A 32-year-old laboring patient demonstrates cervical dilatation of 9 cm. Her contractions are two minutes apart and 60 to 90 seconds in duration. She complains of excruciating rectal pressure. How should the nurse interpret this complaint?
1. The patient's complaint is congruent with her current stage of labor.
2. The patient's complaint may indicate the need for delivery via cesarean section.
3. Based upon the patient's complaint, she is experiencing the active phase of labor.
4. The patient's complaint is consistent with placental separation, which is normal for her current stage of labor.
Correct Answer: 1
Rationale 1: The objective findings and patient's complaint are consistent with the transitional phase of labor, during which the patient may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.).
Rationale 2: The objective findings and patient's complaint of increased rectal pressure are consistent with the transitional phase of labor, during which the patient may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.).
Rationale 3: The objective findings and patient's complaint are consistent with the transitional phase of labor, during which the patient may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.).
Rationale 4: Placental separation occurs after the infant is born.
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