Report contractions lasting longer than 90 seconds or occurring closer than every 2 minutes (tachysystole) with a Category II or III tracing.
Before you read
Test yourself first: 4 questions
Question 1 of 4
A nurse is evaluating the progress of a client in active labor whose cervix has remained at 6 cm for 4 hours despite adequate contractions. How should the nurse document this finding?
Answer: B. Lack of cervical dilation over time despite adequate uterine activity is an arrest of dilation, a form of dystocia (dysfunctional labor). Precipitous labor is excessively rapid; a normal labor curve shows steady progress; transition phase refers to 8 to 10 cm dilation, not an arrest at 6 cm.
Question 2 of 4
A nurse is monitoring a client in the latent phase of the first stage of labor. Which cervical dilation range corresponds to this phase?
Answer: A. The latent phase of the first stage of labor spans from 0 to about 5 to 6 centimeters of dilation. The active phase follows from about 6 centimeters to full dilation at 10 centimeters.
Question 3 of 4
A client's labor has been progressing, but cervical dilation has not changed in 3 hours despite adequate contractions, and the fetal head remains high. The nurse recognizes this as which complication?
Answer: B. Failure of the cervix to dilate and the fetus to descend despite adequate contractions is consistent with labor dystocia and possible cephalopelvic disproportion, where the fetal head is too large for the maternal pelvis.
Question 4 of 4
A multiparous client arrives in active labor stating she feels the urge to push. On examination she is 10 centimeters dilated, fully effaced, and the fetal head is at plus 2 station. What does the plus 2 station indicate?
Answer: C. Station describes the relationship of the presenting part to the maternal ischial spines. Plus 2 means the presenting part is 2 centimeters below the ischial spines, indicating descent and that birth is approaching.
Keep the streak going with more questions like these, each with a full rationale.
What is stages of labor?
Stage 1 is dilation (0 to 10 cm) and is divided into latent, active, and transition phases. Stage 2 is from full dilation to delivery of the baby, Stage 3 is delivery of the placenta, and Stage 4 is the first 1 to 4 hours of recovery. Knowing which stage the client is in drives the correct nursing priority.
Key points to remember
- Stage 1 ends at 10 cm full dilation; transition (8 to 10 cm) is the shortest, most intense phase with strong urge to push.
- Stage 2 lasts from complete dilation to birth and is when the client pushes with contractions.
- Stage 3 is placental delivery, normally within 5 to 30 minutes after birth; signs include a gush of blood, lengthening cord, and globular firm uterus.
- Stage 4 (first 1 to 4 hours postpartum) carries the highest risk for hemorrhage as the uterus must clamp down.
- True labor produces regular, intensifying contractions with cervical change; false labor (Braxton Hicks) is irregular and eases with rest or hydration.
Nursing priorities
- Monitor contraction frequency, duration, and intensity along with cervical dilation to track progress.
- Assess fetal heart rate before, during, and after contractions to detect distress.
- Encourage upright positions, ambulation, and breathing techniques in early labor; support effective pushing in Stage 2.
- After placental delivery, palpate the fundus and massage if boggy to control bleeding.
- Keep the bladder empty, as a full bladder displaces the uterus and impairs contraction.
Patient teaching
- Go to the hospital when contractions follow the 5-1-1 rule: 5 minutes apart, lasting 1 minute, for 1 hour.
- Report leaking fluid, bright red bleeding, or decreased fetal movement before active labor.
- Empty your bladder regularly during labor to help the baby descend.
Red flags: report now
- Report contractions lasting longer than 90 seconds or occurring closer than every 2 minutes (tachysystole) with a Category II or III tracing.
- A boggy uterus, saturating one pad per hour, or a rising firm fundus signals hemorrhage or retained placenta.
- Never push down on the fundus to deliver the placenta; this risks uterine inversion.
References
Clinical references for this topic
