A client in labor with cervical dilation of 9 cm is experiencing contractions every 2 minutes that are 60 to 90 seconds in duration and is complaining of excruciating rectal pressure. How should the nurse interpret this complaint?
1. The client's complaint is congruent with her current stage of labor.
2. The client's complaint may indicate the need for delivery via cesarean section.
3. Based upon the client's complaint, she is experiencing the active phase of labor.
4. The client's complaint is consistent with placental separation, which is normal for her current stage of labor.
1
Explanation:
1. The objective findings and client's complaint are consistent with the transitional phase of labor, during which the client may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.).
2. The objective findings and client's complaint of increased rectal pressure are consistent with the transitional phase of labor, during which the client may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.).
3. The objective findings and client's complaint are consistent with the transitional phase of labor, during which the client may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.).
4. Placental separation occurs after the infant is born.
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