characterized by the urge to push, which is not the primary symptom described in this scenario.
In summary, based on the dilation of 9 cm, frequent and intense contractions, and increasing rectal pressure, the client is in the transition phase of labor.