Physiological Integrity Q 18
The client is admitted to the unit. A vaginal exam reveals that she is 2cm dilated. Which of the following statements would the nurse expect her to make?
A. "We have a name picked out for the baby."
B. "I need to push when I have a contraction."
C. "I can’t concentrate if anyone is touching me."
D. "When can I get my epidural?"
Correct Answer: D. “When can I get my epidural?”
Dilation of 2 cm marks the end of the latent phase of labor. During the latent phase, the cervix dilates slowly to approximately 6 centimeters. The latent phase is generally considerably longer and less predictable with regard to the rate of cervical change than is observed in the active phase. A normal latent phase can last up to 20 hours and 14 hours in nulliparous and multiparous women respectively, without being considered prolonged.
Option A: This is a vague answer. The latent phase is commonly defined as the 0 to 6 cm, while the active phase commences from 6 cm to full cervical dilation. The presenting fetal part also begins the process of engagement into the pelvis during the first stage. Throughout the first stage of labor, serial cervical exams are done to determine the position of the fetus, cervical dilation, and cervical effacement. Cervical effacement refers to the cervical length in the anterior-posterior plane. When the cervix is completely thinned out and no length is left, this is referred to as 100 percent effacement.
Option B: This indicates the end of the first stage of labor. The first stage of labor begins when labor starts and ends with full cervical dilation to 10 centimeters. Labor often begins spontaneously or may be induced medically for a variety of maternal or fetal indications.
Option C: This indicates the transition phase. The second stage of labor commences with complete cervical dilation to 10 centimeters and ends with the delivery of the neonate. This was also defined as the pelvic division phase by Friedman. After cervical dilation is complete, the fetus descends into the vaginal canal with or without maternal pushing efforts.