A nurse is caring for a client who is in labor and reports increasing rectal pressure. This symptom most likely indicates which of the following?

• A. The client is experiencing Braxton Hicks contractions.
• B. The placenta is beginning to separate from the uterine wall.
• C. The client is entering the latent phase of the first stage of labor.
• D. The fetus is descending into the birth canal and the client is likely in the second stage of labor.

Answer: (D)

Verified step by step guidance

1. Understand the stages of labor: Labor is divided into three main stages. The first stage includes the latent, active, and transition phases, where the cervix dilates. The second stage begins when the cervix is fully dilated (10 cm) and ends with the delivery of the baby. The third stage involves the delivery of the placenta.
2. Recognize the symptoms of the second stage of labor: During this stage, the fetus descends into the birth canal, and the mother may feel intense rectal pressure due to the baby's head pressing against the pelvic floor and rectum.
3. Differentiate between Braxton Hicks contractions and true labor: Braxton Hicks contractions are irregular and do not lead to cervical dilation or fetal descent. They are often described as 'practice contractions' and do not cause rectal pressure.
4. Understand the role of the placenta: The placenta separating from the uterine wall is a sign of placental abruption or the third stage of labor (after the baby is delivered). This is not associated with rectal pressure during labor.
5. Conclude that increasing rectal pressure is a hallmark sign of the second stage of labor, as it indicates the fetus is descending into the birth canal and the mother is preparing for delivery.